The United States Was a Young Society

The United States in the 1700's was predominately comprised of young people for a variety of reasons. Life expectancies were much shorter than they are today, primarily because so many people died in infancy or childhood. That meant that a relatively small percentage of the population lived to old age.

Other that the Native Americans, the country was populated almost entirely by immigrants, many of whom came came from England or other parts of Europe. Getting here required an extremely hazardous ocean voyage, and life on the new continent was equally difficult. The immigrants who came here voluntarily were either fleeing from persecution or were poor and hoping for a better life in the new world, the only reasons they would take such a risk. Few people who were old or ill would have attempted such a trip, and many of those who did probably died in the process. The slave population was also young. Slave-traders were not going to waste their time bringing over those who were old or ill, and relatively few slaves survived long enough in the harsh conditions most of them endured to live to old age. 

Old Age Security Was Children or Wealth

In the early years of this country, few people lived to old age, but for those that did, "old-age security" meant having children or property. Having family living nearby wasn't often an issue. In those days before railroads and automobiles, families were large and few children ventured far from home. 

Before 1800, less than 5% of the U.S. population lived in cities. Everyone else resided in rural areas where extended families could live together easily and cheaply. Generally, people worked for themselves. As a 1937 Social Security pamphlet described it, "The home of a pioneer family was a little world in itself. Members of the family were their own farm and factory workers, butchers, bakers, and barbers; policemen and firemen; often their own doctors and nurses, and sometimes their own teachers as well." (Social Security, 1937) You didn't need cash to survive in that economy, and families were fairly self-sufficient.

Having a family was the key to survival. As later described in that Social Security pamphlet,

"A young man then could hardly afford not to marry. He needed a wife as a business partner, children as helpers. In early New England not only spinsters but bachelors were under a cloud. Bachelors, in fact, were regarded with suspicion. Usually they had to live where the court told them to. Single people had to attach themselves to a family to get a chance to work for their living. Both the children and the old people earned their place at the family table." (Social Security, 1937)

Children were expected to split their earnings with, or otherwise provide for, their parents. If a parent needed care, the children were expected to provide it. Elderly people in need of care who were childless but wealthy could hire whatever help they needed. Dependent elderly people who could not be cared for by their own families could be 'boarded out' with surrogate families, and the adult children paid for the cost of that care. Those elderly who were poor and childless, or whose children refused or were unable to care for them, ended up dependent on charity or public welfare. 

Slaves, of course, had neither families nor property. Their families were often split up, so it would have been impossible for children to look after their own parents. The quality of their life in old age was completely dependent on the master they worked for. 

Poorhouses Became Homes for the Indigent Elderly

The public welfare system in the 18th and 19th centuries was a local, not a federal, obligation, patterned on the English "Poor Laws". The Poor Laws established the government's responsibility to provide for those who could not care for themselves, but left the details about how to do it up to the local town or county officials.

Initially, "paupers" were given cash payments called "outdoor relief", which was paid for by the taxpayers of the city or county. As the cost of outdoor relief increased, governments decided to create a more cost-effective system, called "indoor relief". They built poorhouses, almshouses, poor farms, county infirmaries, asylums, or county homes to house people who were too expensive to support with outside relief, and required welfare recipients to go to these facilities if they wanted assistance. In some states, the state owned and operated some or all of the poorhouses, in others, counties or cities ran them. A few states avoided the cost of building and maintaining poorhouses by boarding paupers out, sometimes with their own relatives, or paying farmers to care for them. Tennessee actually auctioned their paupers off to the lowest bidder. (The Atlantic Monthly, 1881)

A common concern of the public at that time was that the opportunity to get free room and board would be so attractive that people would deliberately pretend to be poor so they could live an "indolent life" in the almshouse at the expense of the taxpayers. Consequently, poorhouse life was made as unappealing as possible. The "inmates" were expected to wear a poorhouse uniform rather than their own clothes, and they were not allowed to leave the poorhouse. Many of the poorhouses had attached farms so they could produce their own food and be self-sufficient, and they were often located far out in the country to keep them out of sight. To offset the cost of care, the inmates were expected to do the work needed to keep the operation going. Even the older women were given jobs like sewing. 

Operators also were careful to check before accepting someone into the poorhouse to see if anyone else could be supporting the potential inmate. If a poorhouse applicant had adult children, he might have to prove that his children were unable or unwilling to support him before he would be accepted. The local government was only responsible for people from their jurisdiction, so they could, for instance, refuse entry to a widow who grew up somewhere else. Someone who had lived in several places might find that none of them considered him or her eligible for taxpayer support. This happened often enough that there were bands of poor homeless people who roamed from place to place, staying in each one only until the authorities ordered them to move on.

Concerns about the high cost of operating the poorhouses lead to other indignities. For instance, New Jersey law included a provision forbidding emancipation of slaves who were 40 years old or more "for fear of the distant contingency, that this freedman might become a public burthen to the township, by being a pauper in his old age, and rather than subject the towns to that they preferred to let the man and his posterity remain in slavery." (Library of Congress: Slaves and the Courts, 1740-1860)

As time passed, the poorhouses became catch-alls for anyone who couldn't survive in the outside world, and they became home to poor dependent elderly people, where they lived in the same rooms with "miscreants" (petty criminals), "inebriates" and "intemperates" (alcoholics), orphans, unwed mothers, and the "feeble-minded" (mentally ill). 

Early Federal Pension Programs Created

One alternative to sending people to the poorhouses was to make cash payments to specific groups of disabled or indigent people to help them support themselves in their own homes. For many years, the only group eligible for federal cash benefits of any kind were veterans and their families. Although these payments were often called "pensions", many were dependent on the disability and/or indigence of the recipients, so some of them took on aspects of welfare payments. 

One of the first acts of the new government in 1776 was to authorize pensions for disabled Revolutionary War veterans. The initial military pension law offered half-pay for the rest of their lives to soldiers who were so disabled in the war that they were unable to work for a living. The federal government and the states disagreed about who should pay for and administer the program. The federal government didn't have the authority to raise funds by taxation at that time, so they said that the pensions were to be administered and paid for by the states. The states didn't want to bear the cost and they refused to do anything, so the federal government took back responsibility. However, the newly-formed government hadn't yet created any organized system for accepting and paying pension claims. For several years, a separate act of Congress had to be voted on to appropriate funds for each individual that requested a pension, until, finally, a general appropriation was made in 1790, and a pension law was enacted in 1792.

The rules for veterans pensions were changed numerous times in the next few years. Gradually, veterans benefits were expanded to include pension payments even for those who were not disabled, if they served during certain wars and time periods -- first for officers, then, several years later, for enlisted men. 

Benefits for veterans' surviving spouses came later, and most were limited to spouses who were indigent. In 1780, the first benefit for surviving spouses was created for widows of officers who died in the Revolutionary War. In subsequent years, the law was changed include officers who died in service after the War, and to their children under age 16, if their mother was deceased. Eventually, when the government needed incentives to get men to fight in the War of 1812, benefits for widows and children were made available to enlisted men as well as officers.

