Hundreds of huge voluntary and non-profit old-age homes were built in the late 1800's and early 1900's, many set on large pieces of property with farms or gardens to help support the residents of the home. As their populations grew, they added additional buildings, like hospitals, barns, and homes for some of the staff. Some became small cities in themselves.
The number of people living to old age and the number of years they spent in old age continued to increase. The average life expectancy at birth increased by 10 years from 1900 to 1930, and increased by another 15 years from 1930 to 1990. This change occurred largely because fewer people were dying in childhood, so larger percentage of the population lived to old age. (Changes in Life Expectancy)
In 1900, those hardy souls who outlived diseases and injury in childhood and early adulthood had nearly as many years ahead of them as today's seniors do, and finding a place where they could live for what might be a fairly lengthy period of time was just as important then as it is now. People who reached age 65 in 1900 could expect to live another 10-12 years. Those that reached the age of 85 could expect to live another 4-5 years. (Changes in Life Expectancy) To underscore the fact that the elderly of this period could live a very long time, an 1898 magazine article names hundreds of people who lived to the age of 100 or older, including a man alleged to be the oldest person in the United States -- a pauper who died in a North Carolina almshouse in the summer of 1896 at the reputed age of 128 years. (North American Review, 1898)
At the same time, the United States had become an urban society. At the start of the twentieth century, 40% of the population lived in the cities, and by the end of the century over 75% of the population were city-dwellers. (Changes in Urban/Rural U.S. Population) Some of these people were coming from the rural areas, and others from the flood of immigrants entering the country for the first time.
As the population of the cities swelled, only the rich could afford to build new buildings, and they abandoned homes in the city centers to move farther out. For everyone else, this meant that more and more people had to pack themselves into the buildings that already existed in the central cities, creating the tenements. Rooms in old buildings were divided and subdivided into apartments that sometimes didn't even have a window, until, as the New York City health department put it, "There are numerous examples of tenement-houses in which are lodged several hundred people that have a prorata allotment of ground area scarcely equal to two square yards upon the city lot, court-yards and all included." (Jacob Riis, How the Other Half Lives, 1890)
This had an impact on the care of older family members:
"The cost of maintaining an aged relative in the country is so small as to seem an insignificant burden. In the crowded tenement houses of modern cities the situation is very different. Here, as industry is now organized, there is little for an aged person to do. The positions for which men or women over sixty- five years of age are suited are few, and there is always an excess of old men and women looking for such positions. Furthermore, the cost of maintaining an aged relative in the city is an appreciable item in a wage earner's budget, and even when the burden is cheerfully borne, it means so much less for other necessary family expenditures." (Seager, 1910)
The structure and size of families was changing. City families were much smaller than country families. In the country, a large family was an economic asset, but city children were economic liabilities. They had to be housed and supported, but couldn't contribute to the support of the family for many years. It was not economical to have a lot of children, and the shrinking size of families would continue to have an impact far into the future, when fewer children would be available to provide for their aging parents.
City-dwellers also overwhelmingly worked for others, rather than for themselves, in jobs they could not do indefinitely. Many working class jobs required physical strength and endurance, and employees would be let go when they no longer were able to do the work. Some jobs were dangerous, and injuries could create involuntary "early retirement". These "long term care" recipients lost their salary, and were financially dependent on their wives and children, who often could not earn enough to support the family. (Jane Addams, 1899) (Federal Writer's Project, 1939)
For the first time, older people faced the prospect of being unemployed, a word which wasn't even in the dictionary before 1888. (Social Security, 1937) If older people couldn't work, they had to depend on their families even more. In this new society, unemployed and unemployable older men and women could become a significant financial burden on their families.
Around the turn of the century, tuberculosis or "consumption", the "White Plague" of the eighteenth and nineteenth centuries, became epidemic. Tuberculosis was highly contagious, and spread rapidly in the newly-urban society because so many people were living crowed together in cities. Since the disease was so contagious, patients to be separated from the general population, preferably out in the country where they could get plenty of fresh air, which was believed to be a necessary part of curing the disease.
