To the Congress of the United States:
In 1787, Thomas Jefferson wrote that, "Without health there is no happiness. An attention to health, then, should take the place of every other object."
That priority has remained fixed in both the private and public values of our society through generations of Americans since.
Our rewards have been immeasurably bountiful. "An attention to health"--of the individual, the family, the community and the nation--has contributed to the vitality and efficiency of our system as well as to the happiness and prosperity of our people.
Today, at this point in our history, we are privileged to contemplate new horizons of national advance and achievement in many sectors. But it is imperative that we give first attention to our opportunities--and our obligations--for advancing the nation's health. For the health of our people is, inescapably, the foundation for fulfillment of all our aspirations.
In these years of the 1960's, we live as beneficiaries of this century's great--and continuing--revolution of medical knowledge and capabilities. Smallpox, malaria, yellow fever and typhus are conquered in this country. Infant deaths have been reduced by half every two decades. Poliomyelitis which took 3,154 lives so recently as 1952 cost only five lives in 1964. Over the brief span of the past two decades, death rates have been reduced for influenza by 88 percent, tuberculosis by 87 percent, rheumatic fever by 90 percent.
A baby born in America today has a life expectancy half again as long as those born in the year the Twentieth Century began. The successes of the century are many. The pace of medical progress is rapid. The potential for the future is unlimited. But we must not allow the modern miracles of medicine to mesmerize us. The work most needed to advance the nation's health will not be done for us by miracles. We must undertake that work ourselves through practical, prudent and patient programs--to put more firmly in place the foundation for the healthiest, happiest and most hopeful society in the history of man.
Our first concern must be to assure that the advance of medical knowledge leaves none behind. We can--and we must-strive now to assure the availability of and accessibility to the best health care for all Americans, regardless of age or geography or economic status.
With this as our goal, we must strengthen our nation's health facilities and services, assure the adequacy and quality of our health manpower, continue to assist our States and communities in meeting their health responsibilities, and respond alertly to the new hazards of our new and complex environment.
We must, certainly, continue and intensify our health research and research facilities. Despite all that has been done, we cannot be complacent before the facts that:
--Forty-eight million people now living will become victims of cancer.
--Nearly 15 million people suffer from heart disease and this, together with strokes, accounts for more than half the deaths in the United States each year.
--Twelve million people suffer arthritis and rheumatic disease and 10 million are burdened with neurological disorders.
--Five and one-half million Americans are afflicted by mental retardation and the number increases by 126,000 new cases each year.
In our struggle against disease, great advances have been made, but the battle is far from won. While that battle will not end in our lifetime--or anytimes to come--we have the high privilege and high promise of making longer strides forward now than any other generation of Americans.
The measures I am outlining today will carry us forward in the oldest tradition of our society--to give "an attention to health" for all our people. Our advances, thus far, have been most dramatic in the field of health knowledge. We are challenged now to give attention to advances in the field of health care--and this is the emphasis of the recommendations I am placing before you at this time.
I. REMOVING BARRIERS TO HEALTH CARE In this century, medical scientists have done much to improve human health and prolong human life. Yet as these advances come, vital segments of our populace are being left behind--behind barriers of age, economics, geography or community resources. Today the political community is challenged to help all our people surmount these needless barriers to the enjoyment of the promise and reality of better health.
A. Hospital Insurance for the Aged
Thirty years ago, the American people made a basic decision that the later years of life should not be years of despondency and drift. The result was enactment of our Social Security program, a program now fixed as a valued part of our national life. Since World War II, there has been increasing awareness of the fact that the full value of Social Security would not be realized unless provision were made to deal with the problem of costs of illnesses among our older citizens.
I believe this year is the year when, with the sure knowledge of public support, the Congress should enact a hospital insurance program for the aged.
The facts of the need are well and widely known.
--Four out of five persons 65 or older have a disability or chronic disease.
--People over 65 go to the hospital more frequently and stay twice as long as younger people.
--Health costs for them are twice as high as for the young.
Where health insurance is available it is usually associated with an employer-employee plan. However, since most of our older people are not employed they are usually not eligible under these plans.
--Almost half of the elderly have no health insurance at all.
--The average retired couple cannot afford the cost of adequate health protection under private health insurance.
