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Lowering Medical Costs By Providing Better Care.

In this week's New Yorker, Atul Gawande asks whether it's possible to lower medical costs by giving the neediest patients better care. Gawande says that primary care physicians who target the chronically ill are the new leaders in health care reform.

35:16

Other segments from the episode on January 19, 2011

Fresh Air with Terry Gross, January 19, 2011: Interview with Atul Gawande; Obituary for Sargent Shriver.

Transcript

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Lowering Medical Costs By Providing Better Care

DAVE DAVIES, host:

This is FRESH AIR. I'm Dave Davies, in for Terry Gross.

One of the criticisms of the health care reform bill enacted last year,
is that it expanded coverage without doing enough to control rising
health care costs.

Our guest today, surgeon and journalist, Atul Gawande, says there are
hopeful signs that costs can be contained, not by cutting back but by
providing more intensive service to chronically ill patients who incur
huge costs with long stays in hospital rooms and intensive care units.

Gawande is a practicing surgeon at Brigham and Women's Hospital in
Boston. He's also an associate professor at the Harvard School of Public
Health and a staff writer for the New Yorker. His 2009 article on high
health care costs in McAllen, Texas, was recommended by President Obama
to members of his domestic policy staff.

Guwande's piece in the current issue of the New Yorker, on those who
focus on patients with the highest medical costs, is called "The Hot
Spotters." He spoke to us from the Harvard Medical School. You may hear
some extraneous noise in the background.

Well, Atul Gawande, welcome back to FRESH AIR. Let's talk about this
physician, this young physician in Camden that you write about who has
done some innovative things on cutting health care costs. And he really
began by looking at where the hot spots of health care spending were in
Camden. What did he do?

Dr. ATUL GAWANDE (Surgeon, Brigham and Women's Hospital): It's a
fascinating story. Jeff Brenner is this family physician who had been a
citizen member of a police reform commission and started looking at
emergency room visits the way police look at crime assaults.

He started asking: Where are the people who have the most emergency room
visits and hospital visits, and why is that happening? Just like you
might look, a police chief might look at crime and say: What are the
neighborhoods where the greatest amount of crime are, and let's put our
resources there.

And so he collected data from emergency rooms in the three main
hospitals in Camden, looked to see what's the trouble here. And what he
found was that most of the costs were concentrated in just a handful of
people.

He found two city blocks, for example, that had about 1,000 people
living in them, and they accounted for $200 million in health care costs
over five years. He dug in a little further and saw that there was a
low-income housing project and a large nursing home there and that you
could imagine diving in to make changes.

He could imagine. He said to himself: Now, wait a minute. Our numbers
are showing that one percent of the people using the Camden health
system accounted for 30 percent of the costs. One percent in Camden was
about 1,000 people. That's about half the size of a primary care
physician's office panel, the number of patients they were seeing.

And he said: I can do something about this. And so he decided to try to
attack this problem, address the problem of cost - not so much because
he cared so much about cost, but because he was convinced about another
thing - which is the idea that the most expensive people in the city
were likely getting the worst care.

DAVIES: Yeah, why would you think those that were getting all of those
tests and all of that treatment were getting bad care?

Dr. GAWANDE: The story will vary from city to city. But in the city of
Camden, it was a story of poverty. Camden's a poor city. They have a lot
of people who are in and out of insurance. They go to the emergency
rooms as a primary place of care. And the sickest among them really do
badly.

When he tackled this, he decided to start, just one-by-one, taking care
of the people who were in that top percentage of costs. And his patient
number one that he encountered, was a man who was spending basically
more than six months out of the year in the hospital. He was 560 pounds.
He had a alcohol, and it turned out, a cocaine addiction. He had
congestive heart failure that left him disabled from his cardiac
condition, bad diabetes. And when he caught up with him, he was in an
intensive care unit with a tracheostomy and a feeding tube and a bad
gall bladder infection. He basically...

DAVIES: Let me interrupt you, if I can, here because this is a
fascinating piece of this story. This physician, Jeffrey Brenner,
decides, I guess for his own reasons, he wants to take care of, you
know, the toughest patient, almost, he can find in Camden - the one
who's getting terrible care, generating lots of costs. How does he do
this? He goes to the doctor and says give me your toughest case?

Dr. GAWANDE: Yeah, so the first way you do it is you try to look in the
data and say who are the most expensive and try to track them down. But
you have to jump through all kinds of hoops.