Families Disperse and Children Move Away

The country grew quickly and by the 19th century land in the settled areas was no longer cheap. There was a limit to how many times a father could subdivide his land among his children to give them a plot of their own, so more and more children had to leave the family home in order to make a living. Some of them went to the cities to find work, and others moved west where cheap land was available. 

In the early 1800's, much of the travel to the west was on trails like the "Cumberland Road," later called the "National Road," which funneled early pioneers into the midwest. In the early- to mid-1800's, pioneers began to travel farther west on the Oregon Trail, the Santa Fe Trail, and other major wagon train routes. By the middle of the century, the railroads were beginning to make travel easier, and in 1869 the transcontinental railroad was completed, making it possible to ride coast to coast in comparative comfort on a train. 

Railroads encouraged the use of their new western lines by offering to sell land to potential settlers at low prices, over long terms, and at low rates of interest. Later, the federal government decided to further encourage the development of all the western states and territories by enacting the Homestead Act of 1862. The Homestead Act declared that any citizen or intended citizen could claim 160 acres of unoccupied public land in "public domain states," virtually any part of the country outside the original 13 colonies, Tennessee, Kentucky, Texas, and Hawaii. Claimants had to improve the plot with a dwelling, grow crops on it, and live there for five years. If the original filer met these requirements and was still on the land five years later, it was his property, free and clear. The opportunity to get free or low cost land drew millions of people out to the west, including many of the new immigrants pouring in from Europe and other parts of the world.

In 1800, the largest cities in the country were all in the original 13 colonies. By 1850, some of the "gateways" to the West, like Cincinnati, St. Louis, and New Orleans, overtook the eastern cities as the largest cities in the country. By 1900, the Midwest had become quite settled and many of the largest cities in the country were in the Midwest. (Largest U.S. Cities) (Population Percentage by Region)

The westward migration of the country contributed to the dispersion of families. Although a few families took their elderly relatives along on the difficult journey west, a number of the western settlers left their parents and other relatives behind in the East. Some families made several moves, perhaps settling in the Midwest for a time before moving farther west. Each time they moved on, some members of the family might decide to stay put, leaving relatives scattered along the migration route. Over time, the massive westward migration made it less likely that many, or any, children lived near enough to their parents to provide help. 

Many Elderly Live With Children

Family living arrangements have always had an impact on the need for long term care. Women were less likely than men to have accumulated assets of their own that they could use to take care of themselves in retirement, and unmarried people of both sexes were more vulnerable in old age because they had no partner who could provide them with physical and financial assistance. The most vulnerable group of all were unmarried elderly women. 

Older women were far more likely than older men to be unmarried (whether they were widowed, divorced, or never married). Only about one-third of age 65+ women were married in 1880, less than half the percentage of age 65+ men who were married. Although their life expectancies weren't much longer than men's, most women married men who were much older than themselves, so they often out-lived their husbands. Older unmarried women largely had to rely on children and other family members for help, and often ended up living with them. 10% of married women and nearly 60% of unmarried women age 65 or older were living with children or other family members as dependents in 1890. (Costa, 1997)

Poorhouse System Comes Under Scrutiny

The poorhouse population exploded in the early 1800's and conditions in the poorhouses ranged from barely tolerable to horrific. They were often run by people who got their jobs as political favors. The operators often did as little as they could get away with in exchange for a paycheck, and the governing bodies often did as little as possible to keep costs down and discourage over-use. The operators were particularly incapable of caring for mentally-ill residents. Dorthea Dix reported finding women chained and kept in pens in some poorhouses. The insane patients, criminals, and alcoholics frightened, and sometimes injured, the frail elderly living in the same rooms. 

Ending up in a poorhouse was everyone's nightmare. Songs like "Out from the Poorhouse" illustrated the public perception. In that song, a man bemoans the fact that he gave his children his farm and all his savings and they sent him to the poorhouse instead of taking care of him.

The poorhouses were becoming enormously expensive. "Ohio, which is not especially afflicted with pauperism, pays more than half the money obtained by the state taxation for the welfare of her criminals and paupers; and the estimate does not include the public charities of her cities, or any township aid." (The Atlantic Monthly, 1881)

One way to control cost and deter use was by segregating the poor. New York City purchased Blackwell's Island (now called Roosevelt Island) in 1828 as a remote spot for their paupers. On Blackwell's Island they built a penitentiary for criminals, men's and women's almshouses for the poor elderly, hospitals for those who were poor and ill (Charity Hospital, Smallpox Hospital, and the Hospital for Incurables), a workhouse for the able-bodied poor, and a lunatic asylum for the poor who were mentally-ill. (NYC Corrections History)

In response to the growing concerns about abuse and squalid living conditions, nine states (Massachusetts, New York, Rhode Island, Pennsylvania, Illinois, Ohio, Michigan, Wisconsin, and Kansas) created state-run "Boards of Charities" in the mid-1800's to oversee and report on the local poorhouse operations. These boards, precursors to today's Departments of Welfare, were supposed to inspect and control the poorhouses, and the reports they produced led to some efforts to improve conditions and to "classify" residents to separate the insane from the sane, and the dependent elderly from the able-bodied. 

The growing costs, combined with the rising concerns about quality, arose from the inherent conflicts between the desire to provide good care to those who were truly needy and to reduce the cost to the taxpayers.

"Generally, the county officials lean to the side of mercy; the quality is not strained, since it costs them nothing; for, be it noted, there are two sets of principals in the business, the county directors or supervisors, who manage the almshouses, and are responsible for their expenses, and the justices of the peace and poor overseers, who commit paupers to the almshouses, and have nothing more to do with them. It is for the interest of the poor directors and supervisors to have as few paupers in the almshouse as possible; it is for the interest of justices, who are paid for each order they write, and of overseers, who depend for reelection upon the suffrages of the poor but warm hearted populace, to show a liberal spirit. And, as Sydney Smith has observed, everybody is full of humanity and good nature when he can relieve misfortune by putting his hand into his neighbors pocket. Who can bear to see a fellow-creature suffering pain and poverty, when he can order other fellow-creatures to relieve him? The result of all this is that, practically, most States give almshouse lodging to any one having a settlement who can bring himself to ask it." (The Atlantic Monthly, 1881)

There was a lot of debate about society's role in caring for the poor, but by the mid-1800's, many felt that the "deserving" poor, like children, the insane, and the elderly, should get better treatment than the "undeserving" poor, like alcoholics and those who were healthy but shiftless or lazy. Reformers like Dorthea Dix convinced legislatures to develop better facilities to care for the mentally ill, and they were gradually moved out of poorhouses. Laws prohibiting children from residing in poorhouses were passed, and the children were moved into orphanages. 

That left poor, dependent, elderly adults who had no place else to go as the last group of the "deserving poor" who needed a place of their own, but the poorhouse was still the only public facility available for them. They were sometimes treated slightly better than the "undeserving" inmates, as in New York and Boston where the elderly were eventually separated from the rest of the poorhouse population. Nevertheless, they were still in a poorhouse. (New England Magazine, 1898) 

Institutionalization Reigns

In spite of the problems of the poorhouse system, most people seemed convinced that building large institutions was the best way to deal with those who needed help of one kind or another. In the newly industrialized society these institutions built to "efficiently" care for the poor, the sick, and the elderly bore an eerie resemblance to factories. They were large, warehouse-like buildings that housed dozens, or even hundreds, of people. "Inmates" slept in huge dormitories, with their beds beds neatly organized into rows, and ate at huge tables in a dining hall where meals could efficiently be served.