I ask that our Social Security system-proved and tested by three decades of successful operation--be extended to finance the cost of basic health services. In this way, the specter of catastrophic hospital bills can be lifted from the lives of our older citizens. I again strongly urge the Congress to enact a hospital insurance program for the aged. Such a program should:
--Be financed under social security by regular, modest contributions during working years;
--Provide protection against the costs of hospital and post-hospital extended care, home nursing services, and outpatient diagnostic services;
--Provide similar protection to those who are not now covered by social security, with the costs being paid from the administrative budget;
--Clearly indicate that the plan in no way interferes with the patient's complete freedom to select his doctor or hospital.
Like our existing social security cash retirement benefits, this hospital insurance plan will be a basic protection plan. It should cover the heaviest cost elements in serious illnesses. In addition, we should encourage private insurance to provide supplementary protection.
I consider this measure to be of utmost urgency. Compassion and reason dictate that this logical extension of our proven social security system will supply the prudent, feasible and dignified way to free the aged from the fear of financial hardship in the event of illness.
Also, I urge all States to provide adequate medical assistance under the existing Kerr-Mills program for the aged who cannot afford to meet the noninsured costs.
B. Better Health Services for Children and Youth
America's tradition of compassion for the aged is matched by our traditional devotion to our most priceless resource of all--our young. Today, far more than many realize, there are great and growing needs among our children for better health services.
--Acute illness strikes children under 15 nearly twice as frequently as it does adults.
--One in 5 children under age 17 is afflicted with a chronic ailment.
--Three out of every 100 children suffer some form of paralysis or orthopedic impairment.
--At least 2,000,000 children are mentally retarded, with a higher concentration of them from poor families.
--Four million children are emotionally disturbed.
--At age 15, the average child has more than 10 decayed teeth.
If the health of our Nation is to be substantially improved in the years to come, we must improve the care of the health of our 75 million preschool and school-age children and youth.
There is much to do if we are to make available the medical and dental services our rising generation needs. Nowhere are the needs greater than for the 15 million children of families who live in poverty.
--Children in families with incomes of less than $2,000 are able to visit a doctor only half as frequently as those in families with incomes of more than $7,000.
--Public assistance payments for medical services to the 3 million needy children receiving Dependent Children's benefits throughout the Nation average only $2.80 a month, and in some States such medical benefits are not provided at all.
--Poor families increasingly are forced to turn to overcrowded hospital emergency rooms and to overburdened city clinics as their only resource to meet their routine health needs.
Military entrance examinations reveal the consequences. Half of those rejected cannot pass the medical tests. Three-fourths of them would benefit from treatment, and earlier treatment would greatly increase recovery and decrease life-long disability.
The States and localities bear the major responsibility for providing modern medical care to our children and youth. But the Federal Government can help. I recommend legislation to:
--Increase the authorizations for maternal and child health and crippled children's services, earmarking funds for project grants to provide health screening and diagnosis for children of preschool and school age, as well as treatment and follow-up care services for disabled children and youth. This should include funds to help defray the operational costs of university-affiliated mental retardation clinical centers. Provisions should also be made for the training of personnel who will operate medical facilities for children.
--Broaden the public assistance program to permit specific Federal participation in paying costs of medical and dental care for children in medically needy families, similar to the Kerr-Mills program for the aged.
--Extend the grant programs for (a) family health services and clinics for domestic agricultural migratory workers and their children and (b) community vaccination assistance.
C. Improved Community Mental Health Services
Mental illness afflicts one out of ten Americans, fills nearly one-half of all the hospital beds in the Nation, and costs $3 billion annually. Fortunately, we are entering a new era in the prevention, treatment, and care of mental illness. Mere custodial care of patients in large, isolated asylums is clearly no longer appropriate. Most patients can be cared for and cured in their own communities.
An important beginning toward community preparation has been made through the legislation enacted by the 88th Congress authorizing aid for constructing community mental health centers. But facilities alone cannot assure services.
--It has been estimated that at least 10,000 more psychiatrists are needed.
--Few communities have the funds to support adequate programs, particularly during the first years.
--Communities with the greatest needs hesitate to build centers without being able to identify the source of operating funds.
--Most of the people in need are children, the aged, or patients with low incomes.
I therefore recommend legislation to authorize a 5-year program of grants for the initial costs of personnel to man community mental health centers which older comprehensive services.
