Special Message to the Congress on the Nation's Health

To the Congress of the United States:

The American people are not satisfied with better-than-average health. As a Nation, they want, they need, and they can afford the best of health:

--not just for those of comfortable means.

--but for all our citizens, old and young, rich and poor.

In America,

--There is no need and no room for second-class health services.

--There is no need and no room for denying to any of our people the wonders of modern medicine.

--There is no need and no room for elderly people to suffer the personal economic disaster to which major illness all too commonly exposes them.

In seeking health improvements, we build on the past. for in the conquest of ill health our record is already a proud one:

--American medical research continues to score remarkable advances.

--We have mastered most of the major contagious diseases.

--Our life expectancy is increasing steadily.

--The overall quality of our physicians, dentists, and other health workers, of our professional schools, and of our hospitals and laboratories is unexcelled.

--Basic health protection is becoming more and more broadly available.

Federal programs have played a major role in these advances:

--Federal expenditures in the fiscal 1965 budget for health and health-related programs total $5.4 billion--about double the amount of 8 years ago.

--Federal participation and stimulus are partly responsible for the fact that last year--in 1963--the Nation's total health expenditures reached an unprecedented high of $34 billion, or 6 percent of the gross national product.

But progress means new problems:

--As the life span lengthens, the need for health services grows.

--As medical science grows more complex, health care becomes more expensive.

--As people move to urban centers, health hazards rise.

--As population, which has increased 27 percent since 1950, continues to grow, a greater strain is put on our limited supply of trained personnel.

Even worse, perhaps, are those problems that reflect the unequal sharing of the health services we have:

--Thousands suffer from diseases for which preventive measures are known but not applied.

--Thousands of babies die needlessly; 9 other nations have lower infant death rates than ours.

--Half of the young men found unqualified for military service are rejected for medical reasons; most of them come from poor homes.

Clearly, too many Americans still are cut off by low incomes from adequate health services. Too many older people are still deprived of hope and dignity by prolonged and costly illness. The linkage between ill-health and poverty in America is still all too plain.

In its first session, the 88th Congress made some important advances on the health front:

--It acted to increase our supply of physicians and dentists.

--It began a Nation-wide attack on mental illness and mental retardation.

--And it strengthened our efforts against air pollution.

But our remaining agenda is long, and it will be unfinished until each American enjoys the full benefits of modern medical knowledge.

Part of this agenda concerns a direct attack on that particular companion of poor health--poverty. Above all, we must see to it that all of our children, whatever the economic condition of their parents, can start life with sound minds and bodies.

My message to the Congress on poverty will set forth measures designed to advance us toward this goal.

In today's message, I present the rest of this year's agenda for America's good health.

I. HOSPITAL INSURANCE FOR THE AGED THE AGENDA

Nearly thirty years ago, this Nation took the first long step to meet the needs of its older citizens by adopting the Social Security program. Today, most Americans look toward retirement with some confidence that they will be able to meet their basic needs for food and shelter.

But many of our older citizens are still defenseless against the heavy medical costs of severe illness or disability:

--One-third of the aged who are forced to ask for old age assistance do so because of ill health, and one-third of our public assistance funds going to older people is spent for medical care.

--For many others, serious illness wipes out savings and carries their families into poverty.

--For these people, old age can be a dark corridor of fear.

The irony is that this problem stems in part from the surging progress in medical science and medical techniques--the same progress that has brought longer life to Americans as a whole.

Modern medical care is marvelously effective-but increasingly expensive.

--Daily hospital costs are now four times as high as they were in 1946--now averaging about $37 a day.

--In contrast, the average Social Security benefit is just $77 a month for retired workers and $67 a month for widows.

Existing "solutions" to these problems are (1) private health insurance plans and (2) welfare medical assistance. No one of them is adequate, nor are they in combination:

--Private insurance, when available, usually costs more than the average retired couple can afford.

--Welfare medical assistance for the aged is not available in many States--and where it is available, it includes a needs test to which older citizens, with a lifetime of honorable, productive work behind them, should not be subjected.

This situation is not new.

For more than a decade we have failed to meet the problem.

