The country grew quickly and by the 19th century land in the settled areas was no longer cheap. There was a limit to how many times a father could subdivide his land among his children to give them a plot of their own, so more and more children had to leave the family home in order to make a living. Some of them went to the cities to find work, and others moved west where cheap land was available.
In the early 1800's, much of the travel to the west was on trails like the "Cumberland Road," later called the "National Road," which funneled early pioneers into the midwest. In the early- to mid-1800's, pioneers began to travel farther west on the Oregon Trail, the Santa Fe Trail, and other major wagon train routes. By the middle of the century, the railroads were beginning to make travel easier, and in 1869 the transcontinental railroad was completed, making it possible to ride coast to coast in comparative comfort on a train.
Railroads encouraged the use of their new western lines by offering to sell land to potential settlers at low prices, over long terms, and at low rates of interest. Later, the federal government decided to further encourage the development of all the western states and territories by enacting the Homestead Act of 1862. The Homestead Act declared that any citizen or intended citizen could claim 160 acres of unoccupied public land in "public domain states," virtually any part of the country outside the original 13 colonies, Tennessee, Kentucky, Texas, and Hawaii. Claimants had to improve the plot with a dwelling, grow crops on it, and live there for five years. If the original filer met these requirements and was still on the land five years later, it was his property, free and clear. The opportunity to get free or low cost land drew millions of people out to the west, including many of the new immigrants pouring in from Europe and other parts of the world.
In 1800, the largest cities in the country were all in the original 13 colonies. By 1850, some of the "gateways" to the West, like Cincinnati, St. Louis, and New Orleans, overtook the eastern cities as the largest cities in the country. By 1900, the Midwest had become quite settled and many of the largest cities in the country were in the Midwest. (Largest U.S. Cities) (Population Percentage by Region)
The westward migration of the country contributed to the dispersion of families. Although a few families took their elderly relatives along on the difficult journey west, a number of the western settlers left their parents and other relatives behind in the East. Some families made several moves, perhaps settling in the Midwest for a time before moving farther west. Each time they moved on, some members of the family might decide to stay put, leaving relatives scattered along the migration route. Over time, the massive westward migration made it less likely that many, or any, children lived near enough to their parents to provide help.
Family living arrangements have always had an impact on the need for long term care. Women were less likely than men to have accumulated assets of their own that they could use to take care of themselves in retirement, and unmarried people of both sexes were more vulnerable in old age because they had no partner who could provide them with physical and financial assistance. The most vulnerable group of all were unmarried elderly women.
Older women were far more likely than older men to be unmarried (whether they were widowed, divorced, or never married). Only about one-third of age 65+ women were married in 1880, less than half the percentage of age 65+ men who were married. Although their life expectancies weren't much longer than men's, most women married men who were much older than themselves, so they often out-lived their husbands. Older unmarried women largely had to rely on children and other family members for help, and often ended up living with them. 10% of married women and nearly 60% of unmarried women age 65 or older were living with children or other family members as dependents in 1890. (Costa, 1997)
The poorhouse population exploded in the early 1800's and conditions in the poorhouses ranged from barely tolerable to horrific. They were often run by people who got their jobs as political favors. The operators often did as little as they could get away with in exchange for a paycheck, and the governing bodies often did as little as possible to keep costs down and discourage over-use. The operators were particularly incapable of caring for mentally-ill residents. Dorthea Dix reported finding women chained and kept in pens in some poorhouses. The insane patients, criminals, and alcoholics frightened, and sometimes injured, the frail elderly living in the same rooms.
Ending up in a poorhouse was everyone's nightmare. Songs like "Out from the Poorhouse" illustrated the public perception. In that song, a man bemoans the fact that he gave his children his farm and all his savings and they sent him to the poorhouse instead of taking care of him.
The poorhouses were becoming enormously expensive. "Ohio, which is not especially afflicted with pauperism, pays more than half the money obtained by the state taxation for the welfare of her criminals and paupers; and the estimate does not include the public charities of her cities, or any township aid." (The Atlantic Monthly, 1881)
One way to control cost and deter use was by segregating the poor. New York City purchased Blackwell's Island (now called Roosevelt Island) in 1828 as a remote spot for their paupers. On Blackwell's Island they built a penitentiary for criminals, men's and women's almshouses for the poor elderly, hospitals for those who were poor and ill (Charity Hospital, Smallpox Hospital, and the Hospital for Incurables), a workhouse for the able-bodied poor, and a lunatic asylum for the poor who were mentally-ill. (NYC Corrections History)
In response to the growing concerns about abuse and squalid living conditions, nine states (Massachusetts, New York, Rhode Island, Pennsylvania, Illinois, Ohio, Michigan, Wisconsin, and Kansas) created state-run "Boards of Charities" in the mid-1800's to oversee and report on the local poorhouse operations. These boards, precursors to today's Departments of Welfare, were supposed to inspect and control the poorhouses, and the reports they produced led to some efforts to improve conditions and to "classify" residents to separate the insane from the sane, and the dependent elderly from the able-bodied.