D. A New Life for the Disabled
Today, we are rehabilitating about 120,000 disabled persons each year. I recommend a stepped-up program to overcome this costly waste of human resources. My 1966 budget will propose increased funds to rehabilitate an additional 25,000.
Our goal should be at least 200,000 a year. I recommend legislation to authorize:
--Project grants to help States expand their services.
--Special Federal matching so that rehabilitative services can be provided to a greater number of the mentally retarded and other seriously disabled individuals.
--Construction and modernization of workshops and rehabilitation centers.
II, STRENGTHENING THE NATION'S HEALTH FACILITIES AND SERVICES In our urbanized society today, the availability of health care depends uniquely upon the availability and accessibility of modern facilities, located in convenient and efficient places, and on well organized and adequately supported services. The lack of such facilities and services is, of itself, a barrier to good health care.
A. Multi-purpose Regional Medical Complexes
In this century, we have made more advance than in all other centuries toward overcoming diseases which have taken the heaviest toll of human life. Today we are challenged to meet and master the three killers which alone account for 7 out of 10 deaths in the United States each year--heart disease, cancer and stroke. The Commission on Heart Disease, Cancer and Stroke has pointed the way for us toward that goal.
The newest and most effective diagnostic methods and the most recent and most promising methods of treatment often require equipment or skills of great scarcity and expense such as,
--open heart surgery,
--advanced and very high voltage radiation therapy,
--advanced disease detection methods.
It is not necessary for each hospital or clinic to have such facilities, equipment, or services, but it is essential that every patient requiring such specialized and expensive procedures and services have access to them. Multi-purpose medical complexes can meet these needs. They would:
--speed the application of research knowledge to patient care, so as to turn otherwise hollow laboratory triumphs into health victories,
--save thousands of lives now needlessly taken annually by the three great killers-heart disease, cancer and stroke--and by other major diseases.
A plan to improve our attack upon these major causes of death and disability should become a part of the fabric of our regional and community health services. The services provided under this plan will help the practicing physician keep in touch with the latest medical knowledge and by making available to him the latest techniques, specialized knowledge, and the most efficient methods.
To meet these objectives, such complexes should:
--Be regional in scope.
--Provide services for a variety of diseases--heart disease, cancer, stroke, and other major illnesses.
--Be affiliated with medical schools, teaching hospitals and medical centers.
--Be supported by diagnostic services in community hospitals.
--Provide diagnosis and treatment of patients, together with research and teaching in a coordinated system.
--Permit clinical trial of advanced techniques and drugs.
Medical complexes--consisting of regional organizations of medical schools, teaching hospitals, and treatment centers tied into community diagnostic and treatment facilities-represent a new kind of organization for providing coordinated teaching, research and patient care. When we consider that the economic cost of heart disease alone amounts to 540,000 lost man years annually-worth some $2.5 billion--the urgency and value of effective action is unmistakable.
Action on this new approach, stemming from recommendations of the Commission on Heart Disease, Cancer and Stroke, will provide significant improvements in many fields of medicine.
I recommend legislation to authorize a 5-year program of project grants to develop multi-purpose regional medical complexes for an all out attack on heart disease, cancer, stroke, and other major diseases.
B. Improved Services for the Mentally Retarded
Mental retardation in any individual is a life-long problem of the most serious nature for the family and for the community. But we know today that the problem need not and must not lead to tragic hopelessness. Much is being done to provide a decent, dignified place in society for these unfortunate individuals.
The 88th Congress provided a substantial foundation for building an effective national program for the prevention of mental retardation and care of the mentally retarded. Under this authority, grants are authorized:
--For construction of mental retardation research centers, community mental retardation centers, and university-affiliated mental retardation centers.
--For planning by all the States of comprehensive action to combat mental retardation at the State and community levels.
The 1966 budget includes $282 million-a $40 million increase--for these programs and other mental retardation services, including preventive activities and the training of teachers of the retarded. I urge that this full amount be appropriated.
Extensive resources and programs need to be developed in the States and communities to prevent mental retardation and to care for the mentally retarded. The existing authority for planning grants will end on June 30, 1965. The developmental needs and effective utilization of the construction grants require follow-up action.
