Kongressbotschaft zur Gesundheitsfürsorge
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(Washington, D.C., 27. Februar 1962)
The basic resource of a nation is its people. Its strength can be no greater than the health and vitality of its population. Preventable sickness, disability and physical or mental incapacity are matters of both individual and national concern.
We can take justifiable pride in our achievements in the field of medicine. We stand among the select company of nations for whom fear of the great epidemic plagues is long past; our life expectancy has already reached the biblical three score and ten; and, unlike so many less fortunate peoples of the world, we need not struggle for mere survival. But measured against our capacity and capability in the fields of health and medical care, measured against the scope of the problems that remain and the opportunities to be seized, this nation still falls far short of its responsibility.
Many thousands needlessly suffer from infectious diseases for which preventive measures are available. We are still tenth among the nations of the world in our infant mortality rate. Prolonged and costly illness in later years robs too many of our older citizens of pride, purpose and savings. In many communities the treatment of the mentally ill and the mentally retarded is totally inadequate. And there are increasingly severe shortages of skilled personnel in all the vital health professions.
Basically, health care is a responsibility of individuals and families, of communities and voluntary agencies, of local and state governments. But the federal Government shares this responsibility by providing leadership, guidance and support in areas of national concern. And the Congress last year recognized this responsibility in important ways.
PROGRESS DURING 1961
Our states and communities have responded quickly and with impressive vigor to the invitation to cooperate action extended by the Community Health Services and facilities Act passed by the Congress and signed into law only four months ago. As a result, better care for the chronically ill and the aged will soon be available in many parts of the Nation, both inside and outside the hospitals and other institutions in this program.
There is also visible progress in the effort to control water pollution, resulting from the expanded legislation passed by the Congress in 1961. Last year construction was begun on more waste treatment plants than ever before in our history--30 percent above the calendar year 1960 level.
There were, in addition, other important forward thrusts taken, with federal help, in the protection of our nation's health. Medical research advanced at an accelerated pace. We are now better equipped than ever before to evaluate and deal with radiation perils. The incidence of polio has been reduced to the lowest levels ever recorded. We have engaged our most talented doctors and scientists in an intensified search for the cause and cure of cancer, heart disease, mental illness, mental retardation, environmental health problems and other serious health hazards.
But, of the four basic improvements in the federal health program I recommended to the Congress last year, two urgent needs-health insurance for the aged and assistance to education for the health professions--have not yet been met. The passage of time has only served to increase their urgency; and I repeat those requests today, along with other needed improvements.
I. HEALTH INSURANCE FOR THE AGED
Our social insurance system today guards against nearly every major financial setback: retirement, death, disability and unemployment. But it does not protect our older citizens against the hardships of prolonged and expensive illness. Under our social security system, a retired person receives cash benefits to help meet the basic cost of food, shelter and clothing--benefits to which he is entitled by reason of the contributions he made during his working years. They permit him to live in dignity and with independence-but only if a serious illness does not overtake him.
For, compared to the rest of us, our older citizens go to the hospital more often--they have more days of illness--and their stays in the hospital are thus more costly. But both their income and the proportion of their hospital bill covered by private insurance are, in most cases, substantially lower than those of younger persons.
Private health insurance has made notable advances in recent years. But older people, who need it most but can afford it least, are still unable to pay the high premiums made necessary by their disproportionately heavy use of health care services and facilities, if eligibility requirements are to be low and the scope of benefits broad. Today, only about half of our aged population has any health insurance of any kind-and most of these have insufficient coverage.
To be sure, welfare assistance, and federal legislation to help the needy or "medically indigent," will provide health services in some instances. But this kind of help is not only less appealing, coupled as it is with a means test, it reaches very few of those who are not eligible for public assistance but are still not able to afford the care they need.
I therefore recommend again the enactment of a health insurance program for the elderly under the Social Security system. By this means the cost of health services in later years can be spread over the working years--and every worker can face the future with pride and confidence. This program, of course, would not interfere in any way with the freedom of choice of doctor, hospital or nurse. It would not specify in any way the kind of medical or health care or treatment to be provided. But it would establish a means to pay for the following minimum levels of protection:
First--Inpatient hospital expenses for up to 90 days, in excess of $10 per day for the first 9 days (with a minimum payment by each person of $20), and full costs for the remaining 81 days.
Second--the cost of nursing home services up to 180 days immediately after discharge from a hospital. By providing nursing home care for twice as long as that in the hospital, the patient is encouraged to use the less expensive facilities when these will satisfy his requirements.