The spread of tuberculosis was instrumental in spurring the development of public institutions designed to provide chronic care, since patients needed to be maintained for a fairly long period of recuperation. To effectively control the disease, even those who could not pay for their care had to be removed from the general population and cared for at the expense of governments or charities. A large percentage of these patients were indigent. For instance, it was estimated that 85% of those stricken with tuberculosis in Michigan were unable to pay for their own care. (Medical History of Michigan, 1930)
New buildings were built for this purpose by state or local governments, preferably with an attached farm to help provide for the cost of caring for the indigents. Some counties found a perfect spot for these buildings on land they already owned -- their poor farms, which already had working farms and were generally located far outside the city walls. Over time, conditions improved in the sanitariums as laws were changed and the government and medical community learned how to provide chronic medical care in institutional settings.
"The [Michigan] county sanatorium law of 1925... insures high standards and adequate financial support. The standards require that a sanatorium have a minimum capacity of fifty patients, thus eliminating the old, small tuberculosis hospital that was often nothing more than a boarding-home or retreat for consumptives on county poor farms, where doors and windows were shut, and where medical treatment occasionally consisted of self-administered cough medicine. The institution must employ a full-time physician, provide modern X-ray equipment, have a graduate nurse as supervisor of the nursing staff, and must furnish patients with occupational therapy work." (Medical History of Michigan, 1930)
While the professional nurses and nurse training schools had originally emerged to serve the hospitals, there was a growing demand for nurses to care for the sick in their own homes, either as "private duty" nurses, who were paid directly by the family to care for an elderly or infirm family member, or as "visiting nurses" working for an agency. Dozens of nurse training schools opened or expanded their programs to accommodate the need.
In many places, local families would approach the nursing schools looking for help, and the schools would arrange for their students to serve as private duty nurses during their studies. Once the new nurses had graduated, many returned to their home communities. Individual nurses needed a way to find the families that needed help, and families needed a way to contact them. To bring some order to the process of finding and hiring private duty nurses, the Michigan nursing association established a central registry. Nurses who were willing to go out on call would list their names on the registry and work for a set daily fee. Eventually, there was a need for nurses who could work for less than a whole day, and an hourly fee schedule was established, as well. (Medical History of Michigan, 1930)
The "Visiting Nurse" associations around the country were growing. By 1905 there were 455 visiting nurses in the country employed by 171 visiting nurse associations. By 1909 that had tripled to 1,413 nurses employed by 566 associations. The growth was fueled as the organizations started getting financial support from sources other than private charity. State and local boards of health and education began to sponsor public health nursing, which was focused on prevention and education. In 1912, the American Red Cross created a rural visiting nurse association. The response to the Red Cross program "was so tremendous that the Red Cross could not keep up with the chapters' demands for nurses." (Indian River)
In 1909, Lillian Wald convinced Metropolitan Life Insurance Company to finance home care: "Armed with data documenting that nursing care saved lives, Wald urged MetLife to hire visiting nurses to care for policyholders during illness. For a modest fee per policy, Wald believed that MetLife could reduce the number of death benefits paid." (VNSNY)
The program was so successful that in 1911, it was expanded nation-wide. MetLife hired visiting nurses to provide the services, and, by the close of 1916, they had made visiting nurses available to over 90% of their 10.5 million industrial policyholders in 2,000 cities. The insurance funding gave the home nursing agencies a new source of income which allowed them to thrive, and from 1909 to 1924 the number of visiting nurse agencies in the country more than doubled, from 1,413 to 3,183. (VNSNY) (Indian River)
As more people became unable to support themselves or rely on their families in their old age, there were movements in various states to provide public cash assistance to the poor elderly in order to keep them out of the poorhouses. Arizona enacted a law in 1914 which abolished almshouses and provided pensions for aged persons and people with disabilities. That law was declared unconstitutional by the State Supreme Court in 1916, but they made some changes and passed a law that did conform with the constitution.
