_ NEW FILE _ BEGINS i300. irene E — eourvans STATUS OF THE IMPLEMENTATION OF THE RECOMMENDATIONS _ OF THE PRESIDENT'S COMMISSION ON HEART DISHASE, CANCER, AND STROKE Tn seeking to develop a national program for the immediate reduction and ultimate conquest of heart disease, cancer, and stroke, the President's Commission accepted a complex challenge. There was a need for documentation of the dimensions of the problem and for an assessment of the potential of the Nation's resources to achieve these stated goals. On the one hand, the recommendations had to be comprehensive to encompass the magnitude of the problem; on the other hand, they had to be sufficiently specific to serve as a blueprint for action. The Regional Medical Programs, as authorized in Public Lew 89-239, deal with the innovative thrust of the first three recommendations of the . Report of the President's Commission, The other sections of the Report concern the basic resources of the Nation which must be utilized and enhanced to accomplish a significant reduction in the toll now exacted by our three major killing diseases. These resources are health manpower at all levels, health care and health research facilities, animal resources, communications systems, and the development of new knowledge and its application to patient care, In addition, the Commission concerned itself with broad questions of organization and mechanisms to better carry out the health goals set for our Nation. These other functions which are discussed in the Report will be carried out by other components of the Public Health Service and other constituent agencies of the Department as well, in close coordination with the Regional Medical Programs, ‘The thirty-five recommendations and the status of their implementation are described briefly in the attached document. RECOMMENDATIONS ON THE PRESIDENT'S COMMISSION ON HEART DISEASH, CANCER, AND STROKE December 1964 Recommendation 1. Regional Centers for Heart Disease, Cancer, and Stroke. The Commission recommends the establishment of a national network of Regional Heart Disease, Cancer, and Stroke Centers for clinical investigation, teaching, and patient care, in universities, hospitals, and research institutes and other institutions across the country. Diagnostic and Treatment Stations. The Commission recommends the establishment of a national network of Diagnostic and Treatment Stations in communities across the nation, to bring the highest medical skills in heart disease, cancer, and stroke within reach of every citizen. Development of Medical Complexes. The Commission recommends that a broad and flexible program of grant support be undertaken to stimilate the formation of medical complexes whereby university medical schools, hospitals, and other health care and research agencies and institutions work in concert. Development of Additional Centers of Excellence. The Commission recommends a program of developmental grants to medical schools to enable these institutions to improve their total capability for both academic and research programs for the ultimate purpose of creating a greatly increased number of true "centers of excellence” in medical education and research. A National Stroke Program Unit. The Commission recommends the establishment of a National Stroke Program directed by an administrative unit to be created within the appropriate unit of the Public Health Service to coordinate the numerous existing and proposed activities in the field of stroke. Page 29 32 34 35 36 Recommendation ; Page 6. Commmity Planning Grants. 39 The Commission recommends a special program of incentive grants to commnities to stimlate the development of a system for the planning and coordination of health activities. T. Comminity Health Research and Demonstration. 39 . The Commission recommends that greatly increased emphasis and support be given to programs of community health research and research training within the Public Health Service, and that the program of demonstration projects under the Comminity Health Services and Facilities Act of 1961 be freed from existing appropriations ceilings, more adequately funded, and more liberally interpreted. 8. Support of Commmity Programs. kO The Commission recommends that appropriate units of the Public Health Service be given authority and funds for programs of project grants to commnity agencies, such as public health departments, voluntary agencies, and others, and that the Vocational Rehabilitation Administration launch a 5-year development program to expand its rehabilitation programs for victims of heart disease, cancer, and stroke. 