Third--the cost of hospital outpatient clinic diagnostic services in excess of $20. These benefits will reduce the need for hospital admissions and encourage early diagnosis.
fourth--the cost of community visiting nurse services, and related home health services, for a limited number of visits. These will enable many older people to receive proper health care in their own homes.
It should be emphasized that we are discussing a gap in our self-financed, contributory social insurance system. These are all insurance benefits which will be available to everyone over 65 who is eligible for Social Security or Railroad Retirement benefits. They would be entirely self-financed by an increase in Social Security contributions of one quarter of one percent each on employers and employees, and by an increase in the maximum earnings base from $4800 a year to $5200 a year. No burden on the general revenues is involved. I am not unmindful of the fact, however, that none of our social insurance systems is universal in its coverage-and that direct payments may be necessary to provide help to those not covered for health insurance by Social Security. But the two problems should not be confused-and those who have made no contribution toward such a fund should not be regarded as in the same category as those who have-and because a minority lacks the protection of social security is no reason to deny additional self-financed benefits to the great majority which it covers.
II, HEALTH PROFESSIONS PERSONNEL
The nation's health depends on the availability and efficient use of highly trained and skilled professional people. These people are in very short supply. Unless we take steps to train more physicians and more dentists, the promise of modern medicine can not be fully realized.
In an earlier message this year, I repeated my recommendation for federal aid for the construction and expansion of schools of medicine, osteopathy, dentistry and public health, and for helping talented but needy students pursue their professional education. I recommended: (1) A 10-year program of grants to plan and construct such professional schools in order to increase the nation's training capacity; and (2) a program of federal scholarship aid for talented students in need of financial assistance, plus cost-of-education payments to the schools.
The urgency of this proposal cannot be repeated too often. It takes time to construct new facilities and many years for doctors to be trained. A young man entering college this fall will not be ready to start his practice until 1972--and even later if he plans to enter a specialty. The costs of construction and operation are mounting. Only six schools of medicine have been opened in the last decade; and the number of graduates has risen only 15 percent. Over the same period, student applications to medical schools have declined sharply. Our ratio of active physicians to population is less today than it was 10 years ago, and growing worse, and in the next 10 years we shall need to expand existing medical and dental school facilities, and to construct 20 new medical and 20 new dental schools.
We must also provide financial help to talented but needy students. I have previously expressed concern over the fact that medicine is increasingly attracting only the sons and daughters of high income families-43 percent of the students in our nation's medical schools in 1959 came from the 12 percent of the United States families with an annual income of $10,000 or more.
A survey has shown that four years in medical school cost each student of the 1959 graduating class an average of $11,600. More than half of them had to borrow substantial sums to complete their education, and one-third of the group had an average debt of $5,000. Many of these students still have from one to seven years of additional professional training, at low stipends, still facing them. Obviously further loans and further debts are not the answer.
Also: modern health care is extremely complex. It demands the services of a skilled and diversified team of specialists and technical personnel.
But there are shortages in almost every category--and the shortages are particularly severe in nursing. Last year I authorized the Surgeon General of the Public Health Service to set up a consultant group on nursing, and a comprehensive study of this field is well underway. I expect to receive their report in the near future.
There is no longer any reason why American children should suffer from polio, diphtheria, whooping cough, or tetanus--diseases which can cause death or serious consequences throughout a lifetime, which can be prevented, but which still prevail in too many cases.
I am asking the American people to join in a nationwide vaccination program to stamp out these four diseases, encouraging all communities to immunize both children and adults, keep them immunized, and plan for the routine immunization of children yet to be born. To assist the States and local communities in this effort over the next 3 years, I am proposing legislation authorizing a program of federal assistance. This program would cover the full cost of vaccines for all children under five years of age. It would also assist in meeting the cost of organizing the vaccination drives begun during this period, and the cost of extra personnel needed for certain special tasks.
In addition, the legislation provides continuing authority to permit a similar attack on other infectious diseases which may become susceptible of practical eradication as a result of new vaccines or other preventive agents. Success in this effort will require the whole-hearted assistance of the medical and public health professions, and a sustained nationwide health education effort.
IV. HEALTH RESEARCH
The development of these immunization techniques was made possible by medical research, just as it has made possible the new drugs, surgical techniques and other treatments which have virtually conquered many of the leading killers of a generation ago--tuberculosis, pneumonia, rheumatic fever and many others.
But conquest of the infectious diseases, by increasing our life span has made us more vulnerable to cancer, heart disease and other long-term illnesses. Today, two persons die from heart disease and cancer in the United States every minute. Last year, more than one million Americans fell victim to these merciless diseases.
