History Of Federal Involvement in the Delivery of Healthcare
Health Care History: The Hill-Burton Act
The Hill-Burton Act was a decidedly ambitious piece of legislation that was initially passed in 1946. The act was named after its chief proponents, Alabama’s Senator Lister Hill (Thomas, 2008) and Ohio’s Senator Harold Burton. Although the act was conceived of as a way of providing egalitarian access to improved medical facilities, it was actually created in times that were anything but. 1946 was the year after the end of World War II and racial segregation (as buttressed by Plessey v. Fergusson) (Wormser, 2002) was still rampant across the country. Moreover, the economic politics — many of which are still in effect today — in which federal, state and local legislation typically benefits those with the most economic resources of the day also helped to hamper the egalitarian spirit in which the Act was created. It is notable that racial minorities were also less financially advantaged than their Caucasian counterparts, so that virtually both these aspects of the zeitgeist in which the act was created egregiously circumscribed its efficacy. Still, it was created as a means of bettering medical facilities and providing care to those who needed it most, regardless of how effective it was at actuating those ideas.
The purpose of the Hill-Burton was to provide government money — in the form of loans or grants — to hospitals around the country so that they could offer improved care to U.S. citizens (Thomas, 2008). The goal was that the issuing of such funds would enable facilities to better the care that they provided and help the American people improve and maintain their health. One of the specific designs for the funds provided by this act was to help create conditions so that there were approximately five hospital beds available for every group of a thousand people in the country, which alludes to some of the ambitiousness of this act. In order to receive funding, however, there were certain requirements to which hospitals had to adhere. Perhaps the most eminent of these was the fact that they were supposed to issue free care to those who lived near the facilities and who were too indigent to afford care any other way (Parks, 2010). Hospitals that received these funds were mandated to provide such care, which was to comprise some vague, undetermined portion of their patient services and ‘customers’, for a minimum of 20 years. Additionally, it was determined that medical facilities could not discriminate on the basis of nationality, ethnicity, or race if they were going to receive funds. Again, the fact that the so called “separate but equal” legislation determined by Plessey v. Fergusson all but obliterated any true objectivity in fulfilling this requirement. Another requirement mandated that both state and local municipalities distributed funds to a selected hospital that was commensurate to the funds provided from the federal government.
With these standards in place, there were quite a few interesting things that actually happened once this legislation was enforced and governmental monies were disseminated to hospitals. In most cases, these funds were given to hospitals in areas of relative economic prosperity (which frequently did not include those hospitals in areas in which minorities lived and were serviced). A couple of different factors contributed to this occurrence. One of these pertained to the fact that the local and state governments had to match the funds provided by the federal government. Those best equipped to do so, and which had the financial power of lobbyists at the local level, were those in areas that were more affluent than in others. Moreover, there was a component of the legislation in which medical facilities had to prove their economic worth to receive funding. It became increasingly difficult for those in fiscally unstable and poor areas to do so — which resulted in these sorts of hospitals (once again populated by minorities) from actually garnering this funding. Thus, one of the most interesting things that the Hill-Burton act did was add on to the trend of the rich taking advantages of its monetary benefits in America while the poor are unable to do so.
As previously mentioned the issue of racial discrimination was a major problem with the this particular piece of legislation at its inception. It was not until 1954 with the Brown v. Board of education decision that the separate but equal precedent set by Plessey v Fergusson was outlawed and racial segregation was officially ended in the U.S. (McBride, 2006). In the wake of the passing of the Brown, decision, however, was the fact that de facto segregation still lingered for a number of years during the Civil Rights struggle, and racial tensions in the country were exceptionally high during this time period. This sentiment means that for approximately 20 to 25 years after the Hill-Burton Act was passed, there was rampant discrimination based on color, nationality, and creed within the U.S. And in the states and local areas in which the hospitals receiving funding from this act were established. As such, it was extremely difficult for African-Americans (and certain other racial minorities) to receive any of the monetary benefits from this Act — especially when one considers the monetary measures in place (that both local and state officials approved and provided money for certain hospitals to attain federal funding) that helped reinforce such racist practices. In states located in the southern section of the country, for example, in which racism was its most rampant and segregation and Jim Crow laws were the norm, it was highly unlikely that these officials would willingly select hospitals in inner city ghettoes to receive the monetary benefits from this act. Therefore, racial discrimination proved one of the chief ways in which the egalitarian spirit of this act was roundly defeated — although one should note that in the years following the Brown decision such racism gradually eroded and funding slowly became more available to minorities.
When one considers the blatant racial bias of the Hill-Burton Act and the socio-economic measures discussed in this document which reinforced that bias, it is not surprising that both before and after the desegregation the implantation of this act encountered significant difficulty adhering to another of its principles — that of providing free care to the impoverished. This problem with the act’s implementation is in accordance with the others addressed in this paper, yet is subtly different and certainly exacerbates the issues that the indigent faced in getting treatment. Not only did minorities and those who lived in inner city slums not have medical facilities with access to the federal funding of this piece of legislation (certainly not in proportion to those who lived in areas of more affluence), but those facilities who did get funding became increasingly notorious for not providing free care to those who could not otherwise afford health care. As previously denoted, the wording in the Act regarding the provisioning of care for the poor was rather ambiguous. Although it mandated that hospitals receiving funding were to disseminate such care for 20 years, there were no measures in place to enforce this component of the legislation. Furthermore, there was no well-defined percentage or quota of free care that hospitals were supposed to give out. Essentially, it was left to the discretion of the individual facility to determine how much, if any, free care it provided to the surrounding community. And, in keeping in alignment with the other socio-economic factors pertaining to this law and its implementation, there was precious little free care provided to the indigent. This aspect of the law was contested during the 1970s, when it became apparent that medical facilities were not adhering to it.
Virtually no one can dispute the fact that the Hill-Burton Act was created to produce good within America’s health care system. Even fewer people can argue that it was able to achieve, in varying degrees, some good during its tenure. However, it is difficult to believe that the act was able to be implemented in the spirit in which it was created. The halcyon vision where the vast majority of America’s hospitals could receive government funding and provision free care to those in penury, regardless of racial, national or ethnic features, was never realized. Instead, like many other pieces of legislation and various aspects of this country, it was exploited by the wealthy and utilized in a way so that those who actually required its benefits the most — those who were destitute and living in impoverished conditions — were not able to access them. It is important to realize that although there were lofty ideals discussed within the act, the socio-economic climate in America was decidedly unsuited for those ideals to be put into action. Segregation, the propensity for those who are both wealthy and in power to consolidate these resources, and greed proved enough to undermine the spirit of the act and to keep this potential revolutionary piece of legislation from achieving its intended effect. Still, towards the end of the act’s existence some poor people were able to circumvent some of these restrictions with law suits in order to access some of the benefits that were actually intended for them.
McBride, A. (2006). Brown v. Board of Education. www.pbs.org. Retrieved from http://www.pbs.org/wnet/supremecourt/rights/landmark_brown.html
Parks, P. (2010). What is the Hill-Burton Act? www.jdsupra.com Retrieved from http://www.jdsupra.com/legalnews/what-is-the-hill-burton-act-63450/
Thomas, K. (2008). Hill-Burton Act. Encyclopedia of Alabama. Retrieved from http://www.encyclopediaofalabama.org/face/Article.jsp?id=h-1439
Wormser, R. (2002). Plessy v. Ferguson. www.pbs.org. Retrieved from http://www.pbs.org/wnet/jimcrow/stories_events_plessy.html
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