I recommend the enactment of mental retardation program development grants for 2 additional years to help the States continue this essential work.
C. Modernization of Health Facilities
Great progress has been made throughout the Nation in the provision of new general hospitals under the Hill-Burton program. But relatively little assistance has been available for modernization of the older hospitals, found particularly in our large cities. Without aid, deterioration threatens and rapid scientific and technical change is passing by these essential links to health care for millions of our people.
The 1966 Budget will include funds for a greatly increased hospital modernization effort as well as for expansion in the number and quality of nursing homes. I urge the Congress to approve the full amount requested for each of these purposes.
D. Aid for Group Practice Facilities
New approaches are needed to stretch the supply of medical specialists and to provide a wider range of medical services in the communities. The growth of voluntary, comprehensive group practice programs has demonstrated the feasibility of grouping health services for the mutual benefit of physicians and patients by:
--Integrating the burgeoning medical specialties into an efficient and economical system of patient care.
--Reducing the incidence of hospitalization which may now occur because there are few alternative centers for specialized care.
The initial capital requirements for group practice are substantial, and funds are not now sufficiently available to stimulate the expansion and establishment of group practice. To facilitate and encourage this desirable trend, I recommend legislation to authorize a program of direct loans and loan guarantees to assist voluntary associations in the construction and equipping of facilities for comprehensive group practice.
III. MANPOWER FOR THE HEALTH SERVICES The advance of our nation's health in this century has, in the final measure, been possible because of the unique quality and fortunate quantity of men and women serving in our health professions. Americans respect and are grateful for our doctors, dentists, nurses, and others who serve our nation's health. But it is clear that the future requires our support now to increase the quantity and assure the continuing high quality of such vital personnel.
In all sectors of health care, the need for trained personnel continues to outstrip the supply:
--At present, the United States has 290,000 physicians. In a decade, we shall need 346,000.
Today we are keeping pace with our needs largely because of the influx of numbers of foreign-trained doctors. Last year 1600 came into the United States, the equivalent of the output from 16 medical schools and 21% of our medical school graduates.
--Population growth has badly outpaced the increase in dentists and the shortage of dentists is now acute.
To begin to meet the Nation's health needs, the number of new physicians graduated each year must increase at least 50 percent by 1975, and the output of new dentists by too percent.
The Health Professions Educational Assistance Act of 1963, authorizing grants to schools for construction of medical and other health education schools and loans to students, will help meet this problem. The magnitude of the need is demonstrated by the response:
--90 applications have been received from medical and dental schools, requesting $247 million in Federal aid for construction.
--Only $700 million is available in 1965; and the full authorization for 1966, which I will shortly request in the budget I am submitting, will provide $75 million more.
In the light of these needs, l urge the Congress to appropriate the lull amount authorized and requested for the Health Professions Educational Assistance Act Program.
While we must build new medical and dental schools, we must also retain and sustain the ones we have. To be neglectful of such schools would be wasteful folly.
We must face the fact that high operating costs and shortages of operating funds are jeopardizing our health professions educational system. Tuition and fees paid by medical and dental students meet less than half the institutional costs of their education. Several underfinanced medical and dental schools are threatened with failure to meet educational standards. New schools are slow to start, even when construction funds are available due to lack of operating funds.
I therefore recommend legislation to authorize:
--formula grants to help cover basic operating costs of our health profession schools in order that they may significantly expand both their capacity and the quality of their educational programs.
--project grants to enable health profession schools to experiment and demonstrate new and improved educational methods.
Traditionally, our medical profession has attracted outstanding young talent and we must be certain that this tradition is not compromised. We must draw the best available talent into the medical profession. Half of last June's medical school graduates came from families with incomes of over $10,000 a year. The high costs of medical school must not deny access to the medical profession for able youths from low and middle income families.
l therefore recommend legislation to authorize scholarships for medical and dental students who would otherwise not be able to enter or complete such training.
Looking to the Future
We must also look to the future in planning to meet the health manpower requirements of the Nation.
Unmet health needs are already large. American families are demanding and expecting more and better health services. In the past decades the proportion of our gross national product devoted to health has increased by more than 5%. The trend is still upward. If we are to meet our future needs and raise the health of the nation, we must:
--improve utilization of available professional health personnel;
--expand the use and training of technicians and ancillary health workers through special schools and under the Vocational Education Act and Manpower Development and Training Act programs;
--expand and improve training programs for professional and for supporting health personnel;
--plan ahead to meet requirements for which the lead time is often 10 years or more.
