Hill-Burton Act

Co-written by Alabama Senator J. Lister Hill to provide health services in underserved areas, the Hill-Burton Act became the catalyst for a substantial government spending program that created thousands of health-care facilities across the country in the 1950s and 1960s. In doing so, it also opened hospital doors for many blacks and rural citizens in Alabama and other southern states and provided funding for the University of Alabama Medical Center.

Enacted August 13, 1946, as the Hospital Survey and Construction Act, the law was commonly known as the Hill-Burton Act after its Senate sponsors, Alabamian Democrat J. Lister Hill and Harold H. Burton, a Republican from Ohio. From 1947 until the program ended in 1971 the law sponsored the creation of a modern health-care infrastructure with $3.7 billion in federal funding and $9.1 billion in matching funds from state and local governments. During that period, space for nearly a half million beds was created in 10,748 construction projects that included nursing homes, mental health and other specialized facilities, public health centers, as well as hospitals.

The bill arose out of several personal and professional relationships and the hope to serve poor rural areas. Alabama senator Hill and Alabama-born Florida senator Claude D. Pepper were the South's two most progressive senators and led efforts to assist the nation's most medically underserved populations: southerners, rural inhabitants, and African Americans. Pepper and Hill served together on the Subcommittee on Health, where they introduced the Hill-Burton bill and a variety of healthcare-related legislation, including the National Institutes of Health Act of 1948 to promote medical research. In addition, Pepper's U.S. Senate Subcommittee on Wartime Health and Education generated national support for federal healthcare reform and paved the way for Hill to guide the Hill-Burton Act through Congress.

Hill-Burton was designed to address the severe shortages of hospital beds in underserved areas, particularly the rural South. It was also the first federal program to incorporate a need-based allocation formula that favored poor southern states. Consequently, half of the beds created during the program's first decade were in southern facilities. Between 1948 and 1970, Alabama created more Hill-Burton hospital beds per capita than any other state except Mississippi. Building on Hill-Burton's success, the federal government increased funding for health, education, and welfare programs, as well as costly new roads, airports, and other infrastructure, making prosperity possible in the Sun Belt while allowing southern states to maintain low taxes. Although southern states shifted political allegiance from the Democratic to Republican parties in the postwar decades, the adoption of an anti-"big government" stance belied the dramatic increase in tax-subsidized federal aid to the South. Hill-Burton also fostered the growth of modern, hospital-based, technology-intensive medicine in the South. About 20 percent of the projects funded by the program aided teaching hospitals, including the burgeoning new academic medical centers at the state universities of Alabama, North Carolina, Texas, and Florida. Most buildings for the Medical College of Alabama in Birmingham, founded in 1944, were built with Hill-Burton aid.

Hill-Burton was the only federal legislation to ever include an "equalization clause," which resulted in more modern, well-equipped hospitals that admitted both black and white patients. Prior to Hill-Burton, hospitals in Alabama and across the South had been mostly small, poorly equipped private institutions concentrated in urban areas, and largely closed to black patients. During congressional hearings on Hill-Burton, black medical activists in the National Medical Association (NMA) and the National Association for the Advancement of Colored People proposed that federal funding and facilities built in areas where segregation was required by law should guarantee an equal share for blacks and whites.

Though internally segregated by ward or floor, these biracial hospitals greatly increased the availability of care for black and rural patients. In fact, the percentage of southern black infants born in hospitals rose from 24 percent in 1945 to 74 percent in 1960. Still, in the 1950s, civil rights activists protested that Hill-Burton hospitals were merely "deluxe Jim Crow" and did not afford blacks truly equal care. Until the U.S. Supreme Court struck down Hill-Burton's "separate but equal" clause in 1963, Hill-Burton hospitals remained segregated and many still excluded black physicians, so that black patients had to switch to a white physician in order to enter the hospital.

Under the leadership of southern liberals like Hill and Pepper, as well as early medical civil rights activists like physician Montague Cobb of the NMA, Hill-Burton bridged the New Deal and the civil rights movement by applying massive federal and state resources to meet the health needs of Alabama and the South, which provided a stepping stone toward fully integrated hospitals. The program dramatically increased the number of public-owned hospitals in the South, in which racial discrimination could be deemed state action and thus unconstitutional under the Fourteenth Amendment. In the 1960s, the courts and Congress would bar even private hospitals from practicing racial discrimination if they had received federal funds. Hill-Burton effectively redistributed hospital beds to the poorest, most medically underserved states, so that by 1970 five of the top seven states in per-capita Hill-Burton funding were southern. By the 1970s, however, Congress concluded that Hill-Burton had overbuilt hospital beds in rural areas while leaving inner cities in dire need and that the program had not adequately planned for needs for specific services such as obstetric, surgical, and outpatient facilities. In 1975, the legislation was rolled into the much more expansive Public Health Service Act.

Additional Resources

Beardsley, Edward. A History of Neglect: Health Care for Blacks and Mill Workers in the Twentieth-Century South. Knoxville: University of Tennessee Press, 1987.

Reynolds, P. Preston. "Hospitals and Civil Rights, 1945–1963: The Case of Simkins v. Moses H. Cone Memorial Hospital." Annals of Internal Medicine 126 (June 1997): 898–906.

Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.

Thomas, Karen Kruse. "The Hill-Burton Act and Civil Rights: Expanding Hospital Care for Black Southerners, 1939-1960." Journal of Southern History 72 (November 2006): 823-70.