They are not merely diseases of old age. Cancer leads all other diseases as the cause of death in children under age 15. Of the ten million Americans who suffer from heart disease, more than half of them are in their most productive years, between 25 and 64.
fortunately, medical research, supported to an increasing degree over the past 15 years by the federal Government, is achieving exciting breakthroughs against both cancer and heart disease as well as on many other fronts. We can now save one out of every three victims of cancer, compared to only one out of four saved less than a decade ago. Our nationwide cancer chemotherapy program is saving many children and adults who would have been considered hopeless cases only a few years ago. And advances in heart surgery have restored to productive lives many thousands, while full prevention of many forms of heart disease seems increasingly within our reach.
We must, therefore, continue to stimulate this flow of inventive ideas by supporting medical research along a very broad front. I have proposed substantially increased funds for the National Institutes of Health for 1963, particularly for research project grants, and the training of specialists in mental health. Expenditures by the Institutes in 1963 are estimated to exceed $740 million, an increase of more than $100 million from the current year and a four-fold increase in the last 5 years. I am also renewing my recommendation that the current limitation on payment of indirect costs by the National Institutes of Health in connection with research grants to universities and other institutions be removed.
In keeping with the broadening horizons of medical research, I again recommend the establishment of a new Institute for Child Health and Human Development within the National Institutes of Health. Legislation to create this new Institute was introduced in the last session of Congress.
We look to such an Institute for a full-scale attack on the unsolved afflictions of childhood. It would explore prenatal influences, mental retardation, the effect of nutrition on growth, and other basic facts needed to equip a child for a healthy, happy life. It would, in addition, stimulate imaginative research into the health problems of the whole person throughout his entire life span--from infancy to the health problems of aging.
As a parallel action I am requesting authorization for contracts and cooperative arrangements for research related to maternal and child health and crippled children's services. This legislation, introduced in the last session of Congress, would strengthen the programs of the Children's Bureau in these areas, and foster effective coordination between the research activities of this Bureau and those of the proposed new Institute.
I also recommend that the present Division of General Medical Sciences at the National Institutes of Health be given the status and title of an Institute. This program supports fundamental research in biology and other sciences, and strengthens the research capabilities of universities and other institutions.
Last year, Congress enacted legislation temporarily extending and expanding the program of federal matching grants for the construction of health research facilities. This program has been very successful, and it should be further extended.
In these and other endeavors, including our new National Library of Medicine, we must take steps to accelerate the flow of scientific communication. The accumulation of knowledge is of little avail if it is not brought within reach of those who can use it faster and more complete communication from scientist to scientist is needed, so that their research efforts reinforce and complement each other; from researcher to practicing physician, so that new knowledge can save lives as swiftly as possible; and from the health professions to the public, so that people may act to protect their own health.
V. MENTAL HEALTH
While we have treated the physically ill with sympathy, our society has all too often rejected the mentally ill, consigning them to huge custodial institutions away from the heart of the medical community. But more recently, the signs of progress toward enlightened treatment have been increasing. The discovery and widespread use of tranquilizing drugs over the past six years has resulted in an unprecedented reduction of 32,000 patients in the census of our State mental hospitals. But one-half of our hospital beds are still occupied by the mentally ill; and hundreds of thousands of sufferers and their families are still virtually without hope for progress.
I want to take this opportunity to express my approval, and offer federal cooperation, for the action of the Governors of the 50 States at a special National Governors Conference called last November. In accepting the challenge of the report of the Joint Commission on Mental Illness and Health, they pledged a greater State effort--both to transfer treatment of the majority of mental patients from isolated institutions to modern psychiatric facilities in the heart of the community, and to provide more intensive treatment for hospitalized patients in State institutions.
But this problem cuts across state lines. Since the enactment in 1946 of the National Mental Health Act, the federal Government has provided substantial assistance for the support of psychiatric research, training of personnel and community mental health programs. The Government is currently spending over $1 billion annually for mental health activities and benefits. The National Institute of Mental Health alone will use approximately $100 million this year. Approximately $350 million is budgeted by federal agencies for the care of the mentally ill; over $500 million is spent annually in the form of pensions and compensation for veterans with neuro-psychiatric disorders; and additional sums for similar benefits are paid by the social security and other federal disability programs.
But far more needs to be done. Adequate care requires a supply of well trained personnel, working both in and out of mental hospitals. In 1946, there were only 500 psychiatric outpatient clinics in the nation. Today, there are more than 1500. More than 500,000 people received treatment in these clinics last year. We are making progress--but the total effort is still far short of the need. It will require still further federal, State and local cooperation and assistance.
