July 14, 1971
Page 25166
Mr. MUSKIE. Mr. President, the health care crisis in America has only recently emerged into the public consciousness. We have begun to realize that our health care system does not do an adequate job of keeping Americans healthy. The health crisis affects every American. For those who are very poor, health care is unavailable because of cost. For those who live in our inner cities or in our rural areas, health services are too far away. For the average American family, health care is a problem because costs are rising at alarming rates; routine health care drains our pocketbooks, and serious health care can mean economic catastrophe to a family These are some of the stark facts:
Between 1966 and 1980, the number of workers who cannot work due to illness will climb from 13 million to 21 million.
Seventy-five thousand newborn babies die in the United States each year.
The number of general practitioners has declined 35 percent since 1957 – and foreign physicians now constitute more than 25 percent of our Nation's doctors.
One hundred fifty counties across the country have absolutely no health professionals of any kind.
In most central cities, the situation is as bad – or just a little better. In the Kenwood section of Chicago, there are only two physicians for 46,000 people.
The cost of medical care has sky-rocketed to over $60 billion annually. At the same time, the health insurance industry has used its actuarial studies to exclude segment after segment of our society from access to medical protection The poor are abandoned to uneven and often inhuman public health services. And the average family is caught squarely in the middle – too well off to qualify for government help – too pressured to help themselves with comprehensive insurance.
In the end, millions of Americans go without adequate medical care. They cannot afford it. They are afraid it will break them. Or they cannot find a doctor. Some of them die. Others are left destitute. And most of them fall victim to needless pain and needless suffering. They are our parents – our children – our friends and our fellow citizens.
As Chairman of the Health Care Subcommittee of the Senate Committee on Aging, I held hearings in California during May to see what kind of health care our older citizens are receiving under the medicare and medicaid programs. The hearing clearly demonstrated that because of rising costs and because of poorly designed systems, literally tens of thousands of older Americans receive poor health care or no health care at all. Part of this is due to cutbacks in medicare and medicaid that put even the most basic health care beyond the reach of our elderly citizens. Part of this is a result of rigid and short-sighted regulations of the medicare and medicaid programs.
But the hearing made clear that even if the regulations were changed and finances made available, we still would not be able to have decent health care for our older Americans because we do not have the institutions that can deliver it. In minority communities, there are not enough doctors nor clinics. There are not the kind of people who can communicate with the community and earn their sense of trust. There are no means for getting older people to the doctors or, even better, the doctors to the older people.
To remedy this health crisis we need a medical bill of rights for all Americans. The first medical right of all Americans is care within their means. Admission to a hospital or a doctor's office should depend on the state of an individual's health, not the size of his wallet. And we cannot depend upon reform by halfway measures and halfhearted compromise. A right to medical care which left the burden of cost on the poor and the near poor would mock its own purpose. The only sure security is federally funded universal health insurance. That is our best hope for the future – and a priority goal in 1971.
Senator KENNEDY is leading the battle for this legislation and I support his efforts in every way. National health insurance will mean that all Americans, no matter what their means, no matter what their needs, can afford quality health care. When this legislation is passed, it will be a landmark in the history of social justice in our Nation.
The second medical right of all Americans is care within their reach. For even if we guaranteed the payment of health costs, millions of our citizens could not find sufficient medical services. The system is not only inequitable – it is also undermanned and inefficient. It is on the verge of collapse. The Nation must now respond with Federal financial incentives that will insure real reform.
So health insurance alone is not enough. We need enough doctors and related medical personnel to treat those who will be able to afford decent health care under national health insurance. And we must provide the institutions to bring that health care to every American. We will need special health clinics and out-reach efforts for our inner cities. In rural areas, different systems for health care delivery must be developed. For the aged, we must create home health care teams that can move doctors to the elderly, when the elderly cannot move to the doctors. And we must devise the techniques to insure that every family in America can and will utilize health care facilities for its children.
Finally, the third medical right is health care on a regular basis so that everyone can receive the benefits of preventive medicine. We must provide enough health education, supervision, and periodic checkups so that health problems are caught in the beginning, when they can be cured, rather than in the end, when it is too late for cure. Not only is this health care maintenance approach vastly more economical than our system today, but it is also the only humane way to provide for health care treatment.
These tasks will require great changes. They will require great imagination. They will require great resources. But they must be done, if we are to guarantee to every American a healthy life. I plan to contribute to this effort by offering various proposals to increase our health manpower and to create new institutions for health care delivery. Today the Senate is considering legislation that will allow us to overcome some of these health manpower problems.
