There has always been government-subsidized health care in the United States. Until just after the Civil War, when state governments took more power, most Americans assumed that their local government would tax and spend to take care of the neediest. They frequently griped about the cost of these expenditures, as complaining about taxes is a long American tradition. But for about three centuries from the beginning of British North America, almost no one thought government-provided health care for the poor should go away.
That has changed. Congressional Republicans have campaigned for years on the plank that government’s involvement in health care should partially go away, including its funding of programs for low-income Americans. The Obamacare replacement bill proposed by House Speaker Paul Ryan last month aimed to roll back Medicaid spending at the federal level, which would encourage states to do the same. That legislation failed, but Republicans in Washington continue to look for ways to curb spending on coverage. Yet these efforts to divest government cut against the long history of health care in the United States.
British settlers in North America brought with them the laws of Britain, including measures pertaining to health care. Just a few years before the settling of Jamestown colony in Virginia, Parliament had reorganized a hash of different laws into one big “Elizabethan Poor Law,” which dictated how governments assisted the poor in Britain from 1601 until a major revision in 1832. In British America, the law was adopted by the earliest colonial governments, and government’s involvement in health care was part of the civic fabric—like jury duty and rounding up stray animals. George Washington himself oversaw its provision early in his political career. Starting at age 30, Washington served on the Truro Parish Vestry, a kind of citizen board that assisted the local Church of England parish. As church and state were intertwined in colonial Virginia, this was the body that oversaw tax-supported poor relief, including health care, in that area.
During the Revolution, government-subsidized health care for the poor was part of the self-government cherished by the rebels who fought the war. Recall that the revolution began in Massachusetts, where one of the Intolerable Acts, the Massachusetts Government Act, restricted the ability of local governments to run their own affairs. After the Revolution, newly independent states retained the poor law, making only modest revisions.
Ironically, the law remained virtually unchanged longer in the United States than it did in Britain. By the time New Deal programs began to augment poor relief in the 1930s—because state and local governments during the Great Depression could no longer fund it alone—the oldest American states had been using the Elizabethan Poor Law, more or less, for 300 years.
The details varied from one state to the other, but four principles of the poor law were the same. First, parents and children were legally required to help each other when they were in need. If they could not, then the local government was legally required to step in. Second, poor relief was a function of that local government—whether a town, municipality, city, county, or parish—and not state or national officials. Third, all those who required aid had to be provided with basic provisions: food, shelter, warmth, and medical care. Fourth, all those in need who were not from the town where they sought care or shelter could be banished, with the intention that they return to their hometowns where they would be guaranteed assistance. Until the Great Depression, most Americans paid for health care out of pocket; it was only if costs were too great that they appealed to poor relief for help.
How the poor law’s four principles were applied varied not only from state to state, but also from one town to the next. The law determining who was from a town (or who had a “settlement” there, in legalese) could be very complicated. The simple version was that if one’s ancestor had owned real estate in the town, one had a settlement there until a more recent ancestor—or, in a woman’s case, her husband—bought land somewhere else. The officials who implemented the poor law in a given area, usually called overseers of the poor, had great discretion in deciding who was in need and how best to keep them fed, clothed, housed, and doctored. Bills stemming from doctor and nurse visits, as well as medicine, were part of what made poor relief the biggest expense for almost every local government at the time of the American Revolution.
Indeed, poor relief was the single largest expense in almost every local-government budget until schools and roadwork caught up in the mid-19th century. Larger towns and cities had enough poor patients to build institutions devoted to the health care of the neediest. By 1826, New York City had a dedicated public hospital for the poor and sick called Bellevue. Bellevue was very much in the tradition of the Elizabethan Poor Law: a local institution, funded by local taxpayers, aimed at local needs.
This all meant that local taxes were by far the heaviest tax burden on Americans from the Revolution through the Civil War; by contrast, state taxes were relatively low and federal taxes rare exceptions. For example, Providence, Rhode Island, spent almost $8,500 on poor relief, out of a total budget of $11,300, for the fiscal year ending August 1, 1800. That total would simply be divided up among area real-estate owners for payment, so variations in poor-relief expenses each year would immediately be felt by taxpayers.
But it wasn’t just the needy who benefited from this tax money—so did the townspeople who provided shelter, goods, or services. These included grocers, clothiers, firewood providers, doctors, nurses, and homeowners who housed the homeless. Each of these various townspeople contributed to their own sustenance by being part of what one historian, Elna C. Green of San José State University, has called “the welfare-industrial complex.”
“One-Eyed” Sarah was one such person—an ordinary woman who earned money by caring for the needy, serving as a nurse in Providence in the first decade of the 19th century. While there were many nurses like her around the country, Sarah’s work was described in a newspaper article in 1811. The article read that she was chosen by a pair of paupers “in a situation not fit to be mentioned,” who’d specifically requested her help. Sarah nursed them back to health while being paid by poor-relief taxes. This dynamic seems more modern than perhaps expected: Not only did this pair have health care provided by the government, but they had some say in who their health-care provider would be. Of course, the quality and quantity of the care given could vary, depending on the priorities of the overseers of the poor. The copious receipts that still exist in town records—which paid for doctors, nurses, and medicine—suggest that overseers typically took this responsibility seriously.
By the mid- to late-19th century, state governments began assuming more responsibility for health care. The first state board of public health, created in Massachusetts in 1869, is a good marker of the rise of states’ involvement. A trend toward professionalization and state-level oversight had begun in the 1840s and 1850s, but had been interrupted by the cataclysm of the Civil War. Only in the years following did states begin to enact policies that they were too preoccupied and cash-strapped to pursue during the war. They began building their own poorhouses, facilities for the mentally ill, and other institutions. Hospitals and non-psychiatric health care, though, remained largely run at the local level. Cities continued to build new public health-care institutions, such as San Francisco’s Laguna Honda Hospital, which had completed its transition from poorhouse to public hospital by the 1920s.
Though it had been around for decades, private health insurance didn’t become popular among consumers until the Great Depression. Hospitals began offering insurance, in part, to encourage cash-strapped patients to use their services. The Great Depression also set the stage for the federal government to jump into poor relief in a big way. The Social Security Act of 1935 was intended, in part, to empty local poorhouses of their elderly occupants, allowing older Americans enough of a retirement income to be able to live at home. Between Social Security, unemployment insurance, and welfare for single mothers of dependent children, poorhouses began to fall out of use in the generation after the Great Depression. Many closed their doors in the mid-20th century. Local poor-relief offices were transformed, serving in large measure as administrators of state and federal programs.
The larger landscape of health care also changed. Private health insurance spread during the 1930s, 1940s, and 1950s. In the 1960s, President Lyndon Johnson’s administration added health-care insurance to the Social Security Act for both Social Security recipients—through Medicare—and the poor or disabled through Medicaid. Despite all of this, local institutions providing health care to the poor continued to find patients, and some continue to provide local, tax-supported health care to this day.
In my hometown of Oshkosh, Wisconsin, the county-supported hospital founded in 1875 has quietly survived for more than 140 years. Built as a home for the poor, it remains a popular long-term-care hospital for patients of any income, supported in part by county taxes. Visitors to the spruce, cheerful building might not know that their local taxes help support it, just as local taxes have been doing for centuries. Americans seem to have lost an understanding of government’s historical role in health care, as most of their political battles target programs just a few years old. Also lost is the promise the poor laws made for more than 300 years: If you need health care, you will receive it, thanks to the people you belong to.