Speech of Senator John F. Kennedy, In the Senate, Tuesday, January 26, 1960

Medical Care of Our Older Citizens

Mr. President, I introduce for appropriate reference, a bill to amend the Social Security Act and the Internal Revenue Code so as to provide insurance for our older citizens against the burdens imposed by hospital and nursing costs.

In recent years there has been a dramatic change in the age distribution and composition of our population. In 1900, influenza, pneumonia, tuberculosis, and typhoid still took a high toll. Public sanitation was rare, nutrition was inadequate, and the medical science we know today was in its infancy. A baby girl born in the United States could expect to live 48 years. Today she can expect to live to the age of 73.

Today almost 10 percent of our population – 16 million people – are over the age of 65. Forty percent of these are 75 – and the proportion of our population in these older age brackets continues to grow at an accelerated rate.

Only 3 million of these people are employed. And despite many efforts to modernize and improve our social security system – efforts we have reason to be proud of – the average social security benefit is still only $72 a month. If we include income from every source available, it reaches less than $20 a week for three out of every five of these citizens. Four out of five receive less than $40 per week.

No matter how they retrench – no matter how many comforts they had learned to expect which they do without – no matter how many expenses they reduce, it is obvious that the later years of too many of our older citizens will be attended by hardship. The hardship becomes despair when they are faced with illness and the necessity for meeting medical expenses. No matter how drastically their standard of living is cut back they still cannot reduce the demand for essential health care. Ironically, it is just when their income is lowest that their medical expenses become highest. They are most threatened by the costs of serious illness when their earning capacity is exhausted.

This is the time of life when they are most susceptible to chronic illness and long-term crippling and disabling diseases. In recent years, over 600,000 people age 65 or more died annually of arteriosclerosis, hypertension and related cardiovascular diseases. Each year over 135,000 people over 65 are the victims of cancer. Each year some 300,000 are totally disabled as a result of rheumatic diseases.

This is the time of life when the need for health care rises sharply. Even excluding those who are in institutions, people over 65 suffer twice as frequently from chronic sickness as those under 65 – they spend 2½ times as many days restricted to their beds – they are forced to limit their activities due to illness six times as often. The magnitude of this problem and the gravity of its effect is indicated by the fact that although their average income is less than $1,000 per year, one out of six spends over $500 for medical care.

A person who has left the active labor force no longer has the benefit of wage increases which can help keep pace with the cost of living. But he still must feel the effect of these increases. Of all these costs, the one which has soared highest, the one which is most inflexible, and the one over which we have the least control is the cost of medical care. In the third quarter of 1959 the composite cost of living was 25 percent above the 1947-49 base period. Medical care, however was up 52 percent. And hospital room rates were up 110 percent. 

Mr. President, the treatment of its older citizens is said by anthropologists to be one of the most basic tests of how civilized a society or nation has become. The bill I offer should help us pass that test.

Although social security legislation, private pension plans, the Hill-Burton Hospital Construction Act, and the recently enacted Federal housing program have all taken tentative steps toward honoring our obligations, we owe our older citizens much more. This bill would help them meet their most serious health needs.

Proposals to provide health benefits for our older citizens have been before us since 1942. We are particularly indebted to Representative Aime Forand, who has long led the battle for such legislation. In 1958, and again last year, hearings were held in the other body upon the bill he introduced.

Two years ago I asked the staff of the Subcommittee on Labor of the Senate Labor and Public Welfare Committee to undertake a comprehensive study of the problems and needs of our older citizens. Last year a special subcommittee of the Labor and Public Welfare Committee, under the able leadership of the distinguished senior Senator from Michigan, and on which I served as vice chairman, held hearings and will soon file a report dealing with these matters.

But there are obvious deficiencies in our provision for medical assistance to our older citizens that need not wait for a formal report. The hearings demonstrated – although no demonstration was needed – that we have too long ignored the grave medical problems of our older citizens. Studies and commissions and White House conferences will not alleviate this hardship or calm this distress.

The bill I introduce utilizes a mechanism already available. It will assure complete coverage. It permits us to take advantage of experience we have already acquired in providing benefits to our older citizens. It requires no appropriation from the General Treasury and it permits each beneficiary to maintain his self-respect. The program will be financed on the basis of sound insurance principles, under which the beneficiaries of the program pay for it themselves.

The bill does not impose an intolerable financial burden upon anyone and it does not intrude Government regulation upon the private relationship between doctor and patient.

In return for premiums in the form of slightly increased contribution rates under the Social Security Act the bill gives our older citizens the assurance that:

First. They may have up to 90 days of hospital care per year.

Second. In addition, or in place of hospital care, they will be entitled to the skilled services of a nurse, either in a nursing home or in their own home. The combined hospitalization, nursing home and home nursing service could equal 120 days of combined care. However, 1½ days of nursing home service would count as only 1 day of “combined care” and two nursing home visits would count as only 1 day of “combined care”. This should relieve the pressure upon our hospital facilities by offering an incentive for treatment at home.

Third. As outpatients, they will have available to them diagnostic services. Such necessary but expensive hospital services as X-rays, electrocardiograms, laboratory tests and other diagnostic procedures will be available without the necessity for hospitalization. This, too, should help reduce the temptation to hospitalization.

Fourth. If disabled, they would also be covered.

The procedure for seeking these benefits is patterned after that followed under the many voluntary health insurance plans now in effect. An eligible person would be admitted to the hospital or nursing home or receive home care or diagnostic benefits by direction of his physician. Payments would be made from the Social Security Trust Fund, and the program would be administered by the Department of Health, Education, and Welfare. In effect, every member of the social security system would receive paid-up health insurance for life in return for a small increase in his contribution rates.

