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tion increased and cities and industries expanded the problems of epidemic control increased, and our ports became the main point of entry of epidemic diseases. After the establishment of the Commissioned Corps of the Public Health Service in 1899 the Congress, in 1893, gave the Service full responsibility for foreign and interstate quarantine emphasizing cooperative relationships with State health departments.
In the 1870's the science of bacteriology was born and scientific advances made in Europe and this country in the latter part of the 19th Century began to demonstrate the value of a central organization for research, epidemiological studies and practical assistance in epidemic control. In 1887 a Hygienic Laboratory was established at the Staten Island Marine Hospital to apply the new bacteriologic principles to the study of disease in this country. It quickly proved its worth and was soon transferred to Washington where it became the forerunner of today's National Institutes of Health.
As the production and interstate sale of biologic products for the prevention and treatment of infectious diseases expanded the Congress gave responsibility for their licensing and regulation to the Public Health Service under the Biologics Control Act of 1902.
An important milestone in this evolution was the passage of the Social Security Act of 1935 which among its other provisions authorized annual grants to the States for health purposes. In effect, the Federal Government undertook a partnership with the States to protect and promote the health of the people and this resulted in the establishment of a number of Federal-State programs against specific diseases such as venereal disease and tuberculosis. Prior to World War II major emphasis was given to the strengthening of State and local health agencies and to the promotion of maternal and child health and the control of communicable diseases.
As the population began to age and the leading causes of death began to shift from the infectious diseases to chronic diseases a major national research effort began aimed at the chronic and long term illnesses. This effort was signaled by the passage of the National Cancer Act in 1937 creating the National Cancer Institute dedicated to cancer research and the training of scientists. This was followed by the National Institute of Mental Health in 1946, the National Heart Institute in 1948, the Institutes of Arthritis and Metabolic Diseases and of Neurological Diseases and Blindness in 1950 and the National Institute of Allergy and Infectious Diseases in 1955. These institutes have all made major contributions to our knowledge of the chronic diseases and to the training of scientists dedicated to continuing research in this area.
At the end of World War II a serious problem faced the nation—a shortage of hospital and related medical facilities, and in 1916 the Congress expressed the will of the people by enacting the National Hospital Survey and Construction Programs, otherwise known as the Hill-Burton Program. This legislation authorized Federal financing to aid the States in the construction of hospitals and health centers and has since been broadened to provide grants for the construction of nursing homes and rehabilitation centers.
To bridge the gap between knowledge and service the Community Health Services and Facilities Act of 1961 authorized support of community studies and demonstrations to develop new and improved ambulatory services especially for the chronically ill and aged. This concern for the application of health knowledge was further demonstrated in The Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963, and during this same period the Vaccination Assistance Act was passed authorizing the Public Health Service to assist States and communities in carrying out immunization programs aimed at the eradication of poliomyelitis, tetanus, diphtheria and pertussis.
Since the end of World War II the Congress has become increasingly alarmed about the hazards of the modern environment and has expressed this concern through supportive legislation. The Water Pollution Control Act of 1948, legislation in 1956 authorizing grants for the construction of waste treatment facilities, the Air Pollution Act of 1955, the creation of the Division of Radiological Health in 1958—all these were expressions of the growing concern of government regarding health hazards created by our industrial development and led to the authorization by the Congress in 1964 of funds to plan a new Environmental Health Center as a focal point for research, training and control programs in environmental health,
Health manpower training and development is a more recent area of concern in government, but its recent origin has not in any way dampened the magnitude and scope of the effort. As early as 1956 the Public Health Service was authorized to provide traineeships for professional public health personnel. I, myself, received my Public Health training through a Public Health Service fellowship. In that same year a nurse traineeship program was begun to provide administrative, teaching and supervisory nursing personnel. Later (1963) the Health Professions Educational Assistance Act was passed and provided Federal grants to assist in the construction of all health professions schools, as well as providing a loan program for medical, dental and osteopathic students. The Nurse Training Act of 1964 not only authorized Federal assistance for the construction or rehabilitation of nursing schools, but also established a loan program for student nurses and extended the public health traineeship program to include nurses.