"The poor and the insane customarily were relieved within the family [in the Colonial era], the orphan was apprenticed to a household, the criminal, after being fined and perhaps whipped, was then returned to his residence. The 18th century community had recourse to institutionalization only when some extenuating circumstance--such as debilitating illness or violent insanity--made no alternative arrangement feasible. These ad-hoc institutions that came into being during the colonial era resembled the household both in routine and construction."

"In the decades after 1820, America turned with unprecedented enthusiasm and energy to the construction of custodial institutions for the poor, the insane, the orphan and the criminal. Institutionalization now became the first rather than the last resort. The institution and not the household became the preferred setting...Americans during these years also seem to have shared a confidence in the ability to design an environment and construct a setting in which these faults could be eliminated and the causes of dependency thus eradicated...And, understandably, with the beginnings of a factory system, the institutions built after 1820 were more influenced by and more nearly resembled the factory; whereas those built before 1820 more nearly resembled the household." (Abe Bortz, 1970)

Some Elderly Moved Into Mental Facilities

In 1845, Congress enacted a law giving public land to each of the states "for the benefit of indigent insane persons", and the states started to build insane asylums and hospitals for the insane. Many of the mentally-ill poorhouse inmates transferred to these new facilities were elderly. (Vladek, 1980) 

That group probably included some victims of dementia. The words "dotage" and "dementia" had been used by physicians and researchers as far back as Roman times, but the distinctions between dementia, other types of mental illness, and normal aging were not well understood in the 1800's. The term "senile dementia"  was first used in 1838 by Dr. Jean Étienne Esquirol. Dr. Alois Alzheimer would not discover that "Alzheimers Disease" resulted from plaques and tangles in the brain until 1906. (David Shenk, The Forgetting, 2001)

Early Nonprofit Old-Age Homes Established

In response to the problems of the poorhouses, numerous nonprofit organizations began building old age homes to give "respectable" poor people a way to avoid the degradation of the poorhouse. 

"Benevolent societies" or "fraternal organizations" affiliated with nearly every ethnic, religious, trade, profession, and social group imaginable were established during the 19th century. Hundreds of benevolent societies emerged, including the Irish Benevolent Society, the German Benevolent Society, the Hebrew Benevolent Society, the Odd Fellows, the Masons, and the Knights of Columbus. These were called "voluntary" organizations, because each eligible person could choose whether or not to join. 

Although they had other purposes for their existence, the benevolent societies created one of the earliest organized old-age assistance programs. Members paid monthly dues to the Society while they were young and healthy, then received help when they were elderly, infirm, or in need. The Societies provided cash and food to support people in their own homes. Since that wasn't enough for older members who couldn't live alone any longer, the benevolent societies began to build "homes for the aged" where their elderly members could live. The significant expenses of erecting and maintaining these buildings were paid for by the members of the benevolent societies.

Some of the earliest voluntary homes were designed to house both orphans and the elderly, but eventually state-run orphanages were built and the orphans were moved into them. As that happened, the benevolent societies closed down their facilities for children and concentrated their attention on the elderly.  (Odd Fellows Home History)

New laws were written in the 1800's to allow the creation of charitable organizations that could operate like corporations. In addition to those established by the benevolent societies, many charities were established by bequests from wealthy benefactors, whose wills included stipulations that the money or property be used to provide assistance to people who fit certain criteria, like "deserving widows and deserted wives" or "colored persons over the age of fifty of respectable character" or "old and worn out seamen." To carry out their work, the organizations built "old age homes" to house those who couldn't live on their own.

In sharp contrast to the poorhouses, the voluntary and charitable facilities seemed luxurious. Many were newly-constructed buildings, built specifically to house the elderly, and others were stately old mansions whose owners had died. The facilities were much nicer, but they were still operated with the paternalistic viewpoint of the times. "Inmates" were under the supervision of a "matron" who had complete control. Residents generally had to get permission even to have visitors or leave the facility. In most,  "inmates" were also expected to do chores, and to do sewing or other services that could help bring in money to support the cost of the home's operation. 

Some of these facilities required the recipients to pay an up-front fee and turn over their pensions and any other income or assets they had to the facility, in exchange for a guarantee that they would have a home as long as they needed it. This concept re-emerged a century later as something we now call "lifecare". 

As an example of some of the homes that were built in Brooklyn, New York in this century, Polk's Medical Register lists the following:

• Baptist Home, 665 Greene Avenue, established in 1869 with 60 beds
• Brooklyn Home for Aged Men, 745 Classon Avenue, established in 1878, 150 beds
• Brooklyn Methodist Episcopal Church Home, New York Ave & Park Place, established in 1882, 70 beds
• Denmark Home for Aged, 1051 41st, established in 1906, 20 beds
• German Evangelical Home, Chauncey & Bushwick, established in 1881, 265 beds
• Graham Home for Old Ladies, 320 Washington Avenue, established in 1851, 80 beds
• Greenpoint Home for Aged, 137 Oak, established in 1882, 15 beds
• Home for Aged, 464 Herkimer, established in 1850, 60 beds
• Home of the Aged of the Little Sisters of the Poor, Bushwick and De Kalb
• House of the Good Shepherd, Hopkinson & Pacific, established in 1868, 500 beds

Although they seem to be a precursor to nursing homes, most of the old age homes were more residential than medical. They probably provided something ranging from "room and board" or "board and care" to what we now call "assisted living". There are references to "infirmaries" in some old-age homes, and others included a separate building or section that they called a "hospital" where people who were very ill would be housed. The infirmary or hospital section of these facilities was probably comparable to what we call a "nursing home" today.

Hospitals and Chronic Care Evolve

In studying the evolution of long term care, it's important to understand the way that hospitals were evolving, since there was some overlap between "old age homes" and "hospitals." Hospitals have some roots in the poorhouse system, just as nursing homes do, since from the beginning of the country many of the poor have been old and sick, and many of the old and sick have been poor. Some of the first hospitals in the country were built on poor farms to house the sickest of the poor population. (Medical History of Michigan, 1930) Where there was no poorhouse hospital, private hospitals received money from the county poor fund to care for the sickest paupers, which often made up a significant percentage of their patients. A few poorhouse hospitals, like Cook County Hospital in Chicago, still exist today as public hospitals. 

Nineteenth century hospitals were not places where you expected to be cured, they were places to go when all other options had been exhausted. In the early part of the century medical science was very crude, and often consisted of "cures" like bloodletting, where the doctor cut the veins of the patient to let "bad blood" escape. In some cases the best outcome you could expect was that the "cure" wouldn't kill you. It wasn't until the latter part of the 1800's that researchers began to understand how to deal effectively with illness and disease.