Few people deny the urgency of the need for this medical care. But there are some who prefer to rely upon voluntary health insurance policies. Unfortunately, voluntary health insurance has not and cannot do the job. Although our insurance companies have made a mighty effort, and have enrolled an impressive number of Americans, it is extremely unlikely that they can reach our older citizens. The difficulties which confront both the insurance companies and our older citizens have proved insurmountable. At one time the insurance companies feared that the cost of benefits to our older citizens would be prohibitive, and they both restricted the type of risk and set the premium at high levels. Since then substantial progress has been made. However, it remains a basic economic fact that no program for health insurance for the aged can be effective unless:

First. All persons at all age levels are enrolled so that the premiums can be paid during the long period of youthful good health.

Second. The benefits are sufficient to pay the entire cost of hospitalization and nursing services.

Third. There is some provision for diagnostic services to encourage preventive medicine.

No voluntary health insurance plan can accomplish these objectives.

The very competition between insurance companies tends to either exclude older people or limit their protection. If benefits are restricted the very purpose of the insurance is defeated.

There are those who suggest that we start by building up the rights of those who are still relatively young and abandon those who are already in the older categories. This heartless doctrine is offensive to both the basic premise of our social security system and our status as a great democratic country. The suggestion that each person should assume his own responsibility for his later years was answered poignantly by one witness during the hearings, who pointed out that “it is impossible for a wage earner to put away enough in a lifetime to pay for 6 months in a hospital.”

I agree that we must maintain the highest standards of family responsibility and personal thrift. But I am concerned about the futility of imposing on any person or any family an unwarranted, unpredictable, and often unmanageable burden that could easily be borne by an insurance arrangement – insurance that is spread over the working lifetime of each individual.

Mr. President, the time is long past when there was any question about the need for this legislation. This bill addresses itself to a limited and modest objective. It is practical and the aged and disabled people of our Nation have a right to expect its enactment.

Mr. President, I ask unanimous consent that there be printed in the RECORD a section-by-section analysis of the bill.

There being no objection, the analysis was ordered to be printed in the RECORD, as follows:

SECTION-BY-SECTION ANALYSIS OF KENNEDY BILL TO PROVIDE INSURANCE AGAINST COSTS OF HOSPITAL AND NURSING CARE

  1. The bill contains findings of fact and a declaration of purpose: Congress finds that the present old-age and survivors insurance benefits are inadequate for our older citizens and that it is in the interest of the general welfare for financial burdens resulting from hospitalization and nursing services of our older citizens to be relieved through old-age and survivors insurance.

  2. Eligibility for insurance: Any person is eligible for hospitalization and nursing insurance who is entitled to monthly benefits under the Federal old-age and survivors’ insurance program, including those entitled to disability benefits.

  3. Payments for hospital services are limited to the first 90 days of hospitalization in any 12-month period. Payments for nursing home or home nursing services are made if the individual is transferred to the nursing home or to his home from the hospital or from the nursing home to his home, and if the services are for an illness or condition associated with that for which he received hospital services. The combined hospitalization, nursing home, and home nursing services cannot exceed 120 days. However, 1½ days of nursing home service would be counted as 1 day for this purpose, and two home nursing visits are counted as 1 day for this purpose.

  4. Hospital services are defined to include drugs and appliances furnished by the hospital, laboratory services, ambulance services, use of operating room, staff services, and bed and board.

  5. Nursing home services include nursing care, related medical and personal services, and bed and board in a home operated in connection with the hospital or in which nursing care and medical care are prescribed by or performed under the direction of persons licensed to practice medicine in the State.

  6. Home nursing service is defined to mean professional nursing care furnished by a community-sponsored nursing service, under the direction of a doctor, or practical nurses under the direction of a community-sponsored nursing agency.

  7. Diagnostic outpatient services mean hospital services furnished to an individual as an outpatient for a diagnosis of illness or injury.

  8. Every person entitled to benefits under the act is given completely free choice of the hospital, nursing home, home nursing, or diagnostic outpatient hospital service he chooses.

  9. Agreements may be made between any hospital, nursing home or nursing agency and the Federal old-age and survivors’ insurance trust fund for providing these services. The amount of payments under the agreement is determined on the basis of the reasonable cost incurred or, in the case of a nursing agency, the fee for all patients receiving like services. The agreement shall preclude the hospital, nursing home or nursing agency from requiring additional payments from individuals.

  10. No supervision or control over details of the administration or operation, or over the selection, tenure or compensation of personnel shall be exercised by the Government. 

  11. All information concerning an individual obtained from him by any physician, dentist, nurse, hospital, nursing home, or any other person, is confidential. Any violation of this provision is a misdemeanor punishable by fine or imprisonment, or both.

  12. Provision is made for not duplicating any of the benefits under this act and benefits received under workmen’s compensation.

  13. In administering this act, the Secretary of Health, Education, and Welfare shall establish a National Advisory Health Council consisting of the Commissioner of Social Security and eight others. Four of the eight shall be from fields pertaining to hospitals and health activities and the other four shall represent consumers. This Council shall advise the Secretary in the administration of the act.

  14. In carrying out the act, the Secretary is authorized to utilize the services of private nonprofit organizations which either represent qualified providers of hospital or nursing services or operate voluntary insurance plans.

  15. The Internal Revenue Code is amended to provide for an increase in the taxes of self-employed individuals of three-eighths of 1 percent, an increase in taxes upon employees of one-fourth of 1 percent, and an increase upon the taxes of employers of one-fourth of 1 percent of wages.

Source: Papers of John F. Kennedy. Pre-Presidential Papers. Senate Files, Box 905, "Medical Care for Our Older Citizens, Senate floor, 26 January 1960." John F. Kennedy Presidential Library.