You'd have to get hospital permissions and legal permissions to pull the
names out of the database and approach them. So instead, he said, let me
just go to the docs and say: Who's your hardest, hardest, worst-of-the-
worst, as he put it, patients? And let me see them. And they were more
than happy to hand over patients like this man.

I mean, you know, this was a man who, you know, he's homeless, living in
a welfare motel when he's discharged. You know, if you're in the
hospital that much, you don't keep your home. He has drug problems. He
doesn't turn up for his appointments.

And, you know, here's this doctor, Jeff Brenner, saying: I'll help you
with these folks. In fact, I want to help take care of them, and I think
we can do a great job.

And so they did. They would find their most difficult of the difficult,
and then when he'd look back in the data to see where they are in the
cost map, these were, indeed, some of the most expensive patients in the
city.

DAVIES: So let's talk about this one gentleman. You said he tracked him
down in the intensive care unit, where he spends a lot of the year. Then
what happens?

Dr. GAWANDE: So Jeff Brenner described it as just being like a medical
student for a while. He'd go and spend an hour a day just sitting and
trying to figure out what made the guy tick. As he got better in the
intensive care unit and started getting out into the regular floor of
the hospital, and then into a rehab facility, they neared the point
where he was going to be discharged.

And the minute he goes out, you know, it's back to that world where
there could be cocaine, there could be drugs, alcohol, he'd be homeless,
he would lose, you know, any kind of basic care that would keep him
going. And instead, he began providing that care.

He got a nurse practitioner, in addition to himself, who agreed to help
pitch in. And she started visiting him every other day, at home, just to
make sure his blood pressure was being checked and under control, and he
was doing the right things by his diabetes.

He got a social worker to work with him and make sure that, you know, he
got the Medicaid he qualified for. So he had steady insurance, and some
of the specialists he needed would actually see him.

And probably the most important thing was simply working on him the way
a primary care doctor works on people who have gotten into a rut in
their lives. He said, you know, probably the most important thing that
he did was just tried to care about him. And he worked on things like:
How are we going to get you to stop smoking? How do we introduce value
into your life again?

He pushed him to rejoin the church that he used to go to, that he didn't
go to anymore. It turned out, he learned about him, that he was a line
cook in his former life, before he got so sick, and that he knew how to
cook. And so, you know, he said, start cooking for yourself so that
you're getting back in the habits and eating better.

And slowly, it took three years, but I spoke to the patient, and he's
not had any more of those catastrophic intensive care unit stays. He has
lost 220 pounds. When he falls down, he does not have to call 911 to get
up. He is off of cocaine for three years, alcohol for two years, smoking
for a year.

Sometimes, because of his heart failure, he does go back to the
hospital, but it'll be a day or two at a time instead of weeks and
weeks. And his costs have dropped dramatically, while the quality of his
care has been just turned completely around.

DAVIES: So part of it is, kind of, helping repair the social and moral
infrastructure of his life. And then part of it is medical, right? I
mean, you need people to make sure that he is getting his blood sugar
tested regularly and that his medications are coordinated so that the
medical care is more coordinated, and he's living a healthier lifestyle,
which sounds terrific.

But it's - we're not going to get doctors to volunteer to do this very
often. What does it take to fund that kind of effort? Well, how did they
do it in Camden? They actually expanded this to get more patients,
right?

Dr. GAWANDE: Yeah, so, you know, it didn't work. I mean, Jeff Brenner is
something of a saint. He was ending up taking patient after patient,
like this man, being very successful, lowering their costs by double-
digit percentages, improving the quality of care until the point he had
more than 300 patients enrolled under wing with a team of the nurse
practitioner and the social worker and other folks, got some temporary
grants from foundations. But it was - you know, he struggles from year
to year, about whether his organization can even survive.

What he is recognizing is that in the current health care system, you're
not paid to keep people healthy. The main mechanism that the health care
system manages through is you have 20-minute office visits, maybe 30
minutes, and you have emergency room visits. Those are - you know,
Americans make a billion of these kinds of visits a year. And that's how
things get done.

If you're a complex patient, with this kind of range of problems, it
doesn't fit into that world. It needs a whole kind of a project manager,
a whole team to take you under wing and see you through this course of
illness. And so what he's started creating is the system as it should
be.

DAVIES: And so his organization has these 300 patients. Is he the
primary care physician for these 300 folks?

Dr. GAWANDE: No, he has not been. Even his organization still hasn't had
the funds to have a clinic staff of doctors. They visit at home. They go
to the patients' houses. They can order tests and get things squared
away, and then they coordinate with their doctors because that's
currently the way that they can do it.