The collection of Vital Statistics is another area in which the Public Health Service has provided leadership. The transfer, in 1946, of the National Office of Vital Statistics from the Census Bureau to the Service marked the beginning of a new era in the collection, analysis and dissemination of health data, and when in 1956 the Congress authorized the National Health Survey, this set the stage for the later development (1960) of the National Center for Health Statistics. (1)
I am certain there are those who will hasten to remind me that most of what I have so far described are the traditionally accepted roles of government in the field of "Public Health": quarantine and epidemic control, food and drug inspection and regulation, venereal disease and tuberculosis control, research, health professions training, construction of health education and health care facilities, and environmental health activities.
The fact is that although the medical services of the Public Health Service have been provided only to special categories of persons, they have amounted to a considerable imput into the national medical care effort. Other agencies of government have provided even greater quantities of care. The medical services of the military are well known to all of you and include the Medicare program for military dependents not living near a military facility. The Veterans Administration has a long history of magnificent medical services to eligible veterans.
CONCERN ABOUT Costs Since 1948 there has been growing concern among the public and their elected representatives about the costs of medical services and the inability of certain segments of the population to pay for them. This concern has been expressed in a series of legislative proposals which culminated, in 1965, in the passage of the medical aspects of P.L. 89–97, better known as Medicare and Medicaid. These legislative enactments have addressed themselves to the medical needs of certain well defined population groups. It is worthy of note that all the recent health legislation-P.L. 89-97, P.L. 89-239 and P.L. 89–749_pledge in very brave words not to interfere with existing patterns of medical practice. The conspicuous exception is the OEO 211 neighborhood health center groups program which deliberately intends to foster new ways of delivering comprehensive health care to disadvantaged populations. The clear implication is that the medical and related health professions have failed to create and provide health services responsive to the needs of these communities.
Only one year after the inception of our federal programs for the financing of health care it has become obvious that if government is to assume the responsibility for this financing it must also become concerned about the prices of medical care. The recent report to the President followed by a two day conference on Medical Care Prices in Washington is a reflection of this concern. The Secretary of H.E.W. in addressing the health experts gathered at that meeting challenged them to re-examine the efficiency, productivity and even the logic of our present health care systems. (3)
This governmental concern and involvement may be translated into dollars if one reviews our health expenditures for a recent year. In 1965 the nation expended $40.8 billion or 6% of the gross national product for the purchase of health services and supplies, the support of health research and the construction of health facilities. 91.5% of the total was spent for health care and supplies.
Of the $40.8 billion total $30.5 billion represented private expenditure and $10.2 billion were public funds. The distribution of the health dollar among the various elements of expenditure differs widely between public and private spending. For example 40 cents of the private dollar is spent for the services of private practitioners but only 6 cents of the public dollar. Less than 5 cents of the private dollar is spent on research and construction, but 13 cents of the public dollar is spent on research and 6.5 cents on construction.
One bit of information which to me speaks volumes is that health insurance payments met less than 13 of the private health bill. During the legislative conflict which culminated in the passage of the Medicare law we were frequently reminded that more than 80% of the American public are protected by voluntary health insurance. This tid bit of intelligence was supposed to convince us all that we did not need the federal legislation, but I, like the Congress, have deep questions about the effectiveness of a system which covers more than 80% of the population but pays less than a third of the bill. (4)
In view of the past and the present what shall our national health goals for the future be and what shall be the role of government in the achievement of these goals? As a matter of national policy it is already the stated goal that optimal health services shall be available to every American Community. But what is the definition of “optimal health services”? The Task Force on Comprehensive Personal Health Services of the National Commission on Community Health Services has defined it in these words:
"It must be comprehensive and it must be personal. It starts in the relationship of a personal physician to his patient. It must support and supplement the patient-physician relationship with a team drawn from all the health professions. As a consequence of being personal and comprehensive, it must cover the full range of medical functions, beginning with health maintenance and preventive care, taking in diagnosis and treatment of acute disorders, and including rehabilitation. It must be available to everyone. It must be available at all times and in all places. It must recognize and cope with the special health needs of people at all stages of life, from infancy to old age. : (5)
Does this seem a grandiose goal? It does to me, but I believe it is an achieve able goal. It can only be achieved, however, as we begin to look at health services in proper perspective. As health professionals both in the public and private sectors we frequently behave as if health services are the only factor which affect the health of a community. As long as we take this limited and narrow point of view we shall never achieve the national goal of optimum services for all who need it because too many will need it.