In the earliest years of the country, and in the parts of the country that weren't yet settled, people cared for their sick at home. If a doctor was needed, he would come on horseback or by buggy, sometimes staying overnight. As time went on, some doctors began to board a few of the sickest patients in the doctor's own home. As demand grew, religious and other nonprofit organizations built better facilities and hired additional physicians. Hospitals as we know them today began to emerge in most of the country in the early- to mid-1800's, a bit earlier than the voluntary and non-profit old-age homes. Some early hospitals included care for the elderly as a part of their mission, even building "homes" attached to the hospital where the poor elderly could live. (Medical History of Michigan, 1930)

Unlike the younger, healthier patients, poorhouse patients tended to have chronic conditions that required long term care. People who weren't poor cared for the chronically ill at home. Those who were poor and ill, many of whom were also elderly, often ended up in hospitals for very long periods of time. (Charity Hospital, 1890)

Early Retirement Communities Are Created

There were some surprisingly modern concepts used during this period by private and non-profit developers, including some early planned communities and retirement campuses. 

One of the earliest planned "retirement communities" was the William Enston Home in Charleston, SC, constructed in 1889. It is described by the National Park Service Register of Historic Places as follows: 

"The home is comprised of 24 residential cottages; Memorial Hall, a community building; an infirmary; an engine house; a water tower and an entrance gate. Designed in 1889, the water tower served as the centerpiece of a model waterworks system, and the spacious, landscaped grounds exemplified suburban planning ideals of the 19th century...Enston specified that the complex be comprised of neat and convenient two-story brick cottages with at least eight acres of land. He also stipulated that potential residents be the old and sick, from 45 to 75 years old, of 'good honest character,' and not suffering from 'lunacy'." (National Park Service)

Sailor's Snug Harbor was built in 1833 on Staten Island New York as a 130-acre campus for "old and worn out seamen", funded by a generous bequest from Robert Randall, who left the bulk of his fortune to endow "...an Asylum, or Marine Hospital, to be called "Sailor's Snug Harbor" for the purpose of maintaining and supporting aged, decrepit, and worn-out sailors." Randall had originally made a bequest of land in Manhattan, but by the time litigation surrounding the will was settled, New York City had grown substantially and the Trustees of Snug Harbor decided that Randall's farmland was too valuable a piece of real estate to be used for a seamen's retreat, so they sold it and used the proceeds to purchase the 130-acre Isaac Housman farm in what was then a rural area of Staten Island. Eventually, the site included dormitories, gardens, a greenhouse, dining rooms, workrooms, barns, a dairy, a hospital, a sanitarium, a bakery, a laundry, a snack bar, a library, a vaudeville house, a church and a chapel. 

Sailor's Snug Harbor was continuously in operation until the late 1960's, creating an interesting opportunity to see life in an old age home across several eras. That long span of existence and its location near a large city meant it was well-documented. Author Theodore Dreiser, lived nearby and got to know the the inmates of the place well. In his 1899 book, The Color of the Great City, he concluded that institutionalization was not a good solution for their old age, because "...this is a great institution and indeed a splendid benefaction, but it insists upon what is the bane and destruction of heart and mind: conformity to routine, a monotonous system which wears as the drifting of water." (Snug Harbor Cultural Center) More insight was provided in an article in Harpers Magazine which describes life in Sailor's Snug Harbor in 1873, and in another article from the depression-era Federal Writer's Project which describes life in Sailor's Snug Harbor in 1938.  (Harpers Magazine, 1873) (Federal Writer's Project, 1938)

Some Elderly Move Into Private Homes

A small number of the non-indigent frail elderly people lived in early "proprietary", privately-owned facilities called "rest houses," "convalescent homes," or "medical boardinghouses", generally just rented rooms in a family home. 

Professional Home Health Care Emerges

Nursing began to emerge as a profession in the late 19th century, along with professional "home health care." The newly created hospitals needed nurses to care for their patients, and developed schools to train them. As trained nurses became available, wealthier families sometimes hired them as live-in care providers for invalids and the elderly.

"The basis for all nursing was the care that the mother bestowed upon the members of her household in time of illness. Her anxiety for her loved ones, along with her desire to give aid and relief to the suffering, made her gentle and painstaking in the methods she used. At first, the mother was concerned with her own family, but as settlements grew larger, she would offer her services to a neighbor in time of trouble. Apparently there was no need for greater skill than that acquired by experience within the family and the neighborhood. Certain women, however, were handier in caring for the sick than their neighbors; naturally they would be called into service very often. Gradually, women, because of their natural inclination and repeated experience, were set aside by the neighborhood to minister to the sick. These women were called nurses.

"As communities grew, the limits of friendship were less observed and women skilled in giving aid to the suffering were called into homes of strangers and would receive remuneration for their services. This was the beginning of the practical nurse for hire, and for decades she was sufficient for the needs of the people." (Medical History of Michigan, 1930)

Poorer families couldn't afford to hire private nurses, but home care services for the poor also emerged around this time, launched by women like Lillian Wald of New York City, who had been trained as a nurse and was studying to become a doctor. During her medical studies Wald volunteered to visit poor immigrant pregnant women, elderly, and disabled people in their homes. When she saw the need of the poor for medical care, she dropped her medical studies and organized the Henry Street Settlement in 1893, also called the Visiting Nurse Society (VNS) of New York. These early home care agencies were directed to the poor and were supported by philanthropy, often "Societies" of wealthy women interested in public works. (VNSNY) 

Veterans Benefits Cover More People

The Civil War created thousands of newly disabled people who needed long term care and beneficiaries for veterans benefits of all kinds. The Civil War involved 2.8 million men, about 10% of the entire population of the country, compared to the 300,000 men involved in the Revolutionary War. Hundreds of thousands of wives, children, and elderly parents lost the family breadwinner in the Civil War, either because he died, or because he ended up disabled and unable to work. 

Because of the devastating impact of the war, veterans benefits were expanded during and after the war, first to stimulate recruitment, and later to avoid sending a flood of disabled soldiers and indigent widows to the poorhouses. This expansion in benefits led to what may have been the first instance of fraud and abuse of a federal benefits program. Thousands of profiteers throughout the country encouraged everyone, eligible or not, to sign up for these new benefits. The deluge of claims overwhelmed the Pension Bureau, slowed down claims processing, and added huge, and unexpected, costs to the veterans' pension program. (Atlantic Monthly, 1890)

Cash assistance wasn't enough in some cases. Eventually, the federal government started building hospitals and homes to provide long term care to disabled soldiers and sailors, where many lived into their old age. In spite of the problems and limitations, veterans benefits succeeded in providing a source of income that kept many veterans and their families out of the poorhouse. The cash payments could also be used to help pay for care in other facilities.

Employers Begin to Provide Assistance

At the end of the century, employers began to take a role in providing assistance for their employees. In 1875, American Express developed the first private employer-sponsored pension program. It wasn't available to all retirees, but was limited to those age 60 and over who were incapacitated and unable to work. The Baltimore and Ohio Railroad inaugurated a pension in 1884 and its example was quickly followed by  other railroads. The railroad pensions required no contribution from the employee, but were designed to tie the employee to the employer for life by limiting benefits to employees with very long tenure, as long as 30 years. Other employers created innovative programs, some even provided housing for employees or retirees.