But I visited another system that he's on the advisory board for in
Atlantic City that has been able to create it and get actual money from
the insurers to be able to pay for it. And it has been able to take it,
not just to 300 patients, but to 1,200 patients who represent the top
five percent of costs for the casino workers in Atlantic City.

DAVIES: We're speaking with Dr. Atul Gawande. We'll talk more after a
break. This is FRESH AIR.

(Soundbite of music)

DAVIES: If you're just joining us, our guest is Dr. Atul Gawande. He is
a staff writer for the New Yorker magazine. He's also a practicing
surgeon and an associate professor at the Harvard School of Public
Health. He has a new piece in the New Yorker about cutting medical costs
by providing intensive care to chronically ill patients.

So let's talk about the Special Care Center in Atlantic City, which is a
clinic set up specifically for the toughest patients, those that are
chronically ill. Who established this and why?

Dr. GAWANDE: Yeah, this was just so interesting. The union for the
casino workers have a health fund that started this, along with the
hospital, and both of them were facing problems that the costs of their
employees' health care had gone beyond what they could afford.

For the unions, they negotiate contracts that are often for total
compensation, meaning the wages plus the benefits, and since the workers
vote every year on how that total compensation gets divvied up between
wages and benefits, the workers have, every year, voted that they do not
want to cut their health care benefits.

But because those costs rise so much, they haven't seen a pay increase
in years, apparently. So they were desperate to have something that
would actually bring those health care costs down without simply cutting
them off for themselves.

But interestingly, the hospital was also facing a similar problem that
their own employees' health care costs were going up so high that they
wanted a solution for it and put in with the union to create this really
interesting experiment, which is kind of like Jeff Brenner is producing,
only doing it for the casino workers and hospital employees.

DAVIES: And this is a clinic, not for all of the casino workers and
hospital employees, but those who are the sickest, right?

Dr. GAWANDE: Yeah, the design of this is really interesting. You cannot
get into the clinic unless you are in the top 10 percent, basically, of
the health care costs that their health funds have. When you are
enrolled in the clinic, there are no bills.

The clinic is just paid a flat, monthly fee for every patient they take
care of for providing whatever services are needed, to give them good
service and improving care.

DAVIES: And they're paid this flat monthly fee by the benefit fund of
the union and the hospital, right?

Dr. GAWANDE: That's correct. So, one of things that means is that the
whole staff, that all of us have to have in medicine, who handle
insurance paperwork and that kind of thing, disappeared. So that cost
was lopped off the top.

Then the second thing was that by having that kind of a - they call it a
retainer-based payment, if they aren't providing good services, the
patients will walk. They will simply leave and take their retainer to
somebody else, go back to their regular physicians.

So that led them to focus intensely on service for these patients,
service to make sure that they are creating health goals for every
patient, creating a staff that can help them achieve it.

They have one person on staff, for example, whose sole goal - not sole
goal - but they are fundamentally responsible for ensuring that there is
a strategy for every patient in the clinic to quit smoking, and they've
reduced smoking among their population of, especially among the heart
disease and lung disease patients, by two-thirds. Which is, you know,
massively beyond what you see in general clinics in the United States.

And they've just tackles sort of problem after problem: How do I keep my
cardiac patients on their main medications, their cholesterol-lowering
agent? How do I control their high blood pressure? They have a whole
staff that, in fact, is invented for it.

DAVIES: And they had this category of health care coaches who, if I read
this right, they are not recruited among people with a medical
background, right?

Dr. GAWANDE: Yeah, so the doctor that the health fund pulled in to run
the site is a doctor named Rushika Fernandopulle. And Dr. Fernandopulle
ended up on a mission when he was a young physician, that went to the
Dominican Republic, and he saw community workers in action. I guess they
call them promotoras(ph).

And they kind of coached people around maintaining their health. And he
thought: We could do this here. And so he hired what I met of eight
health coaches, and these are people whose job is, besides the doctor,
to work intensively - whether it's with phone calls, visits to the home,
email, whatever is the way to work with each of the key patients - on
how they're doing with their health goals.

And those health coaches, you know, he interestingly emphasized they
don't have to be from health care. He often wanted people who were from
retail. One of his best health coaches was a woman who worked at Dunkin'
Donuts. Another worked as an assistant manager in a McDonald's. And they
knew how to provide service to people and focus on getting results.

DAVIES: So give us an example of what some of the services that the
health care coach would provide and how that contributes both to better
care and lower cost.

Dr. GAWANDE: There's the simple fact of every day, the team meets,
including the health coaches, to go through the list of all the patients
being seen that day or during the week, and troubleshoot.