There is a sound and workable solution. Hospital insurance based on Social Security payments is clearly the best method of meeting the need. It is a logical extension of the principle--established in 1935 and confirmed time after time by the Congress--that provision should be made for later years during the course of a lifetime of employment. Therefore:

I recommend a hospital insurance program for the aged aimed at two basic goals:

First, it should protect against the heaviest costs of a serious illness--the costs of hospital and skilled nursing home care, home health services, and outpatient hospital diagnostic services.

Second, it should provide a base that related private programs can supplement.

To achieve these goals:

1. These benefits should be available to everyone who reaches 65.

2. Benefit payments should cover the cost of services customarily furnished in semiprivate accommodations in a hospital, but not the cost of the services of personal physicians.

3. The financing should be soundly funded through the Social Security system.

4. One-quarter of one percent should be added to the Social Security contribution paid by employers and by employees.

5. The annual earnings subject to Social Security taxes should be increased from $4,800 to $5,200.

6. for those not now covered by Social Security, the cost of similar protection would be provided from the administrative budget.

Under this proposal, the costs of hospital and related services can be met without any interference whatever with the method of treatment. The arrangement would in no way hinder the patient's freedom to choose his doctor, hospital, or nurse.

The only change would be in the manner in which individuals would finance the hospital costs of their later years. The average worker under Social Security would contribute about a dollar a month during his working life to protect himself in old age in a dignified manner against the devastating costs of prolonged hospitalization.

Hospitalization, however, is not the end of older people's medical needs. Many aged individuals will have medical expenses that will be covered neither by social security, hospital insurance nor by private insurance.

Therefore, I urge all States to adopt adequate programs of medical assistance under the Kerr-Mills Legislation. This assistance is needed now. And it will be needed later as a supplement to hospital insurance.

II. HEALTH FACILITIES

Good health is the product of well-trained people working in modern and efficient hospitals and other facilities.

Extension and Expansion of Hill-Burton Program

We can be proud of the many fine hospitals throughout the country which were made possible in the last 16 years by the Hill-Burton program of federal aid.

But there is more still to be done:

--too often a sick patient must wait until a hospital bed becomes available;

--too many hospitals are old and poorly equipped;

--new kinds of facilities are needed to care for the aged and the chronically ill.

I recommend that the Hill-Burton program--scheduled to end on June 30, 1964--be extended for an additional five years including the amendments outlined below.

1. Planning

Hospital care costs too much to permit duplication, inefficiency, or extravagance in building and locating hospitals. Individual hospitals and other health facilities should be located where they are most needed. Together, these facilities in a community should provide the services needed by its citizens. This means planning. Therefore:

(a) I recommend that the Congress authorize special grants to public and nonprofit agencies to assist them in developing comprehensive area, regional, and local plans for health and related facilities.

(b) I also recommend that limited matching funds be made available to help State agencies meet part of their costs of administering the Hill-Burton program, so that these agencies can plan wisely for our hospital systems.

2. Modernization

The Hill-Burton program has done much to help build general hospitals where they were most needed when the program began--particularly in rural areas.

While rural and suburban areas have been acquiring modern facilities, city hospitals have become more and more obsolete and inefficient. Yet city hospitals are largely responsible

--for applying the latest discoveries of medical science;

--for teaching the new generations of practitioners;

--for setting the pace and direction in care of the sick.

They must have adequate facilities.

A recent study showed that it would cost $3.6 billion to modernize and replace existing antiquated facilities--more than three times our annual expenditures for construction of all health facilities.

The present Hill-Burton Act cannot meet this critical need. further neglect will only aggravate the problem. Therefore:

(c) I recommend that the Act be amended to authorize a new program of grants to help public and nonprofit agencies modernize or replace hospital and related health facilities.

3- Long-Term Care facilities

Our lengthening life span has brought with it an increase in chronic diseases. This swells our need for long-term care facilities.

We have been making some progress in meeting the backlog of demand for nursing homes and chronic disease hospitals. But there is still a deficit of over 500,000 beds for the care of long-term patients.

This is a national health problem.

Our communities need better and more facilities to deal with prolonged illness, and to make community planning of these facilities more effective. Therefore:

(d) I recommend that the separate grant programs for chronic disease hospitals and nursing homes be combined into a single category of long-term care facilities. The annual appropriation for the combined categories should be increased from $40 million to $70 million.