The growing costs, combined with the rising concerns about quality, arose from the inherent conflicts between the desire to provide good care to those who were truly needy and to reduce the cost to the taxpayers.
"Generally, the county officials lean to the side of mercy; the quality is not strained, since it costs them nothing; for, be it noted, there are two sets of principals in the business, the county directors or supervisors, who manage the almshouses, and are responsible for their expenses, and the justices of the peace and poor overseers, who commit paupers to the almshouses, and have nothing more to do with them. It is for the interest of the poor directors and supervisors to have as few paupers in the almshouse as possible; it is for the interest of justices, who are paid for each order they write, and of overseers, who depend for reelection upon the suffrages of the poor but warm hearted populace, to show a liberal spirit. And, as Sydney Smith has observed, everybody is full of humanity and good nature when he can relieve misfortune by putting his hand into his neighbors pocket. Who can bear to see a fellow-creature suffering pain and poverty, when he can order other fellow-creatures to relieve him? The result of all this is that, practically, most States give almshouse lodging to any one having a settlement who can bring himself to ask it." (The Atlantic Monthly, 1881)
There was a lot of debate about society's role in caring for the poor, but by the mid-1800's, many felt that the "deserving" poor, like children, the insane, and the elderly, should get better treatment than the "undeserving" poor, like alcoholics and those who were healthy but shiftless or lazy. Reformers like Dorthea Dix convinced legislatures to develop better facilities to care for the mentally ill, and they were gradually moved out of poorhouses. Laws prohibiting children from residing in poorhouses were passed, and the children were moved into orphanages.
That left poor, dependent, elderly adults who had no place else to go as the last group of the "deserving poor" who needed a place of their own, but the poorhouse was still the only public facility available for them. They were sometimes treated slightly better than the "undeserving" inmates, as in New York and Boston where the elderly were eventually separated from the rest of the poorhouse population. Nevertheless, they were still in a poorhouse. (New England Magazine, 1898)
In spite of the problems of the poorhouse system, most people seemed convinced that building large institutions was the best way to deal with those who needed help of one kind or another. In the newly industrialized society these institutions built to "efficiently" care for the poor, the sick, and the elderly bore an eerie resemblance to factories. They were large, warehouse-like buildings that housed dozens, or even hundreds, of people. "Inmates" slept in huge dormitories, with their beds beds neatly organized into rows, and ate at huge tables in a dining hall where meals could efficiently be served.
"The poor and the insane customarily were relieved within the family [in the Colonial era], the orphan was apprenticed to a household, the criminal, after being fined and perhaps whipped, was then returned to his residence. The 18th century community had recourse to institutionalization only when some extenuating circumstance--such as debilitating illness or violent insanity--made no alternative arrangement feasible. These ad-hoc institutions that came into being during the colonial era resembled the household both in routine and construction."
"In the decades after 1820, America turned with unprecedented enthusiasm and energy to the construction of custodial institutions for the poor, the insane, the orphan and the criminal. Institutionalization now became the first rather than the last resort. The institution and not the household became the preferred setting...Americans during these years also seem to have shared a confidence in the ability to design an environment and construct a setting in which these faults could be eliminated and the causes of dependency thus eradicated...And, understandably, with the beginnings of a factory system, the institutions built after 1820 were more influenced by and more nearly resembled the factory; whereas those built before 1820 more nearly resembled the household." (Abe Bortz, 1970)
In 1845, Congress enacted a law giving public land to each of the states "for the benefit of indigent insane persons", and the states started to build insane asylums and hospitals for the insane. Many of the mentally-ill poorhouse inmates transferred to these new facilities were elderly. (Vladek, 1980)
That group probably included some victims of dementia. The words "dotage" and "dementia" had been used by physicians and researchers as far back as Roman times, but the distinctions between dementia, other types of mental illness, and normal aging were not well understood in the 1800's. The term "senile dementia" was first used in 1838 by Dr. Jean Ã?tienne Esquirol. Dr. Alois Alzheimer would not discover that "Alzheimers Disease" resulted from plaques and tangles in the brain until 1906. (David Shenk, The Forgetting, 2001)
In response to the problems of the poorhouses, numerous nonprofit organizations began building old age homes to give "respectable" poor people a way to avoid the degradation of the poorhouse.