What are the problems? What are the issues? Most of the patients only
take a few seconds to run through, but they would be things like: We
caught, on the computer system, that this person didn't fill their blood
pressure medication. Fine, I'll give them a call. So-and-so didn't turn
up for their appointment, we'll go and deal with that. This person has
some laboratory results that suggest he's getting into kidney failure.
Okay, we'll go - and he hasn't shown up for three appointments. Fine,
we're going to go visit him at home and find out what the deal is.

And then it goes to the point where the health coaches are working their
way through with the patients. Okay, you have smoking, or you have -
obesity is a major issue, or your diabetes and your blood sugar control
is where we really have to work.

The doctors and the nurse practitioners set the major goals. They take
care of the medical issues. But the additional issues - includes social
workers who can recognize this person is homeless and needs to get
proper housing or has a problem with infestation with dust mites that
are causing asthma for the children who are in the health plan - those
kinds of things that normally we don't touch in medicine, or if we do,
it's between visits that might occur once every five months, six months.
They are able to jump in and try to drive those changes in behavior and
in just making the health system work for them.

It was interesting that you describe them as, these health care coaches,
as people who are used to saying yes. I mean, if you - whatever the
patient needs, you figure out a way to make it happen.

And I'm sure that when people do get their meds checked and do have
their prescriptions filled, they're much less likely to end up in the
emergency care or the intensive care unit and thereby cut costs, and
they will be healthier.

On the other hand, this is a much more expensive set of services to
provide than a doctor's office, which just kind of treats you rudely and
says, you know, come in here, and we'll get you out of here in 20
minutes. Have they done studies to show how the costs cut, whether this
is really saving money?

Dr. GAWANDE: Yeah, so they - the union health fund, which is investing
in this, then engaged an independent economist, and he went and compared
how these workers were doing to a matched set of people who were in the
Las Vegas casino workers union and found that there were, even after
taking into account the costs of providing all of this and the fact that
these patients were getting more personal care, they're more likely to
get their mammograms and their drug costs had gone up, that they had
what appeared to be, on average, a 20-percent reduction, reduction, in
total costs, not bending the curve, not slightly making the rise lower
but actually slashing their costs. And this, in the most difficult and
the expensive population.

One of the points you made is that these services are intense. This is
outpatient intensive care, in a sense. The - part of the strategy that
works here is really borrowing from that crime world that you are
deploying to the place with the hot spots, where the statistics indicate
you have the people with the most need, and designing medicine around
that way, saying that yes, we are going to provide these kinds of
services but only intensively to the place we need it.

It's sort of like the intensive care unit within a hospital. It saves
lives, it does good, and outside of the hospital, what - when you have a
group of people focusing on keeping people out of the emergency room,
keeping them healthy enough that they need the hospital much less than
they used to, they are not only improving the care for people that are
some of the sickest people in a community but also reducing the costs.

DAVIES: Atul Gawande is a surgeon at Brigham and Women's Hospital in
Boston and associate professor at the Harvard School of Public School
and a staff writer for the New Yorker. He'll be back in the second half
of the show. I'm Dave Davies, and this is FRESH AIR.

(Soundbite of music)

DAVIES: This is FRESH AIR. I'm Dave Davies in for Terry Gross, back with
Atul Gawande. He's a practicing surgeon and associate professor at the
Harvard School of Public Health and a staff writer for The New Yorker.
His latest piece on cutting medical costs and improving care is called
"The Hot Spotters."

We've talked about a couple of cases where people have innovated in
particular practices with particular groups of patients and seem to have
had some success by bringing in extra services to the chronically ill
and cutting costs and getting them better care.

You also write about a company that does this on a macro level. I think
it's called Verisk, which analyzes health data for companies that are
looking to cut costs. Explain what they do.

Dr. GAWANDE: It's sort of a vague name isn't it? And they are in this
nondescript office park in a suburb of Boston. But they have contracts
for - with businesses mainly, businesses that have their own insurance,
so these usually medium-sized to larger businesses. And they are all
struggling with their health care costs. They all tend to try to
contract with advisers on how to cut health care costs. And Verisk is
one of these advisers that are out there. And the typical way these
advisers work is they look at their data and they tell them where to
change their benefits or how to change their benefits.

So they might encourage them to increase the co-payments on brand-name
drugs or increase the payments co-payments on an emergency room visits
to try to drive behavioral change. But what this particular company
does, is they have a small platoon of doctors that also look through
data and try to see the medical story underneath. They look in the hot
spots, where look at that one percent that accounts for 30 percent of
the cost, the five percent account for the 60 percent, and then begin
trying to see the patterns.