4. Mortgage Insurance

Raising funds to build health facilities is a problem for almost every community:

--Federal aid is not always obtainable.

--States must set priorities for hospital projects which are to receive federal aid; many worthwhile projects necessarily fail to win approval.

--Nonprofit agencies often have great difficulty raising local funds to match federal grants.

--Loans available from private lenders often call for large annual payments and short payoff periods. This can either threaten a hospital's financial soundness or lead to excessive increases in the cost of hospital care.

These financing difficulties do not alter the fact that the need for hospital beds is increasing. Therefore:

(e) I recommend amendment of the Hill-Burton Act to permit mortgage insurance of loans with maturities up to 40 years to help build private nonprofit hospitals, nursing homes, and other medical facilities.

(f) In addition, I recommend that authority to insure mortgage loans for the construction of nursing homes operated for profit be transferred from the federal Housing Administration to the Public Health Service.

These changes will help us build more hospitals and other medical facilities. And they will bring together in the Public Health Service an adequate and inter-locking program of federal aid to profit-making--as well as nonprofit--nursing homes, hospitals, and other facilities.

Encouragement of Group Practice

To meet the needs of their communities, groups of physicians--general practitioners and specialists--more and more are pooling their skills and using the same buildings, equipment, and personnel to care for their patients.

--This is a sound and practical approach to medical service.

--It provides better medical care, yet it yields economies which can be passed on to the consumer.

--It makes better use of scarce professional personnel.

--It offers benefits to physicians, patients, and the community.

The specialized facilities and equipment needed for group practice are often not available, especially in smaller communities. Therefore:

I recommend legislation to authorize a 5-year program of federal mortgage insurance and loans to help build and equip group practice medical and dental facilities.

Priority should be given to facilities in smaller communities, and to those sponsored by nonprofit or cooperative organizations.

III. HEALTH MANPOWER

Medical science has grown vastly more complex in recent years--and its potential for human good has grown accordingly. But to convert its potential into actual good requires an ever-growing supply of ever-better trained medical manpower.

--The quantity and quality of education for the health disciplines has been unable to keep pace.

--Shortages of medical manpower are acute.

By enacting the Health Professions Educational Assistance Act of 1963, the Congress took a major step to close this gap in medical manpower, especially as it relates to physicians and dentists.

But the task is far from finished.

A Stronger Nursing Profession

The rapid development of medical science places heavy demands on the time and skill of the physician. Nurses must perform many functions that once were done only by doctors.

A panel of expert advisors to the Public Health Service has recommended that the number of professional nurses be increased from the current total of 550,000 to 680,000 by 1970.

This requires raising nursing school enrollments by 75 percent.

But larger enrollments alone are not enough. The efficiency of nursing schools and the quality of instruction must be improved. The nursing profession, too, is becoming more complex and exacting.

The longer we delay, the larger the deficit grows, and the harder it becomes to overcome it.

I recommend the authorization of grants to build and expand schools of nursing, to help the schools perfect new teaching methods, and to assist local, State and regional planning for nursing service.

We must remove financial barriers for students desiring to train for the nursing profession and we must attract highly talented youngsters.

I therefore recommend federal loans and a national competitive merit scholarship program. for each year of service as a nurse up to 6 years a proportion of the loan should be forgiven.

In addition, I recommend continuation and expansion of the Professional Nurse Traineeship Program to increase the number of nurses trained for key supervisory and teaching positions.

Federal action alone is not enough:

--State and local governments, schools, hospitals, the health professions, and private citizens all have a big stake in solving the nursing shortage.

--Each must take on added responsibilities if the growing demand for essential and high quality nursing services is to be met.

Strengthened Training in Public Health

Our State and local public health agencies are attempting to cope with mounting problems, but with inadequate resources.

Our population has risen 27 percent since 1950, and public health problems have become more complex. But there are fewer public health physicians today than in 1950. The number of public health engineers has increased by only a small fraction; and other essential public health disciplines are in short supply.

These shortages have weakened health protection measures in many communities.

