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As virus advances, the vestiges of Hill-Burton form a tattered line of defense

By Tom Baxter

Lister Hill was an Alabama Democrat, the son of the first American physician to suture a human heart. Harold Burton, an Ohio Republican, was a former Cleveland mayor who was already serving on the U.S. Supreme Court when the legislation he’d co-sponsored with Hill was signed in 1946.

The health care system which today faces its greatest crisis is in large part a creature of the law which bears these senator’s names, the Hill-Burton Act. It financed the construction of some 6,800 hospitals, nursing homes and mental health facilities in more than 4,000 communities.

A disproportionate number of these were in the South, vast swaths of which were lacking in even the most basic health care services. Hill-Burton was the last great New Deal project, and one of its express purposes was to bring the region closer to the level of the rest of the country.

The law was altered several times, and in 1975 its programs were rolled into the Public Health Services Act. Today there are only 131 officially designated Hill-Burton facilities which still have the same obligations to serve the uninsured. But a huge share of our health system’s physical plant — a third of the hospitals built before 1975 — was financed through Hill-Burton.

“When the history of health legislation in the 20th Century is written, the place of honor as the most significant piece of federal legislation may well be accorded to the Hill-Burton Hospital Hospital Survey and Construction Act of 1946, at least until the era of a national healthcare program arrives,” William J. Curran, a pioneer in the field of health law, wrote in 1970. Twenty years into a new century, nothing, including the Affordable Care Act, has changed that assessment.

Hill-Burton was enacted at a critical juncture point in the nation’s history, and it reflects the complicated and often problematic aspects of the post-World War II period.

It was the last law in American history with language which sanctioned racial segregation, a “separate but equal” clause which Hill inserted to win the support of other Southern senators. It was also the first to institute a state-federal matching program as a means of paying for itself.

Anticipating a new era of growth, Hill and Burton drafted the bill in the closing months of the war. It appeared to be dying in committee until in December of 1945, President Harry Truman proposed a national health care system along the lines of those taking shape in the United Kingdom and Europe.

That rattled the nation’s medical establishment, and prompted the American Hospital Association to give the Hill-Burton bill a re-do and support it as an alternative. The “separate but equal” clause stayed in the law until a federal court struck it down in 1963, ending one of the cruelest practices of the Jim Crow era.

So it was, in its original form, a racially discriminatory law which was used to block the passage of more ambitious, comprehensive measures. Bismark’s famous remark that you never want to see laws or sausages made, definitely applies in this case. But we are fortunate as a nation that we had it.

As COVID-19 advances into the Wiregrass, the PeeDee, the Ozarks and all the other corners of the South which will never draw as much national attention as New York or Miami, it will be marching into the heart of Hill-Burton country. Many of the hospitals built with Hill-Burton funds have closed in recent years. Those that remain are about to become the tattered front lines of the struggle against the virus.

On Monday the inspector general of the Department of Health and Human Services released a survey of 323 hospitals around the country conducted in late March. They reported severe shortages, not just of ventilators and masks but thermometers and basic cleaning supplies. Smaller and more isolated hospitals reported they were getting the short end in the competition for supplies with hospitals in more populous areas.

Ominously, hospital administrators also reported being under severe financial stress, paying six dollars for masks that used to cost 50 cents, and forced to treat any suspect case as COVID-19 because they don’t have tests.  For rural hospitals already on the ropes, this is a grave development.

It’s likely that in the aftermath of COVID-19, there will be calls for a new version of Hill-Burton to prepare for the next pandemic. In a nation less united, where the idea of a bill co-sponsored by Republicans and Democrats seems fanciful, that will be a tall order.

Tom Baxter

Tom Baxter has written about politics and the South for more than four decades. He was national editor and chief political correspondent at the Atlanta Journal-Constitution, and later edited The Southern Political Report, an online publication, for four years. Tom was the consultant for the 2008 election night coverage sponsored jointly by Current TV, Digg and Twitter, and a 2011 fellow at the Robert J. Dole Institute of Politics at the University of Kansas. He has written about the impact of Georgia’s and Alabama's immigration laws in reports for the Center for American Progress. Tom and his wife, Lili, have three adult children and seven grandchildren.


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  1. George Wilson April 7, 2020 4:11 pm

    We will soon see the folly of the state Republicans not expanding Medicaid to Georgians that will result in more death in rural Georgia.Report

    1. Sally Sears April 10, 2020 9:24 am

      Tom, Thank you for such a splendid reminder of the cavalry riding to the rescue for the last half of the last century,.
      A Hill-Burton hospital in central Alabama saved my father from a heart attack.
      I’m sending this article around as widely as I can.
      Senator Lister Hill may have had feet of clay. But compared to many southern Senators, particularly Alabama senators, he stood tall where it counted.
      Sally SearsReport


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