9. Statewlde Programs for Heart Disease Control. hi The Commission recommends that the Public Health Service be given authority and funds to establish and maintain coordinated Statewide laboratory facilities necessary for heart disease control programs. 10. National Cervical Cancer Detection Program. he The Commission recommends the development of a national program for the early detection of cervical cancer. . ll. Continuing Education of the Health Professions. 43 The Commission recommends that appropriate units of the Public Health Service, and the Vocational Rehabilitation Administration, be provided with funds and any additional authority thet may be necessary to spearhead a national program for the continuing education of the health professions. 12. Public Information on Heart Disease, Cancer, and Stroke. yy The Commission recommends that the Federal government, primarily through the Public Health Service, recognize that public information is a primary responsibility and a major instrument for the prevention and control of disease, and that this activity be encouraged and supported on a scale commensurate with its importance. 13. 14. 15. 16. 17. 18. 19. Recommendation Biomedical esearch Institutes. The Commission recommends the establishment of 25 non- categorical biomedical research institutes at qualified institutions throughout the country. Specialized Research Centers. The Commission recommends the establishment of Specialized Research Centers for intensive study of specific aspects of heart disease, cancer, and stroke to supplement the research and training efforts of the regional centers previously described. Research Project Grants. The Commission endorses the existing system of review of research project grants by study sections and advisory councils at the National Institutes of Health and recommends intensified and expanded support of research in heart disease, cancer, and stroke. Contracting Authority for Research and Development. The Commission recommends that existing Public Health Service authority to contract for research and development be broadened and special funds be earmarked for the use of this mechanism. General Support for Research. The Commission recommends that the existing General Research Support Grants Program of the National Institutes of Health be expanded as rapidly as possible to a level of 15 percent of the total NIH research and training budget and that the program be altered to increase its effectiveness. Standard Policy for Payment of Research Grant Awards. The Commission recommends that the Federal Government develop a standard Government-wide policy for payment of the full costs attributable to research grant awards. Expansion cf Resources for Preparation of Health Manpower. The Commission recommends that legislation be sought to permit forthright support of medical education, this program to include formula grants to the health professions schools. Immediately, there should be full utilization of the Health Professions Educational Assistance Act of 1963 and the Nurse Training Act of 1964. The Commission further recommends substantially greater and more diversified Federal support of programs designed to increase the supply of physicians, dentists, and medical scientists. Page LT 48 50 51 52 52 23 el. 22. 23. ak. 256 26. Recommendation Page 20. Recruitment for the Health Professions. 5h The Commission recommends programs designed to attract young people into the health professions and related disciplines. Undergraduate Training in Medical and Dental Schools. 55 The Commission recommends the continuation and expansion of existing grant programs to support undergraduate training in medical schools in heart disease; undergraduate training in ‘ — medical and dental schools in cancer; and medical under- graduate training in rehabilitation. In addition it recommends the development of an undergraduate training support program in stroke, administered by the National Institute of Neurological Diseases and Blindness. Training for Research. 57 The Commission recommends that the national program of research training grants be enlarged and expanded at a rate commensurate with the training capacity of organizations so engaged and the national pool of young investigators desirous of such training. Support of Clinical Training. 59 The Commission recommends the establishment of clinical fellowships and full-time clinical investigatorships in heart disease and stroke, the expansion of clinical training programs in cancer, and the establishment of clinical fellowships in rehabilitation. Stabilization of Academic Positions. 