In planning for improving the level of health of any community we must begin with a recognition that health is inseparable from all aspects of living. Again the Task Force on Comprehensive Personal Health Services has perhaps said it better than I could :
"The health of the individual is not only dependent upon services specifically aimed at personal health care, but also dependent upon the quality of the relationship of the individual with his environment—his sustenance needs, his shelter, his ability to communicate and his enjoyment of a creative as well as a productive life. Basic to this concept is the viewpoint that * * * the opportunity for employment and job security is as essential to health as a hospital bed for acute * * * care; and, that poverty in all its insidious complexities acts like a virus in affecting the health of the total community." (6)
These are brave words. How are they to be implemented? Can the private practitioner address himself in depth to the employment, housing and sustenance needs of his patients? Obviously not. Can any one physician pretend to provide all the health care a given patient with a complex ailment may need? Of course not. Certainly he can make appropriate referrals, but what if the patient is not eligible for Medicare, or Title XIX, or if your State has not yet implemented Title XIX; or if the patient has health insurance with serious gaps in coverage? How does the private practitioner deliver comprehensive personal health care in these circumstances? Obviously he does not.
A FRAMEWORK FOR LEADERSHIP
There is an answer, and the answer lies in the various roles which government must assume in health matters in the future. Recent health legislation has begun to show the way. P.L. 89–749, also known as the Hill-Staggers law, is intended to create the framework within which government can provide the leadership in the comprehensire planning which will be necessary to deal with health problems within the contert of the total life situation of a community. This law provides for the appointment of State and local interdepartmental comprehensive health planning agencies. These agencies should plan for the mobilization and equitable distribution of all the health resources of a community or region. It should plan for the channeling of the irrationally fragmented and categorized federal funding into rationally designed health programs.
Government must identify gaps in service and provide the leadership and the funds whereby voluntary agencies may fill the gaps. Undoubtedly, present federal programs for the financing of health care will be expanded to provide for other segments of the population. In the implementation of these programs official health and welfare agencies must be accountable for the quality, cost and utilization of the services they purchase. The requirement for utilization review of hospital care and extended care in the Medicare program, the requirement of continuing post-graduate medical education as a criterion for physician participation in New York State's Medicaid program, the responsibility for medical audit of institutional health care conferred upon the State Health Department by New York State's Folsom Law, the authority of the New York City Health Seryices Administration to revoke the license of a private proprietary hospital if an unqualified physician is permitted to perform major surgery, (7) all these are examples of government's responsibility to be accountable to the people.
But this responsibility for comprehensive planning must go further. It must include an assessment of present and future health manpower needs not only by analyzing the need for traditional categories of health workers, but by taking the leadership and providing the funds to stimulate the analysis of present and future health functions to determine whether the devision of labor may not be as effective in increasing productivity in the health field as it has been in industry. The medical corpsman and a variety of technicians have proven their value on the field of battle and on the capital ships of the Navy. Are not their skills transferrable to the civilian medical market place? Are not some of the functions now performed by doctors susceptible of performance by nurses or a variety of doctor's assistants? These are questions that must be answered if we are to resolve our manpower dilemma.
I have raised these questions before and have immediately been reminded by my colleagues of the doctor's malpractice liability. Perhaps it will be necessary to change the laws which define the functions and liability of both nurses and doctors in order that imaginative use may be made of our human resources. Clearly, these decisions cannot be left to the professions for it was only about a decade and a half ago that we were assured by the medical profession that there was no shortage of physicians and that such a shortage was not likely to develop. Now, in 1967, we are told belatedly by the A.M.A. that there is indeed a severe shortage of doctors. We have all heard the old “saw” that war is too important to be left to the generals. I suggest now that health planning is much too important to be left to organized medicine. Even voluntary health agencies are too parochial and chauvinistic in their interests to address themselves to the broad scope of planning which will be necessary to solve our problems.
We must also explore new methods for the delivery and financing of health care for in today's context the private, solo-practice model seems not to be viable, and the fee-for-service system of payment has already caused serious financial diffioulty in one large State's Title XIX program.