First, we need more doctors and more medical personnel. By 1980 our estimated shortage of doctors will be 26,000, of dentists 56,000, of nurses 210,000, and of allied health manpower 432,000. We simply do not have enough people being trained today to provide the health care for America tomorrow. In fact, we are losing ground, because the increase in the number of medical personnel has not kept up with the increase in our population.
Second, we must reorient our medical training so that doctors are trained in those types of medical practice where we have critical manpower shortages. The largest such category is the "primary care" area. This includes the practice of family medicine – a new kind of general practitioner – internal medicine, pediatrics, obstetrics, and gynecology. An estimated 90 percent of the health care needs of Americans can be handled by these doctors. It is only the unusual case, on a statistical basis, that requires the medical specialist. Yet, only one-third of medical students are now being trained in these areas. It does not make sense to train only one-third of our new medical personnel to take responsibility for about 90 percent of our health care needs.
Third. as I mentioned above, we must directly focus on the problem of training medical personnel to work in our inner cities and rural areas.
Fourth, we must take immediate steps to train ancillary medical personnel. These physicians' assistants and nurses should be trained to assume the routine tasks of examination and medical practice so that doctors will be free to spend more time to use their special skills. If we don't use our doctors more efficiently, we will never be able to provide decent health care for everyone.
Fifth, we must begin to introduce into our medical schools more training for interdisciplinary care and the health team approach. The physician and the supporting personnel must be prepared to work together effectively on a single health problem so that we can break down the fractured. disjointed approach to the health care of particular individuals that too often prevails today.
Finally, we must increase the number of minority and disadvantaged group members into medical training at all levels. Without these people we will never be able to fully serve the communities from which they come. Only they can establish the trust and communication with medical consumers which will introduce health care into many of our communities.
The legislation now being considered in the Senate begins to remedy many of these problems. I support this legislation. Last month, Senator Eagleton and I offered an amendment containing proposals that we both felt would substantially improve the bill now under consideration. The Health Subcommittee and the Labor and Public Welfare Committee adopted these proposals.
These proposals now in the bill provide for:
First. Construction Grants:
Under Part B of Title VII of the Public Health Services Act for the construction of new health teaching facilities. Section 722 (b) requires that all the funds needed to complete each construction project will be held in reserve from the funds available in the first year that the grant for construction is awarded. This means that a project that will take three or four years to complete takes three or four times the amount of money out of the appropriated funds than is actually spent.
Since the program began in 1965 only about 40 percent of the appropriated funds have actually been spent. As a result there is now a backlog of 79 approved but unfunded construction projects.
Of these projects, 19 already have local matching funds – usually 40 percent to 50 percent of the cost of the project – ready and waiting.
To reduce this backlog, our provision changes section 722(b) to require the Secretary of HEW to reserve only a portion of the funds appropriated for the construction of health education facilities. This will allow us to immediately begin construction of health teaching facilities that are needed today and that will be even more desperately needed tomorrow.
Second. Grants for resident training.
The program for training medical residents needs help. The quality of education provided to residents in various institutions varies tremendously. We need good educational programs, programs that take time and money in additions to the already fine practice of medicine in these hospitals. Now the cost of educating these residents is borne either by medical schools or by the patients in the hospitals involved. This is unfair. All Americans should help pay for the decent education for the next generation of practitioners.
We also have the problem of balance between training in primary care and in specialities, that I spoke of above. It must be remedied by balanced training of residents. Finally, postgraduate training in medicine is too long. The development of shorter training for our doctors must be encouraged.
Our provision tries to remedy these problems by authorizing per capita grants to public and private accredited schools for payment of the educational costs of approved resident postgraduate training. This will set a baseline for quality education and relieve some of the burden of this training for the hospitals and patients involved.
The bill provides for a grant to such institutions of $3,000 for each full-time resident being trained in primary health care or in any other speciality in which there is a shortage of physicians. A grant of $1,500 is provided for other residents. In this way, we will help correct the serious imbalance of health manpower training. In addition, institutions applying for grants must also undertake a program to encourage doctors to enroll in training in primary health care and must assure the Secretary that they will increase the number of resident training slots in that area.
Finally, no training institution will receive such grants for residency training for more than 3 years. This will encourage the movement to shorten the years of postgraduate medical training consistent with recent initiatives by organized medicine.
I believe these sections of the bill are solid contributions to the remaking of our health care system. They will allow us to begin building more medical schools at once, expanding the pipeline that supplies tomorrow's doctors. They will upgrade our residency programs. And they will help more doctors into those fields where we now have severe shortages. I believe that the sections of the health manpower bill will be a good start in curing the shortage and imbalance in our health manpower training.