I have directed the Secretary of Health, Education, and Welfare, the Secretary of Labor and the Administrator of Veterans Affairs, with the assistance of the Council of Economic Advisers and the Bureau of the Budget, to review the recommendations of the Joint Commission on Mental Illness and Health and to develop appropriate courses of action for the federal Government. They have been instructed to consider such questions as the desirable alignment of responsibility among federal, State and local agencies and private groups; the channels through which federal activities should be directed; the rate of expansion possible in the light of trained manpower availability's; and the balance which should be maintained between institutional and non-institutional programs.
Meanwhile, we must continue our vigorous support of research to learn more about the causes and treatment of mental illness. We must train many more mental health personnel. We must continue to strengthen treatment programs for federal beneficiaries through our many existing federal institutions, including St. Elizabeth's Hospital. And I have recommended added funds for the National Institute of Mental Health to increase its program for the training of professional mental health workers and physicians.
VI. MENTAL RETARDATION
The nature and extent of mental retardation is often misunderstood. It is frequently confused with mental illness. While mental illness disables after a period of normal development, mental retardation is usually either present at birth or underway during childhood. It is not a disease but a symptom of a disease, an injury, or some obscure failure of development. It refers to a lack of intellectual ability, resulting from arrested mental development, and manifesting itself in poor learning, inadequate social adjustment, and delayed achievement. Its causes are many and obscure. We are encouraged with each new discovery--but present knowledge of this condition is still so fragmentary that its prevention and cure will require continued and persistent research over an extended period of time. The present limitations of knowledge make diagnosis' extremely difficult, particularly since it involves the very young. And a major obstacle to progress is the lack of personnel trained in the special skills required to work effectively with the mentally retarded.
Thus, in spite of the progress made in recent years, mental retardation remains one of our most serious health and education problems. Approximately 5 million people in the United States are mentally retarded; and each year more than 126,000 more babies are born who will suffer from this tragic affliction.
I have asked the Panel on Mental Retardation which I appointed last year to appraise the adequacies of existing programs and the possibilities for greater utilization of current knowledge. It will review and make recommendations with regard to: (1) the personnel necessary to develop and apply new knowledge; (2) promising avenues of investigation, and the means to support and encourage research along these lines; and (3) improvement and extension of present programs of treatment, education and rehabilitation.
I expect the Panel's report before the end of this year; and we should then be ready for the next phase of the attack upon this problem. I am confident that the work of this Panel will help us chart the path toward our ultimate goal of preventing this tragic condition.
VII. TOWARD A MORE HEALTHY ENVIRONMENT
There is an increasing gap in our knowledge of the impact upon our health of the many new chemical compounds and physical and biological factors introduced daily into our environment. Every year 400 to 500 new chemicals come into use. Many of them will improve the public health. Others, regardless of every safeguard, present potential hazards. Each year there are 2 million new cases of intestinal disease. Hepatitis is at an all-time high. We need to apply additional protection against every new hazard resulting from contamination of the air we breathe or the water we drink.
As I already mentioned, the water pollution control legislation passed by the Congress last year has permitted us to step up our efforts to purify our water. We should make a similarly accelerated effort in parallel fields. I am therefore recommending:
I. Legislation to strengthen the federal effort to prevent air pollution, a growing and serious problem in many areas. Fresh air cannot be piped into the cities, nor can it be stored for future use. Our only protection is to prevent pollution.
Under the existing Air Pollution Act, the federal Government is conducting badly needed research on the biological effects of air pollution; developing improved methods for identifying, measuring, analyzing, and controlling pollution; and working with State and local officials to accelerate necessary control programs.
I recommend that the Congress enact legislation to provide:
(a) authority for an adequate research program on the causes, effects, and control of air pollution,
(b) project grants and technical assistance to State and local air pollution control agencies to assist in the development and initiation or improvement of programs to safeguard the quality of air, and
(c) authority to conduct studies and hold public conferences concerning any air pollution problem of interstate nature or of significance to communities in different parts of the Nation.
Legislation along these lines has already passed the Senate, and I urge final favorable action in this Congress.
2. In order to provide a central focal point for nationwide activities in the control of air pollution, water pollution, radiation hazards, and occupational hazards, I recommend the establishment of a National Environmental Health Center. This center will serve as the base laboratory for research and training activities, and as headquarters for Public Health Service personnel concerned with health hazards in the environment. It will facilitate regular and frequent collaboration between Public Health Service scientists and those with whom they should consult in other federal agencies. The center will serve also to encourage closer cooperation with industrial research and control groups, with universities and private foundations, and with State and local agencies.