I sat down with Nathan Gunn, an internist who is one of these people at
the company, and watched him go through the data on one company where he
zeroed in on their top user of emergency rooms, which was a 25-year-old
woman - maybe she was a secretary there or something like that - who'd
had 80 visits to doctors and to emergency rooms for headaches. And by
peering in, he was able to see she was not on the right medication for
migraine headaches. She would go to the emergency room. They'd give her
a CT scan, make sure she didn't have a tumor or an aneurysm. They would
give her a shot of morphine or some narcotic, and then that would be
that. She was on a mild medication for migraines that clearly wasn't
working, but she simply hadn't gotten good care for a hard to treat
migraine problem and he could identify how to zero in and help that sort
of person.

DAVIES: I was really fascinated at one example that you cite, of where
they looked at a company that was trying to cut their health care costs
and so they increased co-pays for their employees with the idea that it
would make them think twice about getting an unnecessary procedure. Give
them skin in the game, as the phrase goes, so that they have an
investment in cutting costs. And that what they found was that for the
most expensive patients, that actually increased their usage and
increased the cost. Why?

Dr. GAWANDE: Yeah. So, well you know, all the company knew was they had
been cutting and cutting and that should have lowered their cost. And
instead, their cost continued to rise - 10 percent a year, 10 percent a
year, 10 percent a year. And so they got Verisk into the game to study
what was happening. And diving deep into the data what they saw was the
company was really two companies. There were the early retirees that
were the predominantly - and a subset of the early retirees, were that
five percent that accounted for 60 percent of the cost - and then there
were the rest of the employees. And so, those co-payments on the whole,
did - it reduced the number of office visits, it reduced the number of
hospital visits people made, they didn't visit the emergency room quite
as much, they used less drugs. And for the rest of the population, their
costs were sort of tottering along without rising but not really
falling.

But then they were just climbing massively for this early retirement
population. And when the doctors dug into this data they found the story
was that these were patients with chronic diseases like bad heart
disease and high blood pressure. Some of them had severe mental illness,
that was also a concern. And they were going off their meds and then
just having disasters happen.

One case being, one that he looked at with me, where - was a man who had
stopped his cholesterol medication, had stopped taking, regularly, his
heart medication, given the co-pays and everything else. And the next
time he's in the emergency room, it's with a massive heart attack. He's
now with severe disability from congestive heart failure and over
$80,000 in bills in the last year of his care.

DAVIES: Because he couldn't spend a few dollars for medicine.

Dr. GAWANDE: That's right. And so, the policy had backfired on them. And
what it made, you know, this whole way of thinking makes you recognize
that the – that succeeding and controlling health care costs means
succeeding in being able to figure out what you want to do for that top
five percent of people.

DAVIES: You've highlighted a couple of really heartening cases of where
people have given better, more consistent care to chronically ill
patients, made them healthier and cut costs. I want to look at the big
picture of that here. To what extent does the Health Reform Act create
meaningful incentives for driving down costs in these ways? Because, you
know, you hear the criticism when the bill was passed was that eh,
there's not really much here on cost control, a couple of pilot programs
here and there. To what extent does the health care reform encourage
this kind of stuff?

Dr. GAWANDE: In many ways the health care reform is gambling heavily on
this kind of work. It has $10 billion in incentives for innovation
centers to develop in communities that are focused on working to improve
the coordination of care and reinvent the way that physicians are paid,
so that these kinds of organizations can start to form. The puzzle of it
is whether these programs can scale successfully. This is the real test.
So far, it's sort of like charter schools. They are forming these really
striking successful programs. I think we've not paid enough attention to
them and understood just what kind of opportunity they represent. And
that's part of the reason that I went out to try to learn more about
them and write about them.

But the next question that they really face is: okay, you are able to do
this for the casino workers program in Atlantic City. You're able to
make it work at that scale. Now can you spread it to all of Atlantic
City or all of Camden, so that you're actually lowering an entire
community's cost?

What we need in health reform for cost control to actually happen is to
have the first community or health plan that actually lowers health care
cost. Not, you know, just bends the curve a little bit, but actually
lowers health care cost. We've never had a community that does it, let
alone one that does it by improving the quality of care.