Some States Provide Cash Assistance to Poor Elderly

California passed the first state old-age assistance law in 1883. Helen Valeska Bary, who had worked at the California State Department of Social Welfare and later became the 8th employee of the Social Security Administration, recalled,

"Back in 1883 a law had been passed giving money to anybody over sixty who was in need. It provided no system of administration. It could be just given out by the counties and was an open end drain on the State Treasury. That was the first law in this country for what you would say was an old age pension. That went on until 1895 when the country ran into the depression of the '90s and the State Treasury was being drained. By that time, the number of people getting pensions had increased so much that the legislature had to abolish it." (University of California/Berkeley Oral Histories Project: Helen Valeska Bary)

Robert Lansdale, a professor who headed up a study of state old-age assistance programs for the Social Security Administration in 1936, thought that people in the West were particularly sensitive to the need of the poor elderly. He said,

"In Colorado and on the Pacific Coast one found more general concern for old people than was encountered in the East. The social economists who have written the history of the old age pension movement in this country have looked largely to the industrial nations of Europe for origins because that was the source of their own ideology. They have never satisfactorily accounted for the fact that California had a program of state aid for the aged in the 1870's and 1880's and that the first two old age pension laws in this country were passed by Alaska and Arizona in 1914. This early action did not arise in an industrial economy. For want of a better explanation, I ascribe this movement in the West to a concern for the pioneer. In the East, down to the Great Depression, economic success was generally attributed to individual acumen, and failure to personal inadequacies. In the Far West, it appeared to me that there was greater tolerance for the old person who had not "struck it rich," attributable perhaps to the fact that those who had, knew that good luck rather than superior virtue accounted for their success." (Robert T. Lansdale,1960.)

More Old Age Homes Are Built

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.

Elderly Had Many Years to Live

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)

Urbanization Created More Problems for Elderly

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.

Tuberculosis Epidemic Spurs Chronic Care Facilities

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)

Home Care Explodes

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)

States Provide Limited Help For Poor Elderly

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)

Employers and Financial Institutions Get Involved

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)

The Institutionalized Age 65+ Population

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)

Old Age Dependency

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)

Great Depression Changes Everything

Family life and working conditions drastically changed during the Great Depression. Nearly half of the working age population became unemployed in some parts of the country. Even young, healthy people lost their jobs and watched their savings dry up. (Federal Writer's Project, 1938) President Roosevelt quickly initiated numerous Federal Emergency Relief (FERA) programs after his election, and his Committee on Economic Security estimated that by the end of 1934 there were 750,000 single persons and 4.2 million families receiving some sort of emergency relief. Counting all the members of the affected families, nearly 19 million people, 15% of the total population, were dependent on FERA programs. (Committee on Economic Security,1935)

The problems hit the elderly particularly hard. Those who were retired or close to it watched a lifetime of savings disappear, and they weren't well enough to work or couldn't find the jobs that would allow them to rebuild their lost investments. That made many of the elderly completely dependent on their families, but hard times for younger family members often meant little or nothing left to provide for their parents. 

Hard Times Destroy Support Networks

Families couldn't support their members and often split up. "The divorce rate fell, for the simple reason that fewer people could afford one, but the rate of desertion soared. By 1940, over 1.5 million married couples were living apart." (American History Files) Hard times generated new waves of migration. Unemployed workers crossed the country to search for jobs, further dispersing families. Children were sent away to orphanages and older family members who had no income of their own were more likely to end up in the poorhouse or dependent on charity.

State Assistance Plans Are Little Help

By 1928, just prior to the start of the Great Depression, only 6 states and territories had old-age assistance laws. As the Depression deepened, that number increased, until there were 28 states and 2 territories (Alaska and Hawaii) with old-age assistance programs by 1934, most just enacted in the prior year or two. Unfortunately, the plans were quite limited, and inconsistent from state to state. As summarized in the final report of the Old Age Security Staff to Chairman Witte, the state plans included the following features and restrictions: 

• All but Arizona and Hawaii refused to make payments to older people who had children or relatives who could support them.
• Most limited assistance to elderly people who were age 65 or older, but quite a few set the limit even higher, at age 75.
• Most required that beneficiaries must have been citizens and residents of the state for 15 years, some had even longer residency requirements than that.
• Many required that the beneficiary must transfer to the pension authority any property they possessed before any payment would be made.
• Most had property and income caps to limit eligibility, generally a maximum of $3,000 in property and $300-$365 a year in income.
• Most required that benefits would be denied to anyone who gave away property in order to qualify for public assistance.
• Most required that a lien be placed on the estate of the beneficiary to be collected upon their death.
• Most required that recipients be "deserving", and benefits were denied to anyone who deserted a spouse, failed to support their families, had committed any crime, or had been a tramp or beggar.
• Benefits were denied to inmates of jails, prisons, infirmaries, and insane asylums, although a few permitted the payment of assistance for inmates of a benevolent fraternal institution.
• Most set a cap on monthly payments at $30 a month, although they actually paid about half of that, or $15 a month on average.

The restrictions were so severe and the number of states that actually had launched their plans and committed funds to them were so limited that even in 1935, in the depths of the Depression, there were less than 200,000 people covered under state old-age assistance plans. (Old Age Security Staff Report, 1934)

Society Expects Federal Government to Intervene

The Great Depression made it clear that hard work alone couldn't guarantee financial security, and most people expected the government to help them out. 

"The pressure for relief to the elderly did not come so much from the old people as it came from their children. Their children needed help... Sometimes people seemed to feel that it was greedy old people who wanted something for themselves, but it was much more their children, who wished to be relieved of the burden. The law said that children must support their parents, their grandparents, their children, their grandchildren, their brothers and sisters. Those laws were sometimes enforced very brutally." (University of California/Berkeley Oral Histories Project, Helen Valeska Bary) 

As the depression wore on, private charities and benevolent societies couldn't keep up with the demands for assistance, and the people they would otherwise have helped had to rely on public welfare instead. Local governments couldn't care for the exploding numbers of poor people on their welfare rolls and turned to the states for help in meeting their obligations. The states couldn't operate with deficit budgets or issue new money to pay their obligations, but the federal government could, so the states began to look to the federal government for help. 

A 1937 Social Security pamphlet said, 

"Old people, like children, have lost much of their economic value to a household. Most American families no longer live in houses where one can build on a room or a wing to shelter aging parents and aunts and uncles and cousins. They no longer have gardens, sewing rooms, and big kitchens where old people can help make the family's living. Old people were not dependent upon their relatives when there was need in a household for work they could do. They have become dependent since their room and their board cost money, while they have little to give in return. Now they need money of their own to keep the dignity and independence they had when their share in work was the equivalent in money." (Social Security, 1937)

The Committee on Economic Security reported to President Roosevelt in 1935 that one-third to one-half of the 7.5 million people age 65 or older in the country were dependent on either public assistance or help from their families, and that only a relatively small percentage of that group were receiving any help from the government. (Committee on Economic Security,1935).

By 1935, a majority of legislators agreed that a federal program for old-age pensions and welfare was required, to help the individuals in need, to stimulate the depressed economy by getting cash into the hands of citizens, and to "retire" older workers without impoverishing them in order to make their jobs available to younger people.