3. Finally, I have recommended an increase in the appropriations for the study and control of water and air pollution and for research into protection against radiation peril.
VIII. ENCOURAGEMENT Of GROUP PRACTICE
Akin to the problem of increasing our overall supply of professional and technical health personnel is the problem of making more effective use of the personnel we already have. Experience in many communities has proven the value of group medical and dental practice, where general practitioners and medical specialists voluntarily join to pool their professional skills, to use common facilities and personnel, and to offer comprehensive health services to their patients. Group practice offers great promise of improving the quality of medical care, of achieving significant economies and conveniences to physician and patient alike, and of facilitating a wider and better distribution of the available supply of scarce personnel.
A major obstacle to the development of group practice, however, particularly in our smaller communities, is a lack of the specialized facilities needed. I therefore recommend legislation which will authorize a 5-year program of federal loans for construction and equipment of group practice medical and dental facilities, with priority being given to facilities in smaller communities and to those sponsored by non-profit or cooperative organizations.
IX. HEALTH Of DOMESTIC AGRICULTURAL
Domestic agricultural migrants and their families--numbering almost one million persons--have unmet health needs far greater than those of the general population. Their poor health not only affects their own lives and opportunities, but it is a threat to the members of the permanent communities through which they migrate. The poverty of these migrants, their lack of health knowledge, and their physical isolation and mobility, all tend to limit their access to community health services. To help improve their health conditions, I recommend-in addition to expanding the special Public Health Service activities directed to them--the enactment of legislation to encourage the states to provide facilities and services for migrant workers.
X. PUBLIC HEALTH SERVICE REORGANIZATION
Changes in recent years have greatly increased the responsibilities of the Public Health Service. Some major organizational changes are necessary in order to help this agency carry out its vital tasks more effectively. I will shortly forward to the Congress a proposal which will make these reorganizational changes possible. It will permit more effective administration of community health programs and those dealing with the health hazards of the environment.
OTHER HEALTH GOALS
The struggle for improved health is never-ending. While we are pressing new attacks in sectors of past neglect and present urgency, we must continue to advance along the entire front.
Health facilities Construction. I have asked the Secretary of Health, Education, and Welfare to review the program of federally aided medical facility construction, to evaluate its accomplishments and future course. Through the federal support provided by this very successful program, general medical care facilities have been constructed in most of the areas of greatest need. There are, however, large and urgent unmet requirements for facilities to provide long-term care, especially for the elderly, and short-term mental care at the community level. In addition, a growing number of existing urban hospitals require modernization so that they may continue to serve the needs of the people dependent upon them.
Health of Merchant Seamen. Over the past several years funds for the operation the Public Health Service hospitals have been substantially increased to improve the quality of medical care for merchant seamen and other beneficiaries. A start has also been made on enabling these hospitals to conduct medical research. I have directed the Secretary of Health, Education, and Welfare to develop a plan for providing more readily accessible hospital care for seamen and for improving the physical facilities of those Public Health Service hospitals which are needed to provide such care.
Physical fitness. The foundation of good health is laid in early life. Yet large numbers do not receive necessary health care as infants and school children. The alarming rate of correctable health defects among selective service registrants highlights the problem. In all 50' States there has been a gratifying response to my call of last year for vigorous programs for the physical development of our youth. Pilot projects stimulated by the President's Council on Youth Fitness proved that basic programs, within the reach of every school, can produce dramatic results. Our children must have an opportunity for physical development as well as for intellectual growth. Our increased national emphasis on physical fitness, based on daily vigorous activity and sound nutritional and health practices, should and will be continued.
International Health. Finally, it is imperative that we help fulfill the health needs and expectations of less developed nations, who look to us as a source of hope and strength in fighting their staggering problems of disease and hunger. Mutual efforts toward attaining better health will help create mutual understanding. Our foreign assistance program must make maximum use of the medical and other health resources, skills and experience of our nation in helping these nations advance their own knowledge and skill. We should, in addition, explore every possibility for scientific exchange and collaboration between our medical scientists and those of other nations-programs which are of benefit to all who participate and to all mankind.
Good health is a prerequisite to the enjoyment of "pursuit of happiness." Whenever the miracles of modern medicine are beyond the reach of any group of Americans, for whatever reason--economic, geographic, occupational or other--we must find a way to meet their needs and fulfill their hopes. For one true measure of a nation is its success in fulfilling the promise of a better life for each of its members. Let this be the measure of our nation. ♦