Growing up, many of us heard our parents invoke a popular expression about “winding up in the poorhouse.” This old time expression is a final vestige of a disappearing cultural memory. In the not-so-distant past, poorhouses were a painful reality for many elderly people.

Colleen M. Grogan, in her article in History & Health Policy in The United States, describes the history of the poorhouses (or “almshouses”). Originally meant for poor people of all ages, the mentally ill, the disabled, and others without family support, the poorhouses eventually became long term elderly housing. The first ones appeared in the early nineteenth century. By the twentieth century, reformers had established orphanages and special institutions meant to rehabilitate the mentally ill and disabled. Rehabilitation was not possible for the chronically ill elderly, so they stayed in the poorhouses.

Physicians and hospital leaders of the time thought the poorhouse was the best place for the chronically ill elderly. These professionals wanted to protect their hospital’s reputations for curing disease. Old age and its accompanying illnesses could not be cured, and so were not appropriate for a hospital.

The locked wards and other horrific conditions of the poorhouses finally caught the attention of activists during the New Deal period. Responding to demands for old-age pensions that would allow the elderly to stay at home and avoid the poorhouse, the federal government established OASI – Old-Age Survivor’s Insurance(Social Security) and the OAA program. Elderly people in public institutions were not entitled to the funds, which was part of the government’s successful effort to close the poorhouses.

Without funding, the poorhouses were forced to close. The problem was that some elderly people still needed institutional care. Many used the OAA money to help pay for private nursing home care. In1950, the Social Security Amendments allowed elderly residents of public institutions to collect the funds.

To avoid a return to the poorhouse model, the amendments required states to set standards for public institutions. New nursing homes were built to accommodate the growing need for them. Institutional care, once shunned as being too much like the old poorhouses, was now a standard model of long term care.

Subsequent legislation, including The Kerr-Mills Act of 1960 and the passage of Medicare and Medicaid in 1965 sought to protect elderly who were not originally poor, but who had become impoverished by their medical expenses.  This was a huge problem because many seniors could not obtain affordable private health insurance and were forced to spend their savings on medical care.  Grogan points out that this connection between Medicaid and long term care was later reflected in a 1995 speech by President Clinton, in which he described Medicaid as benefiting middle class families.

Did the poorhouse ever really die, or did it evolve into something else? In her book In Sickness and in Wealth, Rosemary Stevens says that the poorhouse functions were taken over by the tax-funded city and not-for-profit hospitals, also called charity hospitals. Many of these institutions were teaching hospitals, and some critics complained that the poor and elderly were being used to teach medical students.

With Health Reform, caregivers of the future have gained the benefits of the Community Living Assistance Services and Supports (CLASS) Act. Like the New Deal-era OAA funds, which were meant to help the elderly remain at home and out of the poorhouse,  the CLASS Act benefit could pay for a few hours of home health care per day. It is unclear whether this benefit would be sufficient to allow elders to stay home and out of an institution.

CLASS Act benefits are available to those who have paid into the program for at least 5 years. Premiums are expected to start between $100-150 per month.  Critics point out that these premiums could be unaffordable to many people, especially for caregivers who give up their employment to care for an elderly relative.

History shows us that government provision of long term care has never guaranteed all elders their choice of high quality long term care options. In an eCareDiary radio show, health care policy veteran John Mills called for greater advocacy to protect caregivers. Looking beyond government programs may be another part of the answer. We must remember that some version of the poorhouse could appear in the future, if we do not engineer economically sound, comprehensive long term care solutions now. 

About Kim

Kim Harke is a health care technical writer specializing in compliance. She holds a Master’s in history from New York University.