I am not suggesting that government planners should impose upon the professions new methods of practice, new delivery systems, new categories of health workers or new methods of financing health care, Nor am I suggesting what is often referred to as the socialization of medicine. I am, on behalf of government at all levels, extending a hand to organized medicine and inviting and challenge ing you to join us in finding solutions to our mutual problems.
In the past government has proposed and the A.M.A. and others have opposed. I was pleased to note that this organization was one of those few medical bodies which supported the Medicare legislation. Medicare is not perfect, but it is attempting to meet the needs of a segment of the population which clearly needs help. The American public has made it clear that it wants change. The status quo with its dual standards of health care is no longer acceptable. It is foolhardy for our profession to stand against the mainstream of public opinion. The Secretary of H.E.W. in addressing the conference on Medical Care Prices on Jne 28, 1967 said it very well indeed: "We cannot go on as we have in the past. New patterns will be necessary. * * * Those who entertain some apprehensions as to what the new patterns will be had better plunge in and experiment with their own preferred solutions. Standing back and condemning the solutions that other devise will not stem the tide of change * * *. Responsibility for devising solutions must be widely shared among all groups involved in the delivery of health care to the American people. Such a widely accepted sense of responsibility is the best insurance against the Government having to shoulder more than its share of corrective measures." (3) This is the challenge which is offered, and organized medicine's role in planning health care in the future will be determined by the extent to which this challenge is accepted.
Finally, the various roles of government which have been described can only be meaningful to the extent that government guarantees to all, regardless of race or color, equal access to health care, equal opportunity for professional education, equal access to health facilities by both patients and physicians and other health workers and equal opportunity to participate in the formulation of health policy. Without these guarantees all recent and future health legislation will be but empty promises to a large segment of the population. The functions of the Federal Offices of Equal Health Opportunity have recently been transferred to the office of the Secretary of H.E.W. This step has been hailed by some who have made no secret of their opposition to Title VI of the Civil Rights Act. We can only hope and be militantly watchful to make sure that this action does not portend a relaxing of the government's resolve to assure to all the people the blessings of optimal, unsegregated health care.
There is much work before us. We must experiment, we must be imaginative and we must not hesitate to explore the unknown for in this exploration lies the path to new knowledge, to new methods and to a bright future for the health professions and for the level of health of the American people.
1. The Public Health Service Today (PHS, HEW 1965).
2. “Medical Care Prices” JA report to the President of the U.S. by Department of H.E.W. February, 1967.
3. "Change Foreseen in Health System", New York Times, Thursday, June 29, 1967, Page 26.
4. Hanft, Ruth S., National Health Expenditures, 1950–65, Social Security Bulletin, February, 1967, pp. 3–13.
5. "Comprehensive Health Care” Report of the Task Force on Comprehensive Personal Health Services of the National Commission on Community Health Services, page 15, Public Affairs Press, Washington, D.C.
6. Ibid, page 11.
EXHIBIT C. UNRESOLVED ISSUES IN MEDICARE AND MEDICAIDAN ADDRESS DE
LIVERED AT A SPECIAL SESSION OF THE 95TH ANNUAL MEETING OF THE APHA, OCTOBER 24, 1967, AT THE FOUNTAINBLEU HOTEL, MIAMI BEACH, FLORIDA
MEDICARE VERSUS MEDICAID: THE NATION'S DILEMMA
The year 1965 will be a landmark in the annals of medical care legislation. The passage of Public Law 89–97 brought to public view the Congress' ambiyalence regarding the financing of health care, for in one enactment the Congress simultaneously created a contributor health insurance plan with a vob untary component and expanded an existing welfare medical care program. Now, two years later, the House Ways and Means Committee of the Congress has reported out a bill (H.R. 12080) which proposes to expand Medicare benefits but simultaneously to limit Federal responsibility for reimbursement under Title XIX.
It seems, therefore, that the time has come for the nation to make a decision as to which road it shall follow in financing health care Health Insurance or Medical Welfare. In order to focus on the relevant issues may be well to analyzes the programs and to identify their strengths and weaknesses.
The major socially significant aspect of the Medicare program is the absence of the “needs test” and the fact that the hospital insurance (Part A) is provided through a compulsory contributory system. The encouragement of alternatives to in-hospital care, i.e., extended care, home health care, out-patient