The situation would be much worse than it is, but for two Public Health Service training programs:

(1) the program of public health traineeships;

(2) the complementary program of project grants to schools of public health, nursing, and engineering--designed to help strengthen graduate or specialized public health training.

The need for these programs is greater today than ever before.

I recommend that the Public Health Traineeship program and the project grant program for graduate training in public health be expanded and extended until 1969.

IV. MENTAL HEALTH AND MENTAL RETARDATION

Mental illness is a grave problem for the Nation, for the community, and for the family it strikes. It can be dealt with only through heroic measures. It must be dealt with generously and effectively.

Last year, President Kennedy proposed legislation to improve the Nation's mental health and to combat mental retardation.

Congress promptly responded. State and local governments and private organizations joined in that response.

The Congress enacted legislation which should enable us to reduce substantially the number of patients in existing custodial institutions within a decade, through comprehensive community-based mental health services.

Under new legislation passed last year we will train teachers and build community centers for the care and treatment of the mentally handicapped.

It was, as President Kennedy said, "the most significant effort that the Congress of the United States has ever undertaken" on behalf of human welfare and happiness.

We are now moving speedily to put this legislation into effect.

The mentally ill and the mentally retarded have a right to a decent, dignified place in society. I intend to assure them of that place.

The Congress has demonstrated its awareness of the need for action by approving my request for supplemental appropriations for mental retardation programs in the current fiscal year.

This will enable us to get started.

My 1965 budget includes a total of $467 million for the National Institute of Mental Health and for mental retardation activities.

I urge the Congress to approve the full amount requested.

Technological progress is not always an unmixed blessing.

To be sure, we have a wealth of new products, unimagined a few generations ago, that make life easier and more rewarding.

But these benefits sometimes carry a price in the shape of new hazards to our health:

--The air we breathe is being fouled by our great factories, our myriad automobiles and trucks, our huge urban centers.

--The pure water we once took for granted is being polluted by chemicals and foreign substances.

--The pesticides indispensable to our farmers sometimes introduce chemicals whose long-range effects upon man are dimly understood.

We must develop effective safeguards to protect our people from hazards in the air we breathe, the water we drink, and the food we eat.

To provide a focal point for vigorous research, training, and control programs in environmental health, I have requested funds in the 1965 budget to develop plans for additional facilities to house our expanding federal programs concerned with environmental health.

The Clean Air Act, which I approved last December 17, commits the federal Government for the first time to substantially increased responsibilities in preventing and controlling air pollution.

I urge prompt action on the supplemental appropriation to finance this new authority in the current fiscal year.

Pesticides

The President's Science Advisory Committee report on Pesticides, released last May, alerted the country to the potential health dangers of pesticides.

To act without delay:

I have submitted requests to the Congress for additional funds for 1964 and 1965 for research on the effects of pesticides on our environment.

I recommend enactment of pending legislation prohibiting the registration and marketing of pesticides until a positive finding of safety has been made.

In addition, the Department of Agriculture, working with the Departments of Health, Education, and Welfare and of the Interior, is reviewing and revising procedures to make certain that the benefits and hazards of pesticides to human health, domestic animals, and wildlife are considered fully before their registration and sale are approved.

finally, the federal Government's own use and application of pesticides are being reviewed to assure that all safeguards are applied.

Foods, Drugs, and Cosmetics

The 1962 amendments to the Federal Food, Drug and Cosmetic Act will enhance the safety, the effectiveness, the reliability of drugs and cosmetics.

To give this Act the vigorous enforcement it contemplates, I am requesting increased appropriations to the food and Drug Administration, largely for scientific and regulatory personnel.

In addition, I renew the recommendations contained in my Consumer Message for new legislation to extend and clarify the food, Drug and Cosmetic laws.

VI. RESEARCH AND SPECIAL HEALTH NEEDS

Over the past decade, our Nation has developed an unparalleled program of medical research.

This investment has already paid rich dividends, and more dividends are within reach.

The budget that I have proposed for fiscal 1965 assures the rate of growth needed to meet current opportunities and to provide a sound base for future progress.

In addition, the Office of Science and Technology has assembled a group of eminent citizens to study thoroughly the medical research and training programs of the National Institutes of Health.

This study should point to new ways to improve our medical research.

