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Special Message to the Congress on the Nation's Health Needs

April 22, 1949

To the Congress of the United States:

In a special message to the Congress on November 19, 1945, and in a number of messages since that date, I have recommended the enactment of comprehensive legislation to improve the health of our people.

The issues involved in these recommendations have been debated all over the country-in Congressional hearings, in medical societies, and in public forums. Out of all this discussion has come a large measure of agreement. There has been increasing recognition of the need for positive, planned action to bring adequate health services within the reach of all our people. With respect to most of my recommendations, there is no longer any substantial difference of opinion.

Legislation has already been enacted which is helping substantially to provide better health services and medical care. For example, Federal funds are now being made available to help in building badly needed hospitals. The Federal Government's programs of medical research have been expanded. Additional grants have been made available to the States to aid in establishing and maintaining public health services.

However, the action thus far taken falls far short of our goal of adequate medical care for all our citizens. If we are to deal with the problem realistically and in its true dimensions, action is required on a broader scale.

We are in an era of startling medical progress. The technical resources available to the physician are tremendously greater than a generation ago. But to make these resources effective, he must use much more complicated, more exact equipment. He must turn to specialized laboratories and technicians for help. He must apply new techniques and must secure more effective drugs and appliances.

As a Nation we have not yet succeeded in making the benefits of these scientific advances available to all those who need them. The best hospitals, the finest research laboratories, and the most skillful physicians are of no value to those who cannot obtain their services.

Now that we have the medical knowledge that can bring good health within our reach to a degree heretofore undreamed of, we must improve the means for putting that knowledge to practical use. Good health is the foundation of a nation's strength. It is also the foundation upon which a better standard of living can be built for individuals. To see that our people actually enjoy the good health that medical science knows how to provide is one of the great challenges to our democracy.

Our objective must be two-fold: to make available enough medical services to go around, and to see that everybody has a chance to obtain those services. We cannot attain one part of that objective unless we attain the other as well.

Our needs are plain. We are, and shall be for some time, short of physicians, dentists, nurses, medical technicians and public health workers. We need more hospitals and clinics. Medical personnel and facilities are unevenly located in relation to the need in different parts of the country--and are particularly deficient in rural areas. We need broader, better supported medical research. We need much more attention to preventive health care and more adequate public health services. Most of all, we need more widespread use of the modern method of paying for medical care through prepaid insurance.

There is, so far as I am aware, no longer any significant disagreement on these basic objectives. And there is general agreement that the financial problem is at the base of our difficulties.

My first recommendation is that the Congress enact legislation providing for a nationwide system of health insurance.

The traditional method of paying for medical care cannot meet the health needs of today. As medical education and practice have become better, they have become more specialized and at the same time more expensive. As treatment has become more expensive, families have found it more and more difficult to meet the extraordinary costs of accidents, serious illness or major surgery. Thus, at the same time that our knowledge of how to provide medical care is at its highest point, more and more people are unable to afford it. It is no longer just the poor who are unable to pay for all the medical care they need--such care is now beyond the means of all but the upper income groups.

This is an anomalous situation. It can and should be met through social insurance. Under such a system, regular contributions to the insurance fund will replace irregular, often overwhelming, family outlays for medical care.

Insurance against the costs of medical care has been growing rapidly in this country in recent years. This growth is proof that our people understand the advantages of health insurance and desire its extension.

Unfortunately, however, voluntary plans have proved inadequate to meet the need. Most voluntary plans give only very limited protection. While some fifty million people now have some form of health insurance, this insurance usually provides only limited protection so far as hospitalization is concerned and in most cases makes no provision at all for other medical services. Only three and one-half million of our people have insurance which provides anything approaching adequate health protection. Most serious of all, since rates in these voluntary plans are not adjusted to incomes, those who need protection most cannot afford to join.

The only fair and effective means to assure adequate medical care through insurance is to build on the pattern of our existing social insurance plans. As in the case of those plans, we should seek to include as many persons as possible within the health insurance system, so that more may benefit, and costs can be more widely shared.

Health insurance is a method of paying for medical care. It will not require doctors to become employees of the Government. It will not disturb the freedom of doctors and hospitals to determine the nature and extent of treatment to be given. It will not interfere with the personal relationship between doctor and patient. Under such a plan, patients will remain free to choose their own doctors, and doctors will remain free to accept or reject patients. Moreover, patients, doctors, and hospitals will remain free to make their own arrangements for care outside the insurance system if they so choose.

The administration of the program should, of course, be decentralized to the greatest possible extent. It is also of the utmost importance that the quality of medical care be adequately safeguarded. Both these objectives can be accomplished in large measure by having the administration of the program in each locality guided by a local group in which the skills and judgment of local medical personnel are fully represented. Furthermore, the fullest possible use should be made of the medical schools and their faculties.

Health insurance will mean that proper medical care will be economically accessible to everyone covered by it, in the country as well as in the city, as a right and not as a medical dole.

It will mean that more people will obtain the preventive care which is so important, and that more people will be able to have better medical care. Thus health insurance will provide an effective demand for the additional doctors, nurses and other medical personnel we need to improve our health. The provision of more doctors and medical personnel goes hand in hand with better arrangements for paying for their services.