Social Security Provides Reliable Income

There were numerous plans proposed to provide assistance to the elderly. Some of the best-known included:

• Dr. Francis E. Townsend's Townsend Plan would provide $2,400 a year ($200 a month) to everyone age 60 or older, financed by a 2% sales tax.
• Huey Long proposed a plan to guarantee $5,000 a year to every family, with an unspecified pension to everyone age 60 and older.
• Upton Sinclair proposed a plan called End Poverty in California (EPIC) to provide $600 a year ($50 a month) to those age 60 and older who were needy, financed by income and inheritance taxes and a tax on idle land.
• The "Ham and Egg $30 every Thursday Plan", organized by Roy Owens, Lawrence and Willis Allen, and Robert Noble, would give $1,560 a year to every unemployed person in California age 50 or older.

The cost of many of these plans would have been enormous. In contrast, the 1935 Social Security Act as it was finally written seemed relatively modest. The "Old Age Insurance" (OAI) program we call "Social Security" today was created as Title II of the Social Security Act. It established a pool of funds that workers would pay into while they were working, which they could draw upon to support themselves in retirement. The government would not pay for it. Instead, it would be funded out of contributions of both workers and employers. To keep the cost of the program down, the initial Social Security law limited the program to workers in commerce and industry other than railroads. However  amendments to the law in subsequent years have added more and more groups to the program until it is now nearly universal.  (Social Security Act, 1935)

Social Security Act Creates National Old-Age Assistance

Title I of the 1935 Social Security Act created a program, called Old Age Assistance (OAA), which would give cash payments to poor elderly people, regardless of their work record. OAA provided for a federal match of state old-age assistance expenditures. Among other things, OAA is important in the history of long term care because it later spawned the Medicaid program, which has become the primary funding source for long term care today. 

Although many people today only know about the Old Age Insurance (OAI) portion of the Social Security Act, in 1935, when the Act was passed, it was OAA that everyone was really interested in. Support for Old Age Insurance was much weaker, and President Franklin Roosevelt had to work hard to convince Congress that OAI was an important component of the Social Security Act. One problem with the Old Age Insurance plan was that reserves had to be built up before they could begin paying benefits, and no OAI benefits were supposed to be paid before 1942. 

In the meantime, there were many elderly people who needed immediate help, and many others who would never receive much benefit from the OAI program because they were already retired or only had a few years left to work. Among others, Edwin Witte and Arthur Altmeyer,  key contributors to the Social Security legislation, were concerned about those who were age 45-50, a group they called "the half old." OAA was designed to provide a stop-gap to make sure that those people had some help from the government as they aged, since they would not be able to contribute enough before they retired to collect a meaningful benefit.

OAA was fabricated out of the 28 state old-age assistance programs that had been put in place by the early 1930's. These programs varied quite a bit, but they were mostly brought into the new federal system as-is. Each state was allowed to set its own standards for determining eligibility and payments, with the federal government providing cash for a 50% match of up to $30 a month in aid. The lack of federal control was deliberate. The legislation was written that way to to get the support of states that wanted the federal government's assistance without too many strings attached. Only a few federal requirements were added:

• The old-age assistance program had to be available throughout the state, not just in certain counties.
• The State had to provide at least some of the financing for the program. (In some states the existing old-age assistance programs were only funded at the local level).
• Residency requirements could not be any longer than 5 out of the last 9 years, and the minimum age for receiving benefits could not be any older than age 65.
• The state had to create a single state agency to administer the plan and a system of administration and reporting to the federal government..
• The program had to include an appeals process for people who believed they had unfairly been denied old-age assistance.
• If the state or local governments collected money from the estate of any recipient of old-age assistance, half of that money had to be given to the federal government.
• Payments to anyone living in a "public institution" were prohibited.

All the other provisions of the existing plans continued into the OAA program. This meant that in many states OAA was not available to elderly people who had families who "ought" to be supporting them, and that beneficiaries could be required to turn over everything that they owned before receiving any assistance, while other states had no such restrictions.  

Aging Issues Generate National Interest

One interesting outgrowth of all this focus on the elderly was the emergence of "aging" as an issue of national interest.

"Most of the early state old-age assistance program were administered apart from other public aid in accordance with the intent of the legislation. The leaders in these programs were trail-makers in pointing up the special needs of older people...It was not until the 1937 session [of the American Association of Social Security] at Indianapolis that the National Conference of Social Work devoted separate program time to the subject of aging and even then somewhat reluctantly. A special subcommittee was allowed to schedule two meetings but the hours allotted were the least desirable--two to four on Friday afternoon and eleven to one on Saturday morning, by which time most delegates would ordinarily be on the way home. Much to everyone's astonishment, both meetings brought out a full house." (Robert T. Lansdale,1960)

Legislators Debate Institutionalization

One of the big debates in the development of the Social Security Act legislation was how to provide assistance to the poor elderly while getting rid of the poorhouse system that had become so problematic. The National Advisory Council was quite sure they did not want to encourage care in the poorhouses. One way to do that was to give individuals cash payments, which they called "pensions", that would hopefully allow the recipients to remain in their own homes.

"Old folks homes present a traditional and popular escape for some, but are altogether unacceptable for sound psychological reasons to many. Institutional care will always be needed for some proportion of the aged. This may be easily admitted in the case of those who are incapacitated either physically or mentally, but may be optional with healthy old men and women, depending upon their comparative sense of gregariousness. On the other hand the public poorhouse will be condemned by most and, in fact, has been one of the most potent factors in popularizing better methods of provision.

..."The obvious problems that present themselves as soon as the whole question is considered are what to do with the unknown distressing residuum, the people on the bottom, the people who manage to get along, we don't know how. And only slightly above them is the population of our poorhouses and county homes. They present the picturesque though gruesome aspect of the problem of old age. For them private social agencies have advocated private assistance or even public outdoor relief, and more recently old age pensions." (National Advisory Council, 1934)

In addition to the controversy about whether care in a poorhouse was appropriate for the elderly, there was a question of cost. One Council member pointed out that it would cost half as much to support older people with a cash payment in their own home than in an institution. This was founded on the assumption that the older person would continue to work to help support himself if he lived at home, an argument which made sense if those in the poorhouse were too poor to support themselves but were generally healthy, or if they had family or friends who would take care of them in the community. 

"Why is it that an old person can live on a pension of $14.00 a month when it cost $28.00 a month to maintain him in a poorhouse? The answer is found in the fact that the person is not lost to the community and is still partially self-supporting. These old timers earn something. They do some mining, take care of public parks, act as watchmen, and engage in various kinds of activities that permit them to earn a part of their living. They remain among their friends who help them. Remove them to a poor farm and they are lost to society forever. Their self-respect is gone as is their meager earning capacity, and they become dead weight, with nothing to hope for but the call of the Almighty." (National Advisory Council, 1934)

Another consideration was that by keeping people at home the government could further benefit by getting repaid from the sale of the person's house after their death, a house that they wouldn't own if they were in a poorhouse. Again, this argument made the assumption that many of those in the poorhouse owned homes prior to ending up there.