"Benevolent societies" or "fraternal organizations" affiliated with nearly every ethnic, religious, trade, profession, and social group imaginable were established during the 19th century. Hundreds of benevolent societies emerged, including the Irish Benevolent Society, the German Benevolent Society, the Hebrew Benevolent Society, the Odd Fellows, the Masons, and the Knights of Columbus. These were called "voluntary" organizations, because each eligible person could choose whether or not to join.
Although they had other purposes for their existence, the benevolent societies created one of the earliest organized old-age assistance programs. Members paid monthly dues to the Society while they were young and healthy, then received help when they were elderly, infirm, or in need. The Societies provided cash and food to support people in their own homes. Since that wasn't enough for older members who couldn't live alone any longer, the benevolent societies began to build "homes for the aged" where their elderly members could live. The significant expenses of erecting and maintaining these buildings were paid for by the members of the benevolent societies.
Some of the earliest voluntary homes were designed to house both orphans and the elderly, but eventually state-run orphanages were built and the orphans were moved into them. As that happened, the benevolent societies closed down their facilities for children and concentrated their attention on the elderly. (Odd Fellows Home History)
New laws were written in the 1800's to allow the creation of charitable organizations that could operate like corporations. In addition to those established by the benevolent societies, many charities were established by bequests from wealthy benefactors, whose wills included stipulations that the money or property be used to provide assistance to people who fit certain criteria, like "deserving widows and deserted wives" or "colored persons over the age of fifty of respectable character" or "old and worn out seamen." To carry out their work, the organizations built "old age homes" to house those who couldn't live on their own.
In sharp contrast to the poorhouses, the voluntary and charitable facilities seemed luxurious. Many were newly-constructed buildings, built specifically to house the elderly, and others were stately old mansions whose owners had died. The facilities were much nicer, but they were still operated with the paternalistic viewpoint of the times. "Inmates" were under the supervision of a "matron" who had complete control. Residents generally had to get permission even to have visitors or leave the facility. In most, "inmates" were also expected to do chores, and to do sewing or other services that could help bring in money to support the cost of the home's operation.
Some of these facilities required the recipients to pay an up-front fee and turn over their pensions and any other income or assets they had to the facility, in exchange for a guarantee that they would have a home as long as they needed it. This concept re-emerged a century later as something we now call "lifecare".
As an example of some of the homes that were built in Brooklyn, New York in this century, Polk's Medical Register lists the following:
Although they seem to be a precursor to nursing homes, most of the old age homes were more residential than medical. They probably provided something ranging from "room and board" or "board and care" to what we now call "assisted living". There are references to "infirmaries" in some old-age homes, and others included a separate building or section that they called a "hospital" where people who were very ill would be housed. The infirmary or hospital section of these facilities was probably comparable to what we call a "nursing home" today.
In studying the evolution of long term care, it's important to understand the way that hospitals were evolving, since there was some overlap between "old age homes" and "hospitals." Hospitals have some roots in the poorhouse system, just as nursing homes do, since from the beginning of the country many of the poor have been old and sick, and many of the old and sick have been poor. Some of the first hospitals in the country were built on poor farms to house the sickest of the poor population. (Medical History of Michigan, 1930) Where there was no poorhouse hospital, private hospitals received money from the county poor fund to care for the sickest paupers, which often made up a significant percentage of their patients. A few poorhouse hospitals, like Cook County Hospital in Chicago, still exist today as public hospitals.
Nineteenth century hospitals were not places where you expected to be cured, they were places to go when all other options had been exhausted. In the early part of the century medical science was very crude, and often consisted of "cures" like bloodletting, where the doctor cut the veins of the patient to let "bad blood" escape. In some cases the best outcome you could expect was that the "cure" wouldn't kill you. It wasn't until the latter part of the 1800's that researchers began to understand how to deal effectively with illness and disease.
In the earliest years of the country, and in the parts of the country that weren't yet settled, people cared for their sick at home. If a doctor was needed, he would come on horseback or by buggy, sometimes staying overnight. As time went on, some doctors began to board a few of the sickest patients in the doctor's own home. As demand grew, religious and other nonprofit organizations built better facilities and hired additional physicians. Hospitals as we know them today began to emerge in most of the country in the early- to mid-1800's, a bit earlier than the voluntary and non-profit old-age homes. Some early hospitals included care for the elderly as a part of their mission, even building "homes" attached to the hospital where the poor elderly could live. (Medical History of Michigan, 1930)
Unlike the younger, healthier patients, poorhouse patients tended to have chronic conditions that required long term care. People who weren't poor cared for the chronically ill at home. Those who were poor and ill, many of whom were also elderly, often ended up in hospitals for very long periods of time. (Charity Hospital, 1890)
There were some surprisingly modern concepts used during this period by private and non-profit developers, including some early planned communities and retirement campuses.
