THE DEVELOPMENT OF LONG-TERM CARE

Mr Rueter/HSA1100

February 26, 2013

This paper is on the development of long-term care. It will explain the meaning of long-term care

and the effects of the Great Depression and World War II as well as the Social Security Act which all

contributed to the way long-term care is managed today.

LONG-TERM CARE

Long-term care (LTC) generally refers to a variety of health and human service programs for people

with physical, developmental or mental conditions who need care for an extended period of time.

Many people who need long-term care develop the need for care gradually. Care needs often progress

as they age or as their chronic illness or disability becomes more debilitating, causing them to need

care on a more continual basis, for example help using the toilet or ongoing supervision because of

progressive conditions such as Alzheimer's disease. Some people in long-term care facilities are there

for a short period of time while they are recovering from a sudden illness or injury, and then may be

able to be cared for at home. Others may need long-term care services on an on-going basis. Some

may need to move into a nursing home or other type of facility-based setting for more extensive care

or supervision. Long-term care services can be delivered in a variety of settings ranging from private

residences to certain outpatient or day care facilities to residential care home and ultimately to skilled

nursing facilities (SNF).

ALMSHOUSES

In the early years of this country, very few people lived to old age and for those that did meant

having children or property. Having family living nearby was not often an issue. In those days before

railroads and automobiles families where large and few children ventured far from home. Members of

the family were their own doctors and nurses in those days. They did not need cash to survive that

economy, and families were fairly self-sufficient. Having family was the key to survival.

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.

The public assistance programs in the Eighteenth and Nineteenth century was a local obligation and

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 the details about

how to do so was left up to the local town or county officials. ("History of 19th,") As cost increased

governments decided to create more cost-effective systems by building poorhouses, almshouses, poor

farms, county infirmaries, asylums or county homes to house people who were too expensive to

support. The state owned and operated some of these almshouses. Some states avoided these cost by

boarding these people to their relatives or paying farmer to care for them. A common concern of the

public at the time was the opportunity to get free room and board would be so attractive that people

would deliberately pretend to be poor so they could live in the almshouse at the expense of the

taxpayers. Almshouse life was made as unappealing as possible. The “inmates” were expected to wear

a uniform rather than their own clothes, and they were not allowed to leave. Many of the almshouses

had attached farms so they could produce their own food and be self-sufficient, 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.

The people who operated these almshouses were to check before accepting someone to see if

anyone else could be supporting the potential inmate. If an almshouse 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

refuse anyone 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

there were were bands of poor homeless people who roamed from place to place, staying in each one

only until authorities ordered them to move on. Concerns over the high cost of operating the

almshouses lead to other indignities. As time passed, the almshouses became a catch-all for anyone

who could not survive in the outside world, and they became home to poor dependent elderly people,

where they lived in the same rooms with petty criminals, alcoholics and the mentally ill.

In the almshouses conditions 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. The insane patients, criminals, and alcoholics frightened and sometimes injured the frail

elderly living in the same rooms. Ending up in the almshouse was everyone’s nightmare.

REVOLUTIONARY WAR

One alternative to sending people to these almshouses was to make cash payments to specific

groups of disabled or indigent people to help the 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.

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. This was one of the first acts

of the new government in 1776 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

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 did not have the authority to raise funds

by taxation at the time, so they said that the pensions were to be administered and paid for by the

states. The states did not want to bear the cost and they refused to do anything. So the federal

government took back responsibility. The newly-formed government had not yet created an 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, a general

appropriation was made in 1709 and a pension law was enacted in 1792. The rules for veterans

pensions were changed numerous times in the next few year. Gradually, veterans benefits were

expanded to include pension payments even for those who were not disabled, if they served during

certain wars and times periods, first for officers then several years later for the enlisted men. Benefits

for veteran's surviving spouses came later and most were limited to spouses who were indigent. In

1780, the first benefit for surviving spouses were created for widows of officers who died in the

Revolutionary War. In later years the law was changed to include officers who died in service after the

War, and to their children under age sixteen, if their mother was deceased. Eventually, when the

government needed incentives to get men to fight in the War benefits for widows and children were

available to enlisted men as well as officers.

Family living arrangements has 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 the unmarried elderly women. Older women were far more likely then

older men to be unmarried. Although their life expectancies were not much longer than men most

women married men who were much older than themselves, so they often out-lived their husbands.

The almshouses were becoming enormously expensive to maintain. One of the ways to control cost

and deter use was by segregating the poor. This was done by building penitentiaries for criminals, men

and women almshouses for the poor elderly hospitals for those who were poor and ill, workhouses

for the able-bodied poor, and asylum for the poor who were mentally-ill. 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 cost to the taxpayers. There was a

lot of debate about society's role in caring for the poor, many felt that the deserving poor like children

the insane and the elderly, should get better treatment then the undeserving like alcoholics and those

who were healthy but lazy. Legislature decided to develop better facilities to care for the mentally ill,

and they were gradually moved out of the almshouses. Laws prohibiting children from residing in

almshouses were passed and children were moved into orphanages. That left poor, dependent elderly

adults who had no place else to go as the last group who needed a place of their own, but the

almshouse was still the only public facility available for them. In spite of the problems of the

almshouses 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 build 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.

These people slept in huge dormitories, with their beds neatly organized into rows and ate at huge

tables in a dining hall where meals could efficiently be served.