My second recommendation, therefore, is that the Congress enact legislation to help medical schools expand. Special financial aid should be provided for the construction of teaching hospitals and other facilities and to help the schools cover the cost of larger enrollments. At the same time, scholarship aid should be provided for good students who might otherwise lack the means to undertake the long period of professional training.

Today we have about 190,000 active physicians, of whom 145,000 are in private practice. This is not enough. It represents only about 80 per cent of the physicians we require. Unless we take prompt action to expand the medical schools, we shall be no better off ten years from now. We face similar shortages with respect to dentists, nurses, and other professional medical personnel. Obviously, the facilities for professional education will have to be expanded if we are to provide adequate care for our growing population.

Health insurance will have another extremely important result so far as medical personnel are concerned. Since payment of doctors' and other fees will be assured by the insurance system, doctors will be able to practice where they are needed most, without sacrificing income--as too many doctors must now do in rural and low-income areas. Comprehensive health insurance will thus lead to a more equitable distribution of doctors over the country, and we will no longer have the situation where some counties have only one active physician for every three thousand persons, while other counties have five or six.

My third recommendation is that the Federal Government provide increased aid for the construction of hospitals and other medical facilities in communities where they are needed.

In many cases adequate medical treatment can be provided only in hospitals. Under present circumstances, hospitalization is often impossible, both because of the shortage of hospitals and because of inability of the patient to pay the costs of hospital care.

The enactment of health insurance will, of course, permit more of our people to obtain the hospital care they need. Thus health insurance will make it possible to support hospitals in communities where they could not now be supported. At the same time, it will make the present need for hospital construction even more urgent.

The present Federal Hospital Survey and Construction Act, enacted in 1946, represents an important step in a national program to provide more hospitals. Under this Act, expiring in 1951, some funds are provided for the Government to contribute one-third of the construction costs of public and other non-profit hospitals.

I recommend that the Congress extend the duration of this program, increase the funds to be made available, and modify the program so that the Government's share will take account of the varying financial resources of different States.

Furthermore, the program should be broadened to include aid for the establishment of community health centers, diagnostic clinics, and group practice clinics, all of which have proved in recent years to be very effective means of providing better medical care. This aid should be provided in the form of grants to help finance the construction and equipping of public and other non-profit health centers and clinics, and in the form of Government guarantees of loans for the establishment of private facilities, similar to the mortgage guarantees the Government provides for private housing.

Closely related to these measures to increase the availability of private medical care are certain actions we should take to improve the public health preventive and disease control services, which are now inadequate in most areas and totally lacking in many.

At present, the Government provides grants to assist State and local governments in preventing and controlling certain diseases, and to promote maternal and child health services, services for crippled children, and general public health activities.

My fourth recommendation is that the Congress increase the amount of the Federal grants for these activities, consolidate the existing separate grants insofar as possible, and provide for matching by the States adjusted to their differing financial resources.

Another essential step, if we are to continue to improve our medical care system, is to continue to improve our medical research as more facilities and scientific personnel become available. The Government is already contributing substantially to the advance of medical knowledge by conferring fellowships for research in many specialized fields, by providing grants for research by public and non-profit agencies, and through its own research activities. We must keep alert to every opportunity to add to the program of medical research through new scientific techniques, such as the use of the products of atomic energy, and through the wise and balanced expansion of research into diseases which have not so far been conquered.

These recommendations are interrelated parts of a comprehensive plan for improving the quality of medical care and making such care more completely available to our people. They present a sensible and realistic program of action, which complements my recommendations for extending and improving the social security system, including the provision of insurance against loss of workers' incomes during periods of sickness or disability.

We should lose no time in making a full-scale beginning on all parts of our health program. At the same time that we are putting health insurance into operation, we should be establishing the hospitals and clinics, and training the medical personnel, that the insurance system will enable us to afford. We cannot, of course, achieve our goals fully until the system has been in operation for some time. That fact emphasizes the need for early legislative action.

Many people are concerned about the cost of a national health program. The truth is that it will save a great deal more than it costs. We are already paying about four per cent of our national income for health care. More and better care can be obtained for this same amount of money under the program I am recommending. Furthermore, we can and should invest additional amounts in an adequate health program-for the additional investment will more than pay for itself.

The real cost of our present inadequate medical care is not measured merely by doctors' bills and hospital bills. The real cost to society is in unnecessary human suffering and the yearly loss of hundreds of millions of productive working days. To the individual the real costs are the shattering of family budgets, the disruption of family life, the suffering and disabilities, the permanent physical impairments left by crippling diseases, and the deaths each year of tens of thousands of persons who might have lived. This is the price we are now paying for inadequate medical care.

It is plain common sense that we should not permit these needless costs to continue when we have it within our power to reduce them with a practical health program. Where there are differences remaining as to the details of the program, we should not permit these differences to stand in the way of our going forward. They should be threshed out with honesty and tolerance, as is our democratic fashion. We should enact the best possible program and then all of us should get behind it to make it work.

We are striving in this country to see that the strength and flexibility of our political and economic institutions are used to bring the greatest possible good to our people. I consider this health program as part of that endeavor--to adjust to modern conditions without losing traditional values, to bring to the people of this country the full enjoyment of the benefits which our freedom makes possible.

NOTE: On October 25, 1949, the President approved a bill "to amend the Hospital Survey and Construction Act (title VI of the Public Health Service Act), to ex