DAVIES: If you have a system in which, by providing better care you
spend a little more up front but you cut costs overall, I mean it would
seem that would certainly be in the interest of the patients who get
better care, of the employers who pay insurance premiums to fund that
care, and, you know, insurance companies - who by the care from the
providers. Who are the people who are going to resist this? I mean, if
you're cutting costs that means you're cutting spending and somebody's
ox is getting gored. Is there resistance here?

Dr. GAWANDE: You put your finger on it. The people who will resist are
the people who currently benefit from the current system. There is a I
thought a kind of telling story in Atlantic City, where the special care
clinic there, as it's called, for the high cost patients, had gotten so
good at reducing cardiology needs for the patients that the specialists,
the cardiology specialists started experiencing a reduction in the
number of patients they were having come from this clinic. And a
conflict developed.

One patient that was an example that they told me about was a young
woman who had had an inflammatory condition of the heart that was able
to be taking care of just with inflammatory medications when she was in
her 20s, but she had been seeing a cardiologist every three months for
an EKG, and every year, for an ultrasound of the heart for two decades.
And they were able to recognize, you know, that cost is not really
necessary, we're taking good care of you, you're doing really well and
we recommend you don't see the doctor. And the doctor then would call
the patient at home and say, where are you? You have to come in. This is
one of the reasons that you are alive. And the patient, of course, went
back because who are you to believe?

The conflict that will mean that if you are successful in being able to
help keep people out of hospitals and help keep people healthy enough
that you are watching their health and improve, then many of the same
tests and specialty visits and operations, there in Atlantic City, the
number of operations these patients needed went down 25 percent, even as
their health improved, their quality care improved and their service
ratings went through the roof.

In Denmark, where a small set of these kinds of provisions were put in
place, the number of hospitals have dropped by half over the last decade
and a half. And for people here, imagining hospitals going out of
business, imagining that if we are actually controlling costs, we are
going to see some specialists start to think about going back into
primary care, that would be the sign that we're actually succeeding in
attacking the health care cost problem.

DAVIES: Well, Atul Gawande, it's been interesting. Thanks so much for
joining us again.

Dr. GAWANDE: And thank you.

DAVIES: Atul Gawande is a surgeon at Brigham and Women's Hospital in
Boston and associate professor at the Harvard School of Public Health,
and a staff writer for The New Yorker. His piece in the current issue is
called "The Hot Spotters."

(Soundbite of music)

DAVIES: Coming up, we remember Sargent Shriver who died yesterday at the
age of 95.

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Sargent Shriver: A Man Of Public Service

DAVE DAVIES, host:

Sargent Shriver, brother-in-law of President John Kennedy, founder of
the Peace Corps and architect of Lyndon Johnson's "War on Poverty," died
yesterday in Bethesda, Maryland. He was 95.

The son of a Maryland banker, Shriver went to Yale Law School and earned
a Purple Heart in World War II before marrying Eunice Shriver, JFK's
sister, in 1946. He had political ambitions of his own, but backed away
from those ambitions to help the Kennedys win the White House in 1960.
He then joined JFK's administration.

Shriver was named ambassador to France in 1968, at a time of strained
relations with the U.S. In 1972, he was George McGovern's vice-
presidential running mate on the Democratic ticket that lost by a
landslide to Richard Nixon. Four years later, he launched his own
presidential bid, which failed to gain traction in the 1976 primaries.
And in 1994, President Clinton awarded Shriver the Presidential Medal of
Freedom.

But it was his work in the 1960s that had the most lasting impact on the
country. He was founder of the Peace Corps, and its director until 1966.
And he developed a wide array of anti-poverty programs during the
Johnson administration.

Terry Gross spoke to Sargent Shriver in 1995, when the social programs
he initiated were under attack from prominent Republicans, including
Newt Gingrich and Rudy Giuliani.

TERRY GROSS: Which are the programs that are still alive today?

Mr. SARGENT SHRIVER (Politician and activist): Well, for example the
Head Start program was originated in the War Against Poverty. The Job
Corps was originated in the War Against Poverty. The Vista program was
originated then. Foster Grandparents was originated then, legal services
for poor people was originated then, medical services for poor people
was originated then. There's programs for the American Indians on the
Indian reservations. A program for students so that they could go
through college by working and studying so that they'd get a job at
school while they were paying, through the job, for their education.
That was the program, the War Against Poverty. Nobody remembers that.

GROSS: What critics are saying now is that while, you know, look. How
successful could the War on Poverty possibly have been when, in fact,
poverty has gotten worse, the welfare roles have swelled, people have
become dependent on government programs. What do you say to that?