...Often a pensioner has some real estate, but an income of less than $300 per year. It may consist of a home. Before granting the pension the commission may require that this property be deeded to the county, effective upon the death of the pensioner, and from the proceeds of the sale of this property at the time of the death of the pensioner, the amount of pension paid during his lifetime, plus 5 per cent interest, is repaid to the county, and the balance from the sale of property goes to the pensioner's heirs. Thus the counties are often reimbursed the entire amount of the pension paid, with interest. Heirs, who in the lifetime of the pensioner have not been interested in his welfare, do not succeed to the pensioner's property until the county has been repaid." (National Advisory Council, 1934)

The Council had little information to work with. They didn't even have an accurate count of the number of elderly people living in poorhouses, let alone any information about their health, wealth, or family support. The most recent national inventory of poorhouse residents was 10 years old at the time, and it was useless. It had been done before the Great Depression began, and the poorhouse population had exploded since that time.

After much debate, the final decision was to structure OAA to forbid the provision of federal  matching funds for any payments made to residents of "public institutions." The hope was that this would discourage the use of public poorhouses to care for the elderly, and that beneficiaries would use the cash payments to remain in their own homes. 

The law never really did address the question about how to provide for elderly people who did require institutionalization. 

"No provision for any type of institutional maintenance is proposed. Yet there are, of course, aged persons who, while not needing hospitalization, do require constant custodial care. The almshouse or poorhouse of most of the states is, of course, a most unsuitable answer to their needs. The staff is aware of this situation, but feels that lack of factual data bearing on these county institutions and their inmates prevents intelligent planning for this problem now. It therefore recommends that the United States Department of Labor undertake at once a special survey of such institutions with a view to working out a constructive program for the improvement of institutional maintenance of the aged." (Old Age Security Staff Report, 1934)

New Benefits Stimulate For-Profit Nursing Homes

The prohibition on care in public institutions did have an effect on the use of poorhouses -- many of the poorhouses and poor farms saw their population dwindle sharply after 1935. Following a pattern that was repeated throughout the country, 15 Minnesota poor farms closed between 1935 and 1950. (Ramsey County Nursing Home)

Although some potential poorhouse residents may have been able to remain at home, that didn't solve the problems for everyone. The payments were not generous, and some recipients needed to find shared quarters in order to get by. Others needed a level of care or supervision that they couldn't get at home. They couldn't go to a poorhouse without losing their benefits, but they did have some money to pay for their care. Most of the nonprofit old age homes restricted access to members of their own organizations, and, since they were dependent on donations and contributions for survival, they had a limited ability to expand quickly. That left proprietary nursing homes as the only facilities with an unlimited potential to grow to fill the emerging need. As a result, the number of for-profit facilities began to quickly multiply after the Social Security Act became effective. 

OAA recipients were able to pay cash at a time when there was little real money in circulation, making them very attractive customers for proprietary operators, and old age homes were a perfect "cottage" industry. They could be easily and often inexpensively launched by "mom and pop" operators who boarded their elderly customers in unused rooms in private homes. Some were run by unemployed nurses who provided rudimentary care in addition to room and board, giving rise to the term "nursing home." In a time when many people were still out of work, the fledgling industry provided homeowners with an opportunity to use the only asset they owned to generate a welcome source of cash. 

In contrast, while the nursing home industry was becoming primarily a for-profit industry, hospitals continued to develop under government and non-profit sponsorship. By 1935, there were about 6,400 hospitals in the United States, and virtually all were either non-profit or government facilities. Most hospitals had always admitted a significant percentage of "charity" patients who could not pay their own way, whose care was heavily subsidized by the government or by the religious or charitable institutions that supported the hospitals. They also required more capital and operated on a scale that few private operators would have been able to finance. 

Federal and State Governments Share Welfare Costs

The OAA program established the precedent of splitting welfare expenditures between the federal and state governments, while allowing the states to retain a significant amount of authority and autonomy to set standards, eligibility, and payment levels as they desired. The states, in turn, continued to share welfare expenditures with local governments, which meant that at least two, and sometimes three or more, levels of government were involved in the provision of public assistance, a situation which continues to this day.

This division, and the conflicting goals of providing a service that the public considers valuable while guarding the purse of the taxpayers, created inter-governmental tensions and rewarded efforts to shift beneficiaries into programs where some other level of government would assume a greater share of the cost. At the same time, beneficiaries had their own incentives to use or avoid certain types of services, depending on what kind of help they would receive and how burdensome the requirements for receiving it were likely to be. The OAA program was about to demonstrate that "gamesmanship" could affect program costs and utilization.

World War II

During World War II many seniors came out of retirement to help with the war effort. Their employment income probably kept many of them off the welfare rolls during the war, but they had to retire once again when the servicemen returned home and needed jobs. The war also added to the size of the disabled population who needed long term care, and created many new widows and orphans who needed financial assistance. In 1939, the Social Security Act had been expanded to include survivors and dependents benefits, and the war greatly increased the number of people covered under the system. After the war, the Veterans Administration added new benefits for newly-disabled veterans or surviving spouses. 

The size of the elderly and disabled population was growing, and many of them were now eligible for government payments of one kind or another, including veterans benefits, old-age assistance, Social Security, and unemployment assistance. Many of those payments could be used to pay for nursing home care, further encouraging the development of care facilities.

OAA Availability Expands, Federal Share Increases

A number of amendments to the Social Security Act increased both the cap on Old Age Assistance payments and the percentage of OAA that was paid for by the federal government. The cap on the total combined payment that was eligible for a federal match increased from $30 a month to $50 a month, and the maximum federal share of the payment increased from 50% to 60% from 1936 to 1948. (Advisory Council Report, 1948)

The states welcomed the opportunity to share public assistance costs with the federal government and quickly jumped into the program. By 1940, every state had set up an Old Age Assistance program, and coverage increased until 22% of the age 65+ population were receiving OAA benefits averaging about $20 a month in 1940, where utilization leveled off. Somewhere between 2,000,000 and 2,200,000 people received OAA each year throughout the 1940's, representing about 23% of the age 65+ population by 1950. 

OAA Plagued by High Costs and Misconceptions

The public was confused about who OAA payments were intended for, partly because they were called "pensions" and partly because the Social Security welfare plan was introduced simultaneously with the Social Security insurance plan. Many people did not understand that OAA was only intended to provide cash payments to the needy, not to everyone age 65 or older. 

The law required states to ensure that payments only went to those who were truly indigent, so they had to investigate all other sources of income and deduct them from the maximum monthly allotment. "All sources of support had to be explored - even small stipends that children provided to help their parents and the potential yield of a vegetable garden belonging to applicants. Sometimes children were asked whether they could help their parents - even if they currently were not providing assistance." This meant that many beneficiaries got much less than the $30 a month payment they had initially heard about. In Texas, for instance, the average allotment was only $15 a month. (Texas DHS, 1991) This left some people feeling they had been misled or taken advantage of. Others resented the indignity of the probing questions they had to endure in order to receive benefits. 

