Hill-Burton Act (1946)

Roger K. Newman

Depression and war had taken their toll on hospitals by the end of World War II. Many hospitals had become obsolete, and over 40 percent of the nation's counties had no hospital facilities at all. In early 1945 Senators Lister Hill of Alabama and Harold H. Burton of Ohio introduced a bill to construct new hospitals throughout the nation. Hill, a progressive Democrat whose father was the first American to suture a human heart, was the driving force. Their proposal languished in the Senate Education and Labor Committee until November 1945 when President Harry S. Truman announced a comprehensive, prepaid medical insurance program for all Americans, tied to Social Security.

Suddenly, to deflect Truman's plan, the bill emerged, rewritten by the American Hospital Association. Its centerpiece was a five-year program authorizing $75 million annually for hospital construction according to a formula devised by Ohio Senator Robert A. Taft, based on population and per capita income, which favored poorer rural and Southern states. When some senators from larger states objected that the bill ignored the needs of low-income patients, its sponsors stated that facilities agreed to promote a "reasonable" amount of medical services for free or at reduced charges for persons unable to pay in return for federal funds. This program, by default, established the first provision for the uninsured in American law.

In order to secure Southern votes Senator Hill added a provision permitting hospitals to segregate patients and doctors according to the "separate but equal" formula. This was the only time in the twentieth century that racial segregation had been codified in federal legislation, and it remained so until 1963 when a federal court ordered desegregation of facilities. Notwithstanding, compared to the political explosiveness and high cost of national health insurance, it seemed relatively risk-free and inexpensive. The bill passed with little fanfare, becoming law on August 13, 1946.

The law introduced the concept of state and local cost sharing-matching funds. Federal "seed money" and "joint tithing," Hill later said, was in keeping with the biblical injunction "where your treasure is, there will your heart be also." By 1968 it had helped to finance 9,200 new medical facilities, with a total of 416,000 new beds. By 1975 when expenditures ended under the act, the federal government had assisted in financing almost one-third of all hospital projects in the nation, contributing about 10 percent of the annual costs of all hospital construction. The act's standard of 4.5 beds per 1,000 people was nearly double the average twenty years earlier. Many rural areas had access to hospital care for the first time.

The law grew to address other needs. A 1954 amendment added long-term facilities, rehabilitation centers, and outpatient departments. Amendments in 1964 established a precedent for the use of public funds to subsidize planning by voluntary health agencies. The act provided a model for federal and state standards for the design, regulation, and financing of facilities that nursing homes later used.

By 2000 the Hill-Burton Act dispensed more than $4.6 billion as well as $1.5 billion in loans to nearly 6,800 healthcare facilities in over 4,000 communities, which in turn provided free or reduced charged services to persons unable to pay for them.

BIBLIOGRAPHY

Hamilton, Virginia V. Lister Hill: Statesman from the South. Chapel Hill: University of North Carolina Press, 1987.

Perlstadt, Harry. "The Development of the Hill-Burton Legislation: Interests, Issues and Compromises." Journal of Health and Social Policy 6, no. 3 (1995): 77–96.