Ban the HMOs!
The Principles of the Hill-Burton Approach


by Nancy Spannaus

Printed in the American Almanac, January, 2000.


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The Hill-Burton approach to providing health care comes directly out of the experience and outlook with which the United States, under President Franklin Delano Roosevelt, entered and fought World War II. There were four basic principles to this approach:

1. Ensure an infrastructure of necessary facilities and medical personnel, either public or private, to meet certain minimum standards of availability for the public.

2. Provide care to those in need, regardless of their ability to pay, and worry about the costs afterwards.

3. Depend upon the growing wealth of a productive, industrial economy to make sure that sufficient resources, financial and otherwise, are being created to provide for health care needs, and associated public health needs.

4. Carry out special programs to attack and treat leading dangerous diseases, in the interest of the general welfare.

At the conclusion of this report, we will include excerpts from the Hill-Burton legislation, as it remains in law today. But, first, let us review the functioning of the health-care system in the United States under the policies associated with the Hill-Burton law.


- Providing Care: 1940s to 1960s -

Over the 20-year period from the end of World War II until the mid-1960s, the U.S. health care system was characterized by improvements in the quantity and quality of medical care, in provision for public health, and in the commitment to battle against disease. There were problems, but the mindset that prevailed was one of problem-solving.

The centerpiece of this effort was the ``Hospital Survey and Construction Act,'' enacted Aug. 13, 1946, and better known by its principal bipartisan co-sponsors, Senators Harold Burton (R-Ohio) and Lister Hill (D-Alabama). The ``Hill-Burton'' Act launched a nationwide hospital-building program, designed to provide the necessary number of staffed hospital beds per 1,000 people throughout the land--regardless of race, color, creed, gender, or ability to pay. It was an unprecedented move in the history of the United States.

Prior to 1946, the U.S. hospital system had evolved with great disparities in facilities and accessibility. On the eve of World War II, of 3,076 counties in the United States, there were 1,282 counties with no hospital at all for community use; and hundreds of the existing 1,794 community hospitals were substandard. There were local concentrations of malnutrition and disease.

What seemed obvious to a consensus of policymakers as of the end of the war, was the need to wage a peacetime war against disease, and to provide care wherever it was needed to any of the population, then numbering 148 million. Why not build infrastructure? Why not beat back tuberculosis, which was still taking a terrible toll, and poliomyelitis, and other diseases? Plus, the baby boom was at hand. Why couldn't women look forward to giving birth in modern hospitals?

In his 1944 State of the Union address, President Roosevelt spoke of an ``economic bill of rights,'' including ``the right to adequate medical care and the opportunity to achieve and enjoy good health.'' In 1945, in his Jan. 6 State of the Union address (the last he was to give; he died in April of that year), the President again spoke of the right to ``good medical care.''

Co-sponsor of the hospital drive, Lister Hill, a veteran of World War I, championed many national priority public projects, in particular the Tennessee Valley Authority. With the endorsement of FDR, Hill won his Senate seat in 1938, and served until 1968.


- How Hill-Burton Worked -

How the Hill-Burton implementation worked is described by one contemporary account, by Dr. Ralph Chester Williams, Assistant Surgeon General, in 1950:

``The National Hospital Program has now been in operation for three years. It has brought about a comprehensive plan showing the location and size of hospital facilities which are needed in each state. For the first time, a definite plan is being followed by each state in determining the location, size, and type of facility which can best meet the hospital and health center needs of the people. Hospital construction plans prepared by each state agency and approved by the U.S. Public Health Service have been extremely valuable in stimulating local communities to construct hospitals and health centers. In addition, the program has resulted in the enactment of hospital licensure laws in many states where none existed previously. The impact of the program on modern design and construction has been gratifying with respect not only to hospitals built under the program, but also to those built without Federal aid. Improved services to patients have likewise resulted from better planned and better designed hospitals.

``A total of 65,000 hospital beds and 250 public health centers are being added to the nation's health plant by 1,300 projects approved as of June 30, 1950. This represents a total expenditure of nearly $1 billion, toward which the Federal contribution will be about $345 million. Approximately 300 of these projects are already in operation, and 500 of the remainder are under construction.

``In general, hospitals are being built first where they are needed most, and usually these are also in areas of lowest income. General hospital projects predominate in the program. Eighty percent of the total beds added to date are in these facilities. About one-half of the general hospital projects are new facilities, nearly all of which are located in towns of less than 10,000 population. These are typically small hospitals of 50 beds or less.

``Increasing attention is being given to other categories of hospital facilities, particularly tuberculosis, psychiatric, and chronic units in general hospitals, and to public health centers. Four States (Georgia, Louisiana, Mississippi, and South Carolina) now have extensive programs for health centers, and other States are beginning to develop such programs.''

Overall, from 1947 until 1975 (the end of expenditures under the Hill-Burton Act), 6,900 hospitals got assistance. As of the mid-1970s, the nationwide average for beds in community hospitals was at the average Hill-Burton standard of 4.5 beds per 1,000 people, up from fewer than 3 beds per 1,000, the average 20 years before. Many rural areas had access to hospital care for the first time.