One of the earliest planned "retirement communities" was the William Enston Home in Charleston, SC, constructed in 1889. It is described by the National Park Service Register of Historic Places as follows:
"The home is comprised of 24 residential cottages; Memorial Hall, a community building; an infirmary; an engine house; a water tower and an entrance gate. Designed in 1889, the water tower served as the centerpiece of a model waterworks system, and the spacious, landscaped grounds exemplified suburban planning ideals of the 19th century...Enston specified that the complex be comprised of neat and convenient two-story brick cottages with at least eight acres of land. He also stipulated that potential residents be the old and sick, from 45 to 75 years old, of 'good honest character,' and not suffering from 'lunacy'." (National Park Service)
Sailor's Snug Harbor was built in 1833 on Staten Island New York as a 130-acre campus for "old and worn out seamen", funded by a generous bequest from Robert Randall, who left the bulk of his fortune to endow "...an Asylum, or Marine Hospital, to be called "Sailor's Snug Harbor" for the purpose of maintaining and supporting aged, decrepit, and worn-out sailors." Randall had originally made a bequest of land in Manhattan, but by the time litigation surrounding the will was settled, New York City had grown substantially and the Trustees of Snug Harbor decided that Randall's farmland was too valuable a piece of real estate to be used for a seamen's retreat, so they sold it and used the proceeds to purchase the 130-acre Isaac Housman farm in what was then a rural area of Staten Island. Eventually, the site included dormitories, gardens, a greenhouse, dining rooms, workrooms, barns, a dairy, a hospital, a sanitarium, a bakery, a laundry, a snack bar, a library, a vaudeville house, a church and a chapel.
Sailor's Snug Harbor was continuously in operation until the late 1960's, creating an interesting opportunity to see life in an old age home across several eras. That long span of existence and its location near a large city meant it was well-documented. Author Theodore Dreiser, lived nearby and got to know the the inmates of the place well. In his 1899 book, The Color of the Great City, he concluded that institutionalization was not a good solution for their old age, because "...this is a great institution and indeed a splendid benefaction, but it insists upon what is the bane and destruction of heart and mind: conformity to routine, a monotonous system which wears as the drifting of water." (Snug Harbor Cultural Center) More insight was provided in an article in Harpers Magazine which describes life in Sailor's Snug Harbor in 1873, and in another article from the depression-era Federal Writer's Project which describes life in Sailor's Snug Harbor in 1938. (Harpers Magazine, 1873) (Federal Writer's Project, 1938)
A small number of the non-indigent frail elderly people lived in early "proprietary", privately-owned facilities called "rest houses," "convalescent homes," or "medical boardinghouses", generally just rented rooms in a family home.
Nursing began to emerge as a profession in the late 19th century, along with professional "home health care." The newly created hospitals needed nurses to care for their patients, and developed schools to train them. As trained nurses became available, wealthier families sometimes hired them as live-in care providers for invalids and the elderly.
"The basis for all nursing was the care that the mother bestowed upon the members of her household in time of illness. Her anxiety for her loved ones, along with her desire to give aid and relief to the suffering, made her gentle and painstaking in the methods she used. At first, the mother was concerned with her own family, but as settlements grew larger, she would offer her services to a neighbor in time of trouble. Apparently there was no need for greater skill than that acquired by experience within the family and the neighborhood. Certain women, however, were handier in caring for the sick than their neighbors; naturally they would be called into service very often. Gradually, women, because of their natural inclination and repeated experience, were set aside by the neighborhood to minister to the sick. These women were called nurses.
"As communities grew, the limits of friendship were less observed and women skilled in giving aid to the suffering were called into homes of strangers and would receive remuneration for their services. This was the beginning of the practical nurse for hire, and for decades she was sufficient for the needs of the people." (Medical History of Michigan, 1930)
Poorer families couldn't afford to hire private nurses, but home care services for the poor also emerged around this time, launched by women like Lillian Wald of New York City, who had been trained as a nurse and was studying to become a doctor. During her medical studies Wald volunteered to visit poor immigrant pregnant women, elderly, and disabled people in their homes. When she saw the need of the poor for medical care, she dropped her medical studies and organized the Henry Street Settlement in 1893, also called the Visiting Nurse Society (VNS) of New York. These early home care agencies were directed to the poor and were supported by philanthropy, often "Societies" of wealthy women interested in public works. (VNSNY)
The Civil War created thousands of newly disabled people who needed long term care and beneficiaries for veterans benefits of all kinds. The Civil War involved 2.8 million men, about 10% of the entire population of the country, compared to the 300,000 men involved in the Revolutionary War. Hundreds of thousands of wives, children, and elderly parents lost the family breadwinner in the Civil War, either because he died, or because he ended