60 The Commission recommends the establishment of full-time career awards in universities and other institutions, not only for research personnel but also for clinical investigators and clinical professors. Training of Health Technicians. 60 The Commission recommends greatly increased effort and investment in the recruitment and training of health technicians and other paramedical personnel whose skills are essential to the control of heart disease; cancer, and stroke. Training of Specialists in Health Commimications. 61 The Commission recommends that the Office of Information and Publications in the Office of the Surgeon General be allocated @ specific annual sum of $1 million solely for training specialists in health commmications. Recommendation Page 27. Continuous Assessment of Health Manpower Needs. 61 The Commission recommends the establishment in the Bureau of State Services- (Commnity Health) of the Public Health Service of a health manpower unit, comparable to the research manpower unit of the National Institutes of Health, responsible for continuous assessment of national manpower requirements for health services. 28. Expanding Patient Care Facilities. 63 The Commission wholeheartedly endorses the 1964 Amendments to the Hospital ard Medical Facilities Construction (Hill-Burton) Act and urges their full implementation. It is further recom- mended that more funds be made available for the expansion of . long-term care facilities affiliated with hospitals. 29. Strengthening the Federal Hospital Program. 64 The Commission recommends that existing Federal hospital systems administered by the Veterans Administration and the Public Health Service be given authority and funds which will enable them to augment their contribution to research, training, and patient care in heart disease, cancer, and stroke. 30. Medical Libraries. 64 The Commission recommends that the National Library of Medicine be authorized and adequately supported to serve its logical and necessary function as the primary source for strengthening the nation's medical library system. 31. Wational Medical Audiovisual Center. 65 The Commission recommends that the Public Health Service Audiovisual Facility be enlarged in scope and strengthened so that it may become a National Medical Audiovisual Center. 32. Statistical Programs. 66 The Commission recommends improved systems for the collection, interpretation, and dissemination of statistics essential to the understanding and efficient control of heart disease, cancer, and stroke. - 33. Animal Resources for Biomedical Research. 67 The Commission recommends additional appropriations and authority as needed to enable the Division of Research Facilities and Resources, NIH, to support an improved national 1 : program of construction of laboratory animal facilities, to construct special regional facilities, and to support the ; training of specialists in the care of animals needed for : biomedical research. Recommendation 3h. 35 « A Clearinghouse for Drug Information. The Commission endorses current proposals for the establishment of a National Drug Information Clearinghouse, in association with the National Library of Medicine, serving and supporting governmental and nongovernmental drug information units. International Research and Training Programs. The Commission endorses the principle that support of research outside the United States by competent foreign nationals, collaborative: research involving American and foreign labora- tories, training of American scientists in foreign laboratories and of foreign scientists in American laboratories are in our national interest, and endorses programs designed to achieve such ends. Page 68 68 RECOMMENDED CHANGES IN LEGISLATION AND ORGANIZATION Recommendation Page l. Revision of the Public Health Service Act. 70 It is recommended that the Department of Health, Education, and Welfare establish a task force to develop a comprehensive revision and recodification of the Public Health Service Act by November 1, 1965. Expansion of Resources for Preparation of Health Manpower. TL The Commission recommends that legislation be sought to permit forthright support of medical education, this program to include formila grants to the health professions schools. Immediately, there should be full utilization of the Health Professions Educational Assistance Act of 1963 and the Nurse Training Act of 1964. The Commission further recommends substantially greater and more diversified Federal support of programs designed to increase the supply of physicians, dentists, and medical scientists. Construction and Operation of Health Research Facilities. 