Most of the state old-age assistance laws were somewhat limited. For the most part, the state would help to finance the cost of assistance only for people who had no other source of income, and only if counties could pass old-age pension laws and pay for part of the cost themselves. This meant that welfare varied, not just from state to state, but from county to county. (Old Age Security Staff Report, 1934)
Another limitation of these plans was that they applied a "means test" against both the elderly person and any of his or her relatives before awarding benefits, to ensure that none of them was financially able to provide any help:
"I should like to point out one very significant factor which differentiates the old age pensions in the United States from the systems prevailing in other countries, and that is the introduction of the 'means test' not only for the aged themselves but for their so-called responsible relatives... American pension legislation evidently assumes without argument that...support by children, is at least as desirable as, or perhaps preferable to, public support through old age pensions. It makes the violent assumption that wherever such support is found it represents a socially satisfactory answer to the problem of old age. It says little concerning the social cost that the imposition of this burden of support of the aged upon their children represents; it gives no consideration to the lowering of the standard of living of millions of families and their children. It assumes that the average wages today are sufficient not only for the maintenance of the worker and his wife and children, but even of ancestors." (National Advisory Council, 1934)
Progress had been made for older adults who were not disabled or in need. In 1896, New Jersey created the first state-sponsored pension plan for teachers. In 1911, the first pension program for all state government employees was instituted in Massachusetts. In 1920, the Civil Service Retirement Act created a retirement system that covered many governmental employees.
More private companies were providing retirement programs. By 1910, Seager would write:
"Already twenty or more such corporations, including the American Steel and Wire Company, the International Harvester Company, the Standard Oil Company, the Metropolitan Street Railway Company, and the Western Electric Company, have [pension] plans in operation, and many more are contemplating their introduction." (Seager, 1910)
Financial institutions were also developing new products aimed at helping people prepare for retirement:
"The Massachusetts Savings Bank Insurance system was introduced three years ago, for the purpose of bringing cheap life and old-age insurance within the reach of all wage carriers who patronize the savings banks...[and] the Metropolitan Insurance Company has recently offered a combined life and old-age annuity policy at rates that bring it within the reach of all wage earners, except the very poorest, who have the forethought to provide against these contingencies. The Metropolitan Company has also sought to have the insurance laws of the various states amended to enable it to offer group policies." (Seager, 1910)
Somewhere between 2% and 4% of the population age 65 and older may have been living in some sort of institutional setting prior to the Great Depression. Not all of these people needed "long term care". In some cases, they just had no other place to go. Only estimates are available because there were no reliable national statistics available.
Bruce Vladeck estimated that by 1930 there were as many elderly people in facilities for the mentally ill as there were in poorhouses and voluntary and charitable facilities combined. If his estimates are accurate, about half of the total elderly population living in an institution in the early 1900's may have had some sort of mental disease or condition, about the same ratio as we see in nursing homes and assisted living facilities today. (Estimates of Institutionalized Population)
|The Age 65+ Population||1900||1910||1930|
|Age 65+ as % of total population||4.1%||4.3%||5.4%|
|Total population (millions)||76||92||123|
|Population age 65+ (millions)||3||4||7|
Source: Vladeck, 1980; Johnson, 1985
|Institutionalized Population by Location||1904||1910||1930|
|Institutionalized residents as % of 65+ population||2%||2%||3%|
|Facilities for the mentally ill||20,000||35,000||100,000|
|Poorhouses & almshouses||53,000||46,000||50,000|
|Voluntary and proprietary facilities||??||??||50,000|
Source: Vladeck, 1980; Johnson, 1985
A staff report prepared for the committee that studied old age security in 1935 relied on a few reports done in individual states. One of the more comprehensive surveys was done in New York just prior to the 1929 stock market crash. It determined that 50% or more of the age 65+ population was dependent on relatives or friends (either living with them or getting financial assistance from them to live somewhere else), 2.5% were living in poorhouses or mental hospitals, and 1-2% were living in private homes for the aged. If those percentages were representative of the national experience, that would mean that about 175,000 people age 65 or older were living in poorhouses or mental hospitals and 70,000 were living in nonprofit or proprietary homes. Note that a significant percentage were self-sufficient because they were still working. (Estimates of Institutionalized Population)
|Self-Sufficient||Persons 65 and over||Persons 70 and over|
|Living on personal savings||5%||5%|
Source: Old Age Security Report
|Dependent||Persons 65 and over||Persons 70 and over|
|Dependent on relatives or friends||49%||56%|
|In community with public or private charity||3%||4%|
|In poorhouses or other government institutions||3%||2%|
|In nonprofit or proprietary homes||1%||2%|
Source: Old Age Security Report