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 almshouses inmates transferred to these new facilities were elderly. (Vladeck, 1980)

Although there were other purposes for the existence of benevolent societies 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 was not enough for older

members who could not 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 build and the orphans were moved into them. The benevolent societies closed down

their facilities for children and concentrated on the elderly.(Odd fellows home)

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 bequest from the wealth benefactors,

whose wills included stipulations that the money or property be used to provide

assistance to people who fir certain criteria. To carry out their work the organizations

build “old age homes” to house those who could not live on their own. The voluntary

and charitable facilities seemed luxurious compared to the almshouses. Many were

newly-constructed buildings, built specifically to house the elderly and others were

stately old mansions who's owners had dies. The facilities were much nicer but they

were still operated with the same viewpoints of the almshouses. “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 operating the home. 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 “life-care”. Although these seemed to be precursor to nursing homes most of the

old age homes were more residential than medical. The 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 probable

comparable to what we call nursing homes today.

Hospitals have some roots in the almshouses 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 build

on almshouses to house the sickest of the poor population. ("The 1930s: Medicine," 2001)

Where there was no almshouses hospital, private hospitals received

money from the county poor fund to care for the sickest, which often made up a

significant percentage of their patients. A few almshouse hospitals, still exist today as

public hospitals. These were not places where one expected to be cured they were

places to go when all other options had been exhausted. 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. Some early hospitals included care for the elderly as part of their mission,

even building homes attached to the hospital where the poor elderly could live.("The

1930s: Medicine," 2001) Unlike the younger healthier patients, almshouse patients

tended to have chronic conditions that required long-term care for the chronically ill at

home. Those who were poor and ill, many of who were also elderly, often tended up in

hospitals for very long periods. (The training of, 1890)

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. The structure and size of families was also 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.

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 had 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.("The 1930s: Medicine," 2001) 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. 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. 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." ("The 1930s: Medicine," 2001)

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. 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 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.("The 1930s: Medicine," 2001) 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." (The training of, 1890) In 1909, Lillian Wald convinced Metropolitan Life Insurance Company to finance home care: "Armed with data documenting that nursing care saved lives, Wald urged Met-life to hire visiting nurses to care for policyholders during illness. For a modest fee per policy, Wald believed that Met-life could reduce the number of death benefits paid."

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. 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.(Witte, 1935)
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.(Rubinow, 1934) 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 almshouses 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. (Vladeck, 1980) 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 almshouses 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. (Vladeck, 1980)
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.
("The federal writers'," 1935) 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. (Witte, 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. 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." (Vladeck, 1980) 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 almshouses or dependent on charity. 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. (Witte, 1935) 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. 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. 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.

(Witte, 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. 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.(Witte, 1935) 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 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. 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 almshouse 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. In addition to the controversy about whether care in almshouse 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 almshouse 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. 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 almshouse. Again, this argument made the assumption that many of those in the poorhouse owned homes prior to ending up there. 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."(Rubinow, 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 almshouse 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 almshouses 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. (Witte, 1935) 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. A pattern that was repeated throughout the country. (Sek, 2011) 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. 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. The number of people living to old age and the number of years they spent in old age continues to increase, because fewer people were dying in childhood, so larger amounts of people lived to old age. Those who outlived diseases and injury in childhood and early adulthood had nearly as many years ahead of them as today senior citizens do, and finding a place where they could live for what might be a lengthy period of time was just as important then as it is now. (Kinsella) 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.(Gibson) Some of these people were coming from the rural areas, and others from the flood of immigrants entering the country for the first time. 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. 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. 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 market as they were replaced, and the end of the war ushered in an era of nursing home conversions. Hundreds of hotels, homes, and other existing buildings of all kinds were converted to nursing homes. A 1948 Social Security Advisory Council report suggested that additional Old Age Assistance (OAA) payments should be made available for poor people who required medical care, since the amount they were receiving was insufficient to cover it. In 1950, amendments to the Social Security Act said, "The Federal Government will

share in cost of payments made directly to medical practitioners and other suppliers of

medical services, which when added to any money paid to the individual, does not

exceed the monthly maximums on individual payments." This created a significant

change in the way that welfare was delivered and paid for. Nursing home operators

could now contract directly with the states for payment, providing nursing homes with a

new and more reliable source of income. Individuals were more time-consuming to deal

with, and they didn't always pay their bills. The check from the government was one a

nursing home could count on. Initially, the payment to medical providers was capped

so that it would not exceed the amount that would have been paid to the individual, but

in 1956 the Social Security Act was again amended to eliminate that cap. This was

extremely important because nursing home costs were much higher than the individual

OAA payment. The elimination of the cap on payments meant that the government

quickly became the primary purchaser of nursing home care.

Nursing homes were emerging all over the country, but there were no federal standards for their design or operation. They were not licensed, buildings were unsafe, there were allegations of abuse and neglect, and nursing care was sometimes non
-existent. Most states licensed hospitals, because the Hill-Burton Act required it, but few licensed nursing homes. The 1950 SSA amendments for the first time demanded that states that received federal matching funds must create systems to licensing both nursing homes and hospitals. This provision was added to "raise the standards of those institutions that have been understaffed and under financed, that have been firetraps, and in which people have been badly treated."Effective in 1953, "If a State plan for old
-age assistance, aid to the blind, or aid to the permanently and totally disabled provides for payments to individuals in private or public institutions, the State must have a State authority to establish and maintain standards for such institutions." The law did not specify minimum state licensure standards or procedures, nor was there any way to ensure that the states enforced the standards, but it was the first attempt to consistently regulate the industry at the state level. As a result, a number of nursing homes which couldn't meet the new standards closed in the 1950's, while others demolished their old buildings and built new ones. Since 1950, major changes in licensure for nursing homes has taken place and although it is not the same as being in one’s own home due to these changes it can be made to feel like being home. Nursing-homes are governed under ACHA and are inspected yearly to ensure the proper management is adhered to. 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.(Kinsella) 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.(Kinsella) 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 (Kain,M.D., 1898)

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