71 A. There should be an increase in the annual appropriation authorization for health research facility construction from the present $50. million to at least $150 million. B. The participation by the Federal Government should be increased from 50 to 75 percent. C. New substantive authority should be given to construct, on & nonmatching basis, and to provide for the operation of, by contract or otherwise, research facilities for national regional research purposes. Construction and Operation of Facilities for the Application Te of the Fruits of Research. New substantive authority should be given for initial construc- tion, renovation, equipment, and development of regionally oriented diagnostic and treatment stations and to provide necessary incentive through partial operating grant support for a nucleus of highly qualified staff in these stations. Authorization for Necessary Transfer of Program Funds within 72 an Institute, and for Limited Transfer of Funds between Institutes. A. It is recommended that the Institute Directors, after appropriate consultation, be given the authority to transfer funds within their overall annual Institute appropriation. B. The previous authority of the Director of the National Institutes of Health to transfer limited funds from one Institute to another should be reinstated. Recommendation eee . - - . Page 6. More Effective and Flexible Use of Grants and Contracts for Research and Development. 73 A. The Public Health Service should be given basic authority in research contracts to: 1. Commit support for extended periods of time, e-g., up to 5 years and advance payments; ; 2. Provide. for construction when such is essential to the accomplishment of the contract purposes; 3. Contract for clinical and domiciliary care where necessary to achieve research purposes; 4, Provide for the design and conduct of broad and comprehensive research and development programs in which the contractor has wide latitude for action in achieving a given objective. B. The Public Health Service should be given mitiple-year fund availability for research and development activities. Project Grant Authority for Heart Disease Control, Cancer Control, and Chronic Disease Programs, and for the National Center for Health Statistics. Th It is recommended that the Heart Disease Control, Cancer Control, and Chronic Disease Programs, and the National Center for Health Statistics be authorized to make project grants. Authorization for a Program for the Support and Stim lation of a National Medical Libraries Network. és) A legislative proposal should be developed and enacted providing for the support and stimulation of a National Medical Libraries Network. Particular attention should be given to authorizations relating to recommendations of the President's Commission on Heart Disease, Cancer, and Stroke concerning the establishment of a network of medical libraries including a limited number of regional libraries; library Pacility construction; training for medical librarians; and a program of research designed to improve systems and methods of handling medical literature. Establishment of Revolving Fund for the National Medical Audiovisual Center. 5 It is recommended that authorization for the establishment of a revolving fund with any necessary authorities to permit the sale or rental of medical audiovisual productions as appropri- ate be given to permit the National Medical Audiovisual Center of the CIC to carry out its function with maximum efficiency. 9 Recommendation Page 10. Comprehensive Amendment to the Vocational Rehabilitation Act 6) It is recommended that the Department of Health, Education, and Welfare establish a task force to develop a comprehensive revision of the Vocational Rehabilitation Act by November 1, 1965. ll. Amendment of the Commmity Health Services and Facilities Act.- 76 That the Commmity Health Services and Facilities Act be amended to eliminate the phrase restricting projects to those pertaining to “outside the hospital particularly for chronically i11 or aged persons” and suspension of the appropriations ceiling pending overall amendment of the Public Health Service Act. 12, Reorganization. 