A sign reading “Heroes work here” is shown outside a hospital. (Photo by Ethan Miller/Getty Images)
With both infrastructure and hospitals in the news these days, Ohioans should take a moment to learn about the Hill-Burton Hospital Survey and Construction Act. This ground-breaking legislation, signed into law 75 years ago this week on August 13, 1946 by President Harry S. Truman, helped to build and modernize American hospitals. An Ohio senator played a key role in the passage of this legislative hallmark.
The bill is named for its sponsors, U.S. Sen. Lister Hill of Alabama, a Democrat, and U.S. Sen. Harold H. Burton of Ohio, a Republican who served from 1941-1945. Burton was also a former mayor of Cleveland (1936-1940) and Associate Justice of the U.S. Supreme Court (1945-1958).
Truman had big goals for the U.S. in the wake of World War II. Before 1946, Truman and congressional Democrats considered sweeping legislation to reform U.S. health care in ways similar to the National Health Service then being put in place in the United Kingdom. But hyperbolic language about socialism and Soviet-style health care killed Truman’s lofty goals. In fact, there is another Ohio connection in this story.
Burton’s senior colleague, Ohio U.S. Sen. Robert Taft, also a Republican, sponsored the Taft-Smith-Ball Bill that ultimately undermined Truman’s efforts to establish a public health care system in the United States. Instead of Truman’s call for comprehensive national health care services, Taft-Smith-Ball called for the subsidization of private insurance, which Truman opposed as a serious solution. Taft’s efforts effectively shelved health care reform, and when the Republicans took the Senate in the next election, Congress and the president were at a political impasse. Truman regarded the inability to pass meaningful post-war health care reform as one of his greatest presidential failures.
During the rancorous political moment, hospital construction slipped through the cracks and Hill-Burton at least partially filled the void created not only by sagging hospital infrastructure, but also by the failure of the U.S. health care system to provide universal care. Hill-Burton provided federal grants to hospitals and nursing facilities for new construction and modernization. In exchange for the grants, nonprofit hospitals agreed to provide health care services to the communities in which they were located, regardless of patients’ ability to pay. In addition, one of Hill-Burton’s legacies was the establishment of ratio for gauging hospital bed adequacy at 4.5 beds per 1,000 people in the community.
The law also called into question whether poor communities were being served at the levels promised, primarily because Hill-Burton required that communities fund two-thirds of project costs, which only wealthy communities could afford to do. For all its success, Hill-Burton was also a reminder of the chasm that exists between wealthy and poor communities in the United States in accessing medical care.
Inadequate records make it hard to pin down Hill-Burton’s specific impact on hospitals in Ohio, but we know that almost $3 million (the 2021 equivalent of about $42 million today) flowed to Ohio hospitals in 1946 alone. Scholars have argued that Hill-Burton had a “a profound and lasting impact on the U.S. hospital industry.” A key part of Hill-Burton’s enduring legacy, however, was the creation of a new expectation that federal grants to hospitals always come with the obligation of nonprofit hospitals to serve their community gratis when necessary. This conversation continues today, with questions about whether hospitals receiving generous tax benefits are providing adequate care and support to surrounding communities.
There’s another side to the story as well.
Throughout his career as a legislator and jurist, Burton was a lifelong, committed desegregationist. And seven years after Hill-Burton became law, Burton was one of the Supreme Court justices who voted in 1954 to desegregate public schools in the landmark case, Brown v. Board of Education of the City of Topeka. Burton’s legislative partner, Hill, in contrast, was a segregationist, as one would expect of a senator from Alabama in the 1940s.
Thus, another facet of Hill-Burton’s legacy is the role it played in allowing southern hospitals to discriminate against Black patients. While the bill formally forbid discrimination, it allowed for “separate but equal” facilities in hospitals receiving federal funds — the only such authorization in the 20th century that “explicitly permitted the use of federal funds to provide racially exclusionary services.”
Hill-Burton’s discriminatory provisions stood until 1963 when Simkins v. Cone Memorial Hospital, a federal case decided by the Fourth Circuit Court of Appeals, held that publicly funded hospitals violated the equal protection clause of the U.S. Constitution when establishing “separate but equal” facilities. Consequently, the federal funding that Cone Memorial Hospital received through Hill-Burton ultimately led to the constitutional determination that publicly funded hospitals could not discriminate against patients. In other words, the discrimination Hill-Burton legally sanctioned eventually served as the basis for the legal challenge that ended segregation in American hospitals.
This underappreciated moment in American health care, in which an Ohio senator played a central role, set in motion several conversations that endure. We still debate the proper role for public funding in an American health care system that continues to fail to serve millions of people. We still experience gaping disparities linked to race, class, and ethnicity.
The sociologist Paul Starr has written, “In the Hill-Burton program, states’ rights and community autonomy were invoked as the basis for limiting federal intervention.” As a result, while Hill-Burton improved hospital infrastructure and patient access around the U.S., the bill also failed to put in place new dynamics that would have set American hospitals — and the American health care system more generally — on a permanently sustainable path.
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