- Regulating To Provide for All -

What characterized the U.S. health care delivery system, was a prevalent desire to see that all were provided for--not through ``nationalized'' medicine, but much better, through a network of government (county and state, as well as Veterans Administration and other federal facilities) and private (religious, philanthropic, and some for-profit) hospitals and clinics. Standards and availability were regulated, and costs were supported by a working population able to pay for affordable private insurance, or direct care. Hospitals could, in turn, care for indigent in the community.

In 1954, amendments to the Hill-Burton Act authorized funds for chronic care facilities. In 1956, the Health Research Act authorized increased funding for research against major diseases. In 1954 began mass administration of Dr. Jonas Salk's polio vaccine. In 1963, the anti-measles vaccine was developed.

Thanks to these efforts, tuberculosis, a marker for general public health, declined from a peak of 137,000 new cases in 1948, to 55,500 cases in 1960; pertussis (whooping cough) declined from a peak of 156,000 cases in 1947, to 14,800 in 1960; and diphtheria declined from 18,700 cases in 1945, to 900 cases in 1960.

In 1965 the Medicare and Medicaid programs were begun. They mandate that states provide children with Early Periodic Screening, Diagnostics, and Treatment, to prevent disabilities and control transmissible illness. At the same time, drawing on wartime experience, plans were formed to established a nationwide regionalized system of trauma care centers to ensure life-saving care to those who sustained massive critical injuries.

The 1965 Civil Rights Act outlawed the last vestiges of the Jim Crow, ``separate-but-equal'' practices in health care and other services.

The following are excerpts from 42|U.S.C.|291 et seq., which are, at present, incorporated into current U.S. law by the Hill-Burton Act. Note particularly the provision in Section e, which says that states shall provide facilities and care which is needed ``for persons unable to pay therefor.''


- 291. Declaration of Purpose -

The purpose of this title is

(a) to assist the several States in the carrying out of their programs for the construction and modernization of such public or other nonprofit community hospitals and other medical facilities as may be necessary, in conjunction with existing facilities, to furnish adequate hospital, clinic, or similar services to all their people;

(b) to stimulate the development of new or improved types of physical facilities for medical, diagnostic, preventive, treatment, or rehabilitative services; and

(c) to promote research, experiments, and demonstrations relating to the effective development and utilization of hospital, clinic, or similar services, facilities, and resources, and to promote the coordination of such research, experiments, and demonstrations and the useful application of their results.


- 291c. General Regulations -

The Surgeon General, with the approval of the Federal Hospital Council and the Secretary of Health, Education, and Welfare, shall by general regulations prescribe

(a) Priority of projects. The general manner in which the State agency shall determine the priority of projects based on the relative need of different areas lacking adequate facilities of various types for which assistance is available under this part, giving special consideration

(1) in case of projects for the construction of hospitals, to facilities serving areas with relatively small financial resources and, at the option of the State, rural communities;

(2) in the case of projects for the construction of rehabilitation facilities, to facilities operated in connection with a university teaching hospital which will provide an integrated program of medical, psychological, social, and vocational evaluation and services under competent supervision;

(3) in the case of projects for modernization of facilities, to facilities serving densely populated areas;

(4) in the case of projects for construction or modernization of outpatient facilities, to any outpatient facility that will be located in, and provide services for residents of, an area determined by the Secretary to be a rural or urban poverty area;

(5) to projects for facilities which, alone or in conjunction with other facilities, will provide comprehensive health care, including outpatient and preventive care as well as hospitalization;

(6) to facilities which will provide training in health or allied health professions; and

(7) to facilities which will provide to a significant extent, for the treatment of alcoholism;

(b) Standards of construction and equipment, general standards of construction and equipment for facilities of different classes and in different types of location, for which assistance is available under this part.

(c) Criteria for determining needs. Criteria for determining needs for general hospital and long-term care bed, and needs for hospitals and other facilities for which aid under this part is available, and for developing plans for the distribution of such beds and facilities;

(d) Modernization, criteria for determining the extent to which existing facilities, for which aid under this part is available, are in need of modernization; and

(e) State plan requirements. That the State plan shall provide for adequate hospitals, and other facilities for which aid under this part is available, for all persons residing in the State, and adequate hospitals (and such other facilities) to furnish needed services for persons unable to pay therefor. Such regulations may also require that before approval of an application for a project is recommended by a State agency to the Surgeon General for approval under this part assurance shall be received by the State from the applicant that (1) the facility or portion thereof to be constructed or modernized will be made available to all persons residing in the territorial area of the applicant; and (2) there will be made available in the facility or portion thereof to the constructed or modernized a reasonable volume of services to persons unable to pay therefor, but an exception shall be made if such requirement is not feasible from a financial viewpoint.


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The preceding article is a rough version of the article that appeared in The American Almanac. It is made available here with the permission of The New Federalist Newspaper. Any use of, or quotations from, this article must attribute them to The New Federalist, and The American Almanac


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