77 The Commission recommends that a reorganization of the Department of Health, Education, and Welfare be effected to provide specific high-level policy, direction, and coordination of health programs, with adequate supporting policy positions. STATUS OF THE IMPLEMENTATION - OF THE RECOMMENDATIONS OF THE PRESIDENT'S COMMISSION Recommendation of Administration Final Action President's Commission Proposal by Congress 1. Network of Regional Modified version incorporated P.L. 89-239 Centers for Heart in S. 596 and H.R. 3140 as Disease, Cancer, and part of Regional Medical Complex Stroke oe 2. Diagnostic and Treat- Modified version incorporated Deleted from ment Stations in S. 596 and H.R. 3140 as P.L. 89-239 part of Regional Medical Complex 3. Development of Modified version incorporated § P.L. 89-239 Medical Complexes in S. 596 and H.R. 3140 4, Development of Use of General Research Support No action Additional Centers Program for: required of Excellence , Health Sciences Advance. Awards and Biomedical Sciences Support Grants. Health Professions Educational P.L. 89-129 and Assistance Program P.L. 89-290 2+ National Stroke Not Incorporated in Administra- None Program Unit tion proposal 6. Commnity Planning H.R. 10586, FY 1966 P.L. 89-199 Grants Supplemental Appropriation (lst HEW Supple- $1.2 million for research and mental Appropria- training grants tion Act) $1.2 million - CH f- Commnity Health Same as above P.L. 89-199 Research and Demonstration | 8. Support of Commnity H.R. 10586, FY 1966 Supple- P.L. 89-199 Programs and Rehabili- mental- Appropriation tation Commnity Health Practice $1.2 million - CH $1.2 million (same as 6 & 7) VRA $2 million--research and $6.1 million - VRA demonstration $.6 million--training $2.5 million--special centers program 10. dl. 12. 13. 1, 15. 16. 17. 18. Statewide Programs for Heart Disease Control National Cervical Cancer Detection Program Continued Education of Health Professions “Public Information on Heart Disease, Cancer, and Stroke Blomedical Research Institutes Specialized Research — Centers Expanded Support of Research Project Grants in Heart Disease, Cancer, and Stroke Contract Authority for Research and Development General Support for Research Standard Policy for Full Payment of Research Grants Costs H.R. 10586, FY 1966 Supp. Approp. $2.5 million - CH H.R. 10586, FY 1966 Supp. Approp. ~- $5 million for hospital based demonstrations S. 596 and H.R. 3140 H.R. 10586, FY 1966 Supp. - $1 million for Health Comm- nications - CH No new program No proposal H.R. 10586, FY 1966 Supp. - additional funds for categor- ical research centers H.R. 10586, FY 1966 Supp. Appropriation $2.3 million - NCI $2.3 million - NAT $1.0 million - NIGMS $2.3 million - NINDB H.R. 2984 - §. 512 Proposed language in Health Research Facilities Amendments of 1965 H.R. 10586 $.2 million additional General Research Support Funds for FY 1966 Long~standing proposal 2 P.L. 89-199 $2.5 million - CH P.L. 89-199 $5 million - CH .P.L. 89-239 - CH P.D. 89-199 $1 million © None None P.L. 89-199 PL. 89-199 $7.9 million for NIH P.L. 89-115 P.L. 89-156 $.2 million P.L. 89-156--Sec. 203. "None of the funds provided herein shall be used to pay any recipient of a grant.. the entire cost of such project." 19. 20. el. 22. 23. ah. Expansion of Resources for Preparation of Health Manpower Recruitment for Health Professions Undergraduate Training in Medical and Dental Schools . Training for Research Support of Clinical Training Stabilization of Academic Positions H.R. 3141, S. 595 Health Professions Amendments of 1965 "Sclence and Cancer" series for high school science courses and program for improvement of college science curricula Further proposal under study $19 million additional over FY 1965 for Fellowships and Training Grants (of which $4 million is for research career development awards) (H.R. 7765) H.R. 10586, $7 million addl. New Cancer Clinical Training Grants NIGMS-- Postgraduate Training Addl. funds for postgradu- ate training in Surgery, Anesthes., Radiology NCI--Undergraduate Training Program BSS/CH-~Specialized Training H.R. 3140 - 8. 596 Modification of program of research career support No proposal for support of elinical faculty 3 P.L. 89-290 No action required P.L. 89-159, $2 million reinstated for NCI Undergraduate Training Program P.L. 89-156, total of $26 million addi- tional for regular FY 1966 - NIH P.L. 89-199, $11 million additional Total: $37 million addl. training funds for total FY 1966--NIH $3 million approx. P.L. 89-199 $1.25 million, P.L. 89-156 . $2.5 million, P.L. 89-199 $2 million, P.L. 89-156 $3 million, P.L. 89-199 P.L. 89-239 No action required None 25. 26. 27. 28. 29. 30. 