Even the social workers employed by the states to determine eligibility were confused about whether they were supposed to protect the public purse by denying benefits or relieve the pain that they saw by helping people qualify for benefits. As one man said, "I have been advised to give my farm and everything away so I could draw the old age pension. If I was to do that I would be crazy--I'd wake up some morning and find myself in the asylum." Another man reported, "I could git me in old age pension, if I wanted to sign my life insurance away. Woman from the state come here some time ago I says, 'Nothin' doin'', I says. 'Think I'm goin' to sign away my chance for a decent burial?' I says 'That's all I got to look forward to.'"  (Federal Writer's Project, 1939) 

Although the number of people receiving OAA stayed fairly stable during the 1940's, benefits increased precipitously, even after accounting for inflation. Average benefits restated in 1940 dollars increased by nearly 20% from 1940 to 1950. (Friedberg, 1998) Gross OAA expenditures doubled from $474 million in 1940 to $960 million by 1947. (Advisory Council Report, 1948)

The percentage of people age 65 and older receiving OAA would be high if most people in this age group were retired, as is true today. However, about half of all men age 65-74 were still working throughout this time period. (Friedberg, 1998) Either those who were employed earned so little that many still qualified for welfare benefits, or a very large percentage of those who were not working were receiving benefits. Whatever the reason, the percentage of the elderly who were receiving welfare benefits during the 1940's was extremely high.

The federal and state governments reacted in different ways to the exploding costs of the program. Some states just cut their appropriations. For example, Texas Department of Public Welfare Executive Director Adam J. Johnson sent the following letter to all program recipients in October 1939:

"Because there is not enough money coming into the Old Age Assistance Fund in Texas to pay all the old age assistance grants in full, we are forced to cut $6.00 off the grant of everybody on the rolls. This is to notify you that, beginning with this warrant, your grant must be cut by $6.00 below what the Investigator recommends for you and you have been receiving. We regret having to do this, but are powerless to prevent it. Please understand this is due entirely to lack of funds and is not our fault nor the fault of the Investigator, and that the Investigator cannot increase your grant just to take care of the cut. The revenue coming in is not sufficient to do this. Grants to those who are eligible will be increased again as soon as funds are provided." (Texas DHS, 1991)

The benefit levels had risen so much that by 1948 the average OAA benefit ($38.18 per month) greatly exceeded the average Social Security benefit ($25.13 per month), providing a perverse disincentive for people to provide for their own old age by working and saving. (Advisory Council Report, 1948) Amendments were proposed for the Social Security Old Age Insurance program to increase payment levels and expand coverage to more people. In 1939, Social Security OAI was amended to pay benefits to widows, widowers, and dependent children of workers who died, primarily to start moving this population off of the welfare rolls, but the most significant changes weren't made until 1950.  

Benefits Change Family Living Arrangements

One effect of the new federal benefits was on the living arrangements of the elderly. Dora Costa studied the relationship between income, marital status, and living arrangements on elderly women. She found that older women were only half as likely as older men to be married. In earlier eras, those women would have been living with their children, but Costa noted a significant reduction in the percentage of elderly unmarried women who were living with their children in the 1940's, which she was able to attribute directly to the new source of income from OAA. (Costa, 1997) This new independence was good news in many ways, but it also meant that it was less likely that a family member would be present in the same house if those older women needed supervision or medical care in the future.

National Health Insurance Proposed But Defeated

Public interest in national health insurance began to increase during the 1940's, although it would be another 20 years before the Medicare program would finally pass the legislature. The first salvo occurred during the administration of President Franklin Roosevelt. The Social Security Board drafted a bill which was introduced in 1943, by Senator Wagner and Senator James Murray of Montana and Representative John Dingell of Michigan. Historian Peter Corning says, 

"As its drafters and sponsors had expected, the Wagner-Murray-Dingell bill signaled the beginning of the political debate that would come to a climax in the postwar years...[It] was the most comprehensive social measure ever introduced in Congress. It envisioned a federally sponsored health insurance program, along with permanent and temporary disability, maternity and death benefits, full federalization of the existing Federal-State unemployment insurance, expansion of old-age and survivors' insurance, and enlargement of public assistance." (Corning, 1969)

After President Roosevelt died and the war ended, President Truman tried to revive the issue, but was blocked in large part because of the opposition of the American Medical Association (AMA), who mounted a massive campaign to defeat the bill. As Corning puts it, 

"On the heels of President Truman's election victory, an 'Armageddon' psychology set in within the AMA. In December 1948, the AMA's House of Delegates met, in an atmosphere of crisis and voted a special assessment of $25 per member to resist 'the enslavement of the medical profession.' A prominent public relations firm was hired and a $4.5 million fund was deployed to wage a 'national education campaign' against the Wagner-Murray-Dingell bill. The campaign included publicity through the mass media, nationwide distribution of pamphlets, a vast speechmaking effort, and a drive to win and publicize specific pledges of support for the AMA's position from the press and other private organizations." (Corning, 1969)

At the same time, labor unions and the insurance industry were encouraging employers to provide health insurance to their employees as an alternative to a government-sponsored program. Truman and the bill's supporters eventually conceded defeat and dropped the bill.

Hill-Burton Act Stimulates Licensing of Healthcare

World War II halted construction and development of every kind, and by the end of the war, many buildings were badly in need of replacement or modernization. The national health insurance program that was being discussed highlighted the poor quality of the nation's healthcare infrastructure, which could only be improved by devoting significant funds to the construction and modernization of hospitals. During the high-profile controversy over national health insurance, Senators Joseph Lister Hill of Alabama and Harold Burton of Ohio quietly carved out hospital construction financing into a separate bill, and introduced the Hospital Survey and Construction Act of 1946 (commonly called the Hill-Burton Act). Compared to the high cost of national healthcare insurance, the Hill-Burton Act seemed relatively risk-free and inexpensive, and it passed with little fanfare.

Hill-Burton created a system to provide federal financing for construction of new hospitals in rural and poor areas that did not already have them, and to modernize hospitals in metropolitan areas. The sponsors did not want to create an uncontrolled explosion of buildings that weren't needed, so the bill called for each state to develop an agency to organize and coordinate health planning for the state, and to determine where in the state hospitals ought to be built. These agencies were also charged with pre-approving the design of the buildings before they were built, a level of oversight and consistency in healthcare construction design that had never existed. The sponsors felt that wealthier areas would be able to build their own hospitals without federal assistance, so funding was to be directed primarily to areas that were poor or rural. One controversy that arose before the final text of the bill was approved was whether or not federal funding could be provided to hospitals that were not publicly owned. The concern was that it might not be appropriate to gift taxpayer money to non-public entities. There was never any consideration of including proprietary hospitals in the program, but ultimately a decision was made to allow funding for non-profit hospitals, not as gifts, but as loans which would be repaid by providing a certain amount of free care to people who otherwise would have ended up as the responsibility of the government.  (Perlstadt, 1995)

Hill-Burton financing lead to an explosion in public and non-profit hospital construction, and provided a model for federal and state standards for the design, regulation, and financing of healthcare institutions that was later used for nursing homes.

Many Buildings Converted to Nursing Homes

An unplanned result of the Hill-Burton legislation was that many of the old hospitals that were being replaced were converted to another "medical" use -- they became nursing homes. In the late 1940's, all kinds of residential and commercial construction resumed, after stopping completely during the war. The pent up demand for construction made it hard to find the resources to build new buildings, but older buildings were coming on the marke