With these objectives in mind, I have asked the Secretary of Health, Education, and Welfare to develop a long-range health manpower program for the Nation and to recommend to me the steps which should be taken to put it into effect.
IV. HEALTH RESEARCH AND RESEARCH FACILITIES Two decades ago this nation decided that its Government should be a strong supporter of the health research to advance the well being of its people. This year that support amounts to more than two-thirds of the total national expenditure of $1.5 billion for health research.
Continued growth of this research is necessary and the 1966 Budget includes: --10% growth in expenditures for health research and for the related training.
--Funds to begin an automated system for processing the exploding volume of information on drugs and other chemicals related to health.
Health research, no less than patient care, requires adequate facilities. Over the past 8 years the Health Research Facilities Act has been highly successful in helping provide research facilities to universities and other nonprofit institutions. Federal grants of $320 million to 990 construction projects have generated over $500 million in matching institutional dollars.
This authority expires on June 30, 1966, and I recommend that it be extended for five years with an increased authorization and with a larger Federal share for specialized research facilities of a national or regional character.
V. HEALTH GRANTS AND PROTECTION MEASURES Our complex modern society is creating health hazards never before encountered. The pollution of our environment is assuming such important proportion I shall shortly send to the Congress a special message dealing with this challenge.
But the protection of the public health also requires action on other fronts.
A. Health Grants to Communities and States
In safeguarding and advancing the nation's health, States and communities have long had special responsibilities. General and special purpose health grants have proved an effective means of strengthening the Federal Government's partnership with them in improving the public health.
I have directed the Secretary of Health, Education, and Welfare to study these programs thoroughly and to recommend to me necessary legislation to increase their usefulness.
Authorizations for many of these programs expire at the close of fiscal year 1966. So that a thorough review may be made, I recommend that the Congress extend the authorizations through June 30, 1967.
B. Consumers Health Protection
Modernization of the Federal Food, Drag and Cosmetic Act is imperative if our health protection program is to keep pace with the technological and industrial advances of recent years.
The health of all Americans depends on the reliability and safety of the products of the:
--food industry which alone generates nearly $100 billion in retail sales each year.
--drug industry with sales reaching $6 billion.
--cosmetic industry which markets $2.5 billion of products.
All must be operated under the highest standards of purity and safety.
Yet, despite recent improvements in food and drug legislation, serious gaps in our ability to protect the consumer still exist. The law should be strengthened to provide adequate authority in the regulation of nonprescription drugs, medical devices, cosmetics, and food.
Narcotics are not alone among the hazardous, habit-forming drugs subject to improper use. Barbiturates, amphetamines, and other drugs have harmful effects when improperly used. Widespread traffic resulting from inadequate controls over the manufacture, distribution, and sale of these drugs is creating a growing problem which must be met. We must also counter the threat from counterfeit drugs.
I recommend legislation to bring the production and distribution of barbiturates, amphetamines, and other psycho-toxic drugs under more effective control.
For the fuller protection of our families, I recommend legislation to require:
--Adequate labeling of hazardous substances.
--Safety regulation of cosmetics and therapeutic devices by pre-marketing examination by the Food and Drug Administration.
--Authority to seize counterfeit drugs at their source.
CONCLUSION I believe we have come to a rare moment of opportunity and challenge in the evolution of our society. In the message I have presented to you--and in other messages I shall be sending--my purpose is to outline the attainable horizons of a greater society which a confident and prudent people can begin to build for the future.
Whatever we aspire to do together, our success in those enterprises--and our enjoyment of the fruits that result--will rest finally upon the health of our people. We cannot and we will not overcome all the barriers--or surmount all the obstacles--in one effort, no matter how intensive. But in all the sectors I have mentioned we are already behind our capability and our potential. Further delay will only compound our problems and deny our people the health and happiness that could be theirs.
The Eighty-eighth Congress wrote a proud and significant record of accomplishment in the field of health legislation. I have every confidence that this Congress will write an even finer record that will be remembered with honor by generations of Americans to Come,
LYNDON B. JOHNSON
The White House
January 7, 1965