31. Be. 3h 35 - Training of Health Technicians Training of Specialists in Health Commimnication Continuous Assessment of Health Manpower Needs in PHS-CH Expanding Long-term Care - Facilities Strengthening Federal Hospital Program to Augment Their Contribu- tion to Research, H.R. 10586, FY 1966 Supp. Approp. $1 million for Cancer Control Program No proposal H.R. 10586, FY 1966 Supp. Approp. $.5 million H.R. 7765, $.8 million for a study of current state of nursing homes and their services No proposal Training, and Patient Care Medical [Libraries National Medical Audiovisual Center Statistical Programs Animal Resources for Clearinghouse for Drug Information International Research and Training Programs Administration endorsement of Congressional proposal No proposal No new proposal Proposed by NIH in August 1964--not yet transmitted to Congress No proposal $.150 million increase proposed for OIR in FY 1967 (total of $6.147 million for 1967) y P.L. 89-199, $1 million - CH None P.L. 89-199, $.5 million P.L. 89-156, $.8 million Required maintatning of certain of the hospitals P.L. 89-291 None None House hearings September 30, 1965 (to be resumed) No action None RECOMMENDED CHANGES IN LEGISLATION AND ORGANIZATION Reviston of PHS Act Expansion of Resources Construction & Operation of Health Research Faci- lities (75-25 matching) Construction & Operation of Facilities for the application of Fruits of Research Authorization for Nec- essary Transfer of Pro- gram Funds within an Institute, and for Limi- ted Transfer of Funds between Institutes More Effective & Flexible Use of R&D Grants & Con- tracts. ' A. Research Contract Authority: 1. extended periods &@. 5 yr. commit- ments bo advance pay~ ments 2. Essential con- struction 3. clinical & domi- cllary care for research pur- poses Study by Surgeon General and Department Advisory Group H.R. 3141, S. 595, Health Professions Amendments of 1965 H.R. 2984, S. 512 (50-50 matching) H.R. 2984, S. 512, Health Research Facilities Amend- ments of 1965-"Regional & National Facilities" authority H.R. 7765, FY 1966.Pres. Budget-under "General Re- search & Services" No proposal Delegated- authority rests with Secretary H.R. 2984, S. 512 General Courisel indicated in May 1965 that this should be proposed to Congress Hearings by Rogers Committee, Inter- state & Foreign Com. Commission P.L. 89-290 P.L. 89-115 $280 million for 3 years (50-50 matching) Deleted by House from final version of P.L. 89-115 Deleted No action No action required P.L. 89-115 No action 9 Lo. 12. 4, wide latitude for contractor in achieving R&D objectives B. Multiple Year Funds for Research & Development Project Grant Authority for Heart Disease & Cancer Control Programs, Chronic Disease Pro- grams & National Center for Health Statistics National Medical Libraries Network Revolving Fund for National Medical Audio- visual Center Comprehensive Revision to Vocational Rehab. Act by Nov. 1, 1965 (Task Force) Amendment of Community Health Services Facili- ties Act to eliminate provision concerning "outside the hospital particularly for chroni- cally 111 or aged" stipulation Reorganization of DHEW Administratively possible now Some programs--Regional Medical Programs Medical Libraries H.R. 10586, FY 66 Supp. Approp. $8 million in Cancer Control Project Grants No proposal for other areas Administration endorsement of Congressional proposal No proposal No Task Force H.R. 6476 - Partial revision proposed by Administration No proposal Study by Surgeon General and Advisory Group 6 No action required P.L. 89-239, 2 year funds authorized, 14 year funds allowed P.L. 89-291, 2-year P.L. 89-199 $8 million P.L. 89-291 No action P.L. 89-333 (H.R. 6476 plus Committee amend- ments) No action House hearings of Rogers Committee of Comnittee on Interstate & Foreign Commerce - HEART DISEASE, CANCER AND STROKE 1966 SUPPLEMENTAL* NIH - $20,250,000 $7.9 - Research Grants $11.05 Specialized Training Grants and Fellowships $ 1.3 Program Direction $5.15 NCI 5.05 NHI 4.55 NIGMS 5.50 NINDB Also - Increased for support of clinical research facilities ~ NIH Residency and post-graduate training in radi- ology, anesthesiology, and surgery - NIGMS VRA - $6,100,000 $2.0 - Research and demonstration in HDCS 1.6 - Training 2.5 ~~ Special Center program - for rehab. research and training in HDCS Community Health Chronic Diseases - $12,800,000 $1.0 - Research grants 2.5 - Heart disease control (formula) 8.0 - Cancer Control Project Grants $5.0 - Hospital~based cervical cancer control 3.0 - Clinical training (residents, g.p., and technicians) 0.8 - Other 0.430 - Administration of cancer control 0.070 - Care and preventive services Community Health Practice - $2,700,000 $1.0 - Research grants 0.2 - Research training grants 1.0 - Health communications 0.5 - Community health manpower * 1966 HEW Supplemental Appropriation to provide funds for those activities related to the recommendations of the President's Commission which could be supported under legislative authority existing prior to the passage of P.L. 89-239.