Mr. SHRIVER: I just say that's entirely wrong. The War Against Poverty
started in 1964, 65, and by the time 1970 rolled around, the percentage
of people in poverty in the United States had decreased to the smallest
it's been in this century. It went from something like 18 and 19 percent
to 11 percent. After the War Against Poverty was discontinued in some
respects, the poverty ratio in the United States started climbing up. In
the Nixon administration, it began to go up, and went up all through the
Reagan administration until its hit a nice high now. It's almost up to
30 percent.

GROSS: When you say it was discontinued in some respects, what do you
mean? Because some of the some of the programs still exist, and yet you
said it was discontinued in some respects. So where do you draw the line
there?

Mr. SHRIVER: Well, what I mean is that our request, the request I made
to Lyndon Johnson back in 1966, I think it was, was for a program of $7
billion per annum. We were then at one-and-a-quarter billion dollars per
annum. I asked for $7 billion per annum because that was the amount of
money which we believe was necessary if we were going to win the war.
Just like when you have a war in Europe, Eisenhower's in charge of the
thing, he asked for the money that's necessary in his judgment, as the
commander-in-chief, to win the war. We were not given that money.

The War Against Poverty never had enough money to succeed, not only in
eliminating poverty - which may never be possible to eliminate it
altogether - but to reduce it significantly so that it would be at a
much lower level, let's say, five, six, seven, eight percent of the
population of our country. We never got the money to do that. So when I
say we started the war, we did not finance the war adequately to win it,
and therefore, of course, we didn't win it.

GROSS: The slogan of the War Against Poverty was a hand up, not a hand
out. What was the thinking behind that?

Mr. SHRIVER: The thinking was damn simple, and it's this: Most people in
our country don't like handouts - that is, where people get something
for nothing. And I don't blame them. I feel exactly the same way. So
when we created the programs in the War Against Poverty, we didn't give
anybody anything for nothing. I'd like to emphasize that: There was
nothing given to anybody for nothing.

For example, if you volunteered the Job Corps, you really had to leave
your home, go to a place where you worked 10 hours a day, you were on
duty, so to speak, 24 hours. It was seven days a week. This was not a
soft touch. It was a tough job. You learned how to work. You learned
self-discipline. You had to agree to do that. You could quit anytime you
wanted. That's true. And plenty of people quit, because they didn't have
the courage or the intelligence or the combination to stay with the
requirements of the Job Corps. But nobody was drafted into the Job
Corps. Everybody had to volunteer, and they could get out whenever they
wanted to get out.

GROSS: Were you personally opposed to giving people money?

Mr. SHRIVER: Yes. We never gave people money for nothing. No, we never
did it at all. That's a different business. That's welfare. Ours was not
a welfare program.

GROSS: Why not? Why didn't you want to enact a bigger welfare program?

Mr. SHRIVER: Because we believed that the way to get out of poverty was
through human effort, help by government, help by private enterprise
systems - or charity, so to speak. But a person had to have the desire.
They had to have the motivation to move themselves out of poverty. When
they had the motivation, we tried to help keep that motivation alive and
to aid and abet that motivation. But we did not go in and just hand out
money to people who had no motivation and were very content just to
still and take the money.

GROSS: I think one of the more controversial aspects of the War On
Poverty was the Community Action Program, which required a maximum
amount of community representation on the board. Tell us what the
Community Action Program was, first.

Mr. SHRIVER: Well, let me correct one misapprehension, which was
implicit in the way you phrased the question: It did not require the
maximum participation of the poor people on the board. What it did was
require one-third of the people on the board to be poor, so that their
voice could be heard and their appreciation of what they needed could be
given to the other people on the board.

The second one-third consisted of leaders of private, charitable groups
in the community where the community action was to take place. And the
third was representative citizens from that area.

GROSS: Tell me the function of the program.

Mr. SHRIVER: The function was to mobilize the community itself, a
particular part of a city, for example, to mobilize that part of the
community, that part of the city to deal with their own problems
imaginatively and in ways that they thought would be effective - not
ways in which I thought or some federal bureaucrat would be effective,
not ways in which, let's say, a given mayor thought would be effective
or some other outside group would be effective, but in the ways that the
people who were poor thought that they could be most helpful.

So we gave a voice to the, how shall I say, to the customers. The
customers, you might say, were the poor people, and they were expressing
their opinion about what they thought they needed, just as a patient
tells a doctor where the patient hurts, the doctor finds out and
prescribes for the patient. That's what we were attempting to do.