Commission on Heart Disease, Cancer, and Strokes

Cancer, heart disease, and strokes stubbornly remain the leading causes of death in the United States. They now afflict 15 million Americans--two-thirds of all Americans now living will ultimately suffer or die from one of them.

These diseases are not confined to older people.

--Approximately half of the cases of cancer are found among persons under 65.

--Cancer causes more deaths among children under age 15 than any other disease.

--More than half the persons suffering from heart disease are in their most productive years.

--Fully a third of all persons with recent strokes or with paralysis due to strokes are under 65.

The Public Health Service is now spending well over a quarter of a billion dollars annually finding ways to combat these diseases. Other organizations, both public and private, also are investing considerable amounts in these efforts.

The flow of new discoveries, new drugs and new techniques is impressive and hopeful.

Much remains to be learned. But the American people are not receiving the full benefits of what medical research has already accomplished. In part, this is because of shortages of professional health workers and medical facilities. It is also partly due to the public's lack of awareness of recent developments and techniques of prevention and treatment.

I am establishing a Commission on Heart Disease, Cancer, and Strokes to recommend steps to reduce the incidence of these diseases through new knowledge and more complete utilization of the medical knowledge we already have.

The Commission will be made up of persons prominent in medicine and public affairs. I expect it to complete its study by the end of this year and submit recommendations for action.

Narcotics and Drug Abuse

Abuse of drugs and traffic in narcotics are a tragic menace to public health.

To deal promptly and intelligently with this situation we must take effective measures of

education,

regulation,

law enforcement,

rehabilitation.

We must strengthen the cooperative efforts of federal, State and local authorities and public services.

The recent report of the Presidential Advisory Commission on Narcotics and Drug Abuse has rendered signal contributions:

--It places the problem in its proper perspective.

--It proposes policies and actions which deserve full consideration.

The appropriate federal departments and agencies will review this report, and I shall at a later time send my recommendations to the Congress.

Vocational Rehabilitation

Disability--always a cruel burden--has partly succumbed to medical progress. Our Federal--State program of vocational rehabilitation has been demonstrating this fact for more than 40 years. Rehabilitation can help restore productivity and independence to millions of Americans who have been victims of serious illness and injury. Over 110,000 disabled men and women were returned to activity and jobs last year alone.

If more fully developed and supported by the States and the federal Government, this program can be a powerful tool in combatting poverty and unemployment among the millions of our citizens who face vocational handicaps which they cannot surmount without specialized help.

I have already recommended appropriation of increased federal funds for vocational rehabilitation.

I now recommend enactment of legislation to facilitate the restoration of greater numbers of our mentally retarded and severely disabled to gainful employment, by permitting them up to eighteen months of rehabilitative services prior to the determination of their vocational feasibility.

I also recommend enactment of a new program for the construction and initial staffing of workshops and rehabilitation facilities, program expansion grants, and increased State fiscal and administrative flexibility.

International Health

Scientists from many countries have contributed to the enrichment of our national medical research effort. We in turn support medical research in other nations.

International collaboration in medical research, including support of research through the World Health Organization, is an efficient means of expanding knowledge and a powerful means of strengthening contacts among nations. It links not only scientists but nations and peoples in efforts to achieve a common aspiration of mankind-the reduction of suffering and the lengthening the prime of life.

The United States participates in an ambitious international effort to eradicate malaria--a disease which strikes untold millions throughout the world.

Both of my predecessors committed the United States to this campaign, now going forward under the leadership of the World Health Organization. The Congress has endorsed this objective and has supported it financially.

We will continue to encourage WHO in its work to eradicate malaria throughout the world.

We will continue to commit substantial resources to aid friendly nations through bilateral programs of malaria eradication.

The United States will also initiate in 1964 a program to eradicate the mosquito carrying yellow fever. My 1965 budget provides expanded funds for the second year of this program.

CONCLUSION

The measures recommended in this Message comprise a vigorous and many-sided attack on our most serious health problems.

These problems will not be fully solved in 1964 or for a long time to come.

They will not be solved by the federal Government alone, nor even by government at all levels.

They are deeply rooted in American life.

They must be solved by society as a whole.

I ask the help of all Americans in this vital work.

LYNDON B. JOHNSON