GROSS: Now, Nicholas Lemann, in his book "The Promised Land," writes
about how a lot of politicians were threatened by Community Action
Program because by empowering poor people, you were taken away some of
the power from the local political machine. And there was money that was
going - federal money that was going into a city that wasn't getting
routed through the political machine. And so Mayor Daley, for instance,
said you're putting money in the hands of people who are not in my
organization. Was that your experience of it, too, that there was a lot
of political resistance because of community people being on the board?

Mr. SHRIVER: Sure. Normally, tax dollars got distributed through the
elected officials of our country, whether there's the local mayor or the
government or the president of the United States or the Congress of the
United States. One of the reasons people like to get into politics is
not only that they can help their fellow citizens, but because they get
power - especially men. Men love to have power: power over money, power
over other people. But that was not our game. Our game was to empower
the people themselves. So we went straight to where the poor people were
rather than go through the political apparatuses. That enraged political
people who had spent their lives trying to get political power.

DAVIES: Sargent Shriver, speaking with Terry Gross in 1995.

We'll hear more after a break. This is FRESH AIR.

(Soundbite of music)

DAVIES: We're listening to Terry's 1995 interview with Sargent Shriver,
the brother-in-law of President Kennedy, who founded the Peace Corps and
developed many of Lyndon Johnson's anti-poverty programs. Shriver died
yesterday.

GROSS: I'm sure you get asked this all the time, so forgive me for
asking it again. But your son-in-law is very, very famous, Arnold
Schwarzenegger. And he's not only famous as an actor. He's famous as a
Republican, a Republican supporter. What's it been like for you to have
a son-in-law who is for your opposing party?

Mr. SHRIVER: Well, I grew up in a rather large family, the Shriver
family in Maryland. About half of them are Republicans and half of them
are Democrats. So I'm not at all surprised to be closely related to
somebody who is a Republican. Secondly, I understand fully why Arnold,
when he came to this country, became a Republican rather than a
Democrat. He came from Austria, where the Socialist Party in Austria was
really European socialist in its outlook. And he thought - and I think
this is a fair statement. He thought that the Democratic Party in our
country was analogous to the Socialist Party which he had experienced in
Austria. Actually, that's not an accurate comparison, but that's what he
thought.

So when he came here, went to graduate school at the University of
Wisconsin, he was approached by Republicans who invited him to become a
member of that party. And he looked upon the Republican Party as being
more in keeping with his ideas. And his ideas were based on the fact -
which is a great tribute to him - that he had been able to come from,
you might say, very simple circumstances in Austria. I mean, not from
the top upper crust of Austrian society, either socially speaking or
financially speaking. He had made it on his own, and he thought that's
the way everybody should be able to conduct their life. They should
succeed on their own.

GROSS: So this doesn't interfere with the family relationship.

Mr. SHRIVER: No, not at all.

GROSS: One last quick question for you. When I was growing up and your
name was in the news a lot, I always thought Sargent was a military, or
that you must have been a sergeant. And this is a silly question, but
was that a common misconception young people had?

(Soundbite of laughter)

Mr. SHRIVER: Sure. Yeah. Lots of people. And even today, some people say
Sargent Shriver. Well, yes, you know, say well, what was your actual
rank? Were you a master sergeant in the Army?

(Soundbite of laughter)

Mr. SHRIVER: But the place where it was really funny was this: I served
in the Navy for five-and-a-half years, and there are no sergeants in the
Navy. That's a title in the Army. So I can remember when I'd come into
port and they put up a telephone onto the ship. You know what I mean?

GROSS: Uh-huh.

Mr. SHRIVER: And then somebody called up on that phone ask to speak to
Sargent Shriver several times. The man who answered the phone said,
lady, there's no sergeants in the Navy. So there's no Sargent on the
ship.

(Soundbite of laughter)

Mr. SHRIVER: It was particularly funny when it comes - I did get to the
point where I was a lieutenant commander.

GROSS: So you were Lt. Sargent?

Mr. SHRIVER: No, I was Lt. Commander Sargent Shriver.

(Soundbite of laughter)

Mr. SHRIVER: That was enough to confuse anybody, including me.

(Soundbite of laughter)

GROSS: Sargent Shriver, thank you so much for talking with us.

Mr. SHRIVER: Not at all. I'm delighted to be with you.

DAVIES: Sargent Shriver, speaking with Terry Gross in 1995. He died
yesterday in Bethesda, Maryland. He was 95.

(Soundbite of music)

DAVIES: You can join us on Facebook and follow us on Twitter
@npr.freshair. And you can download podcasts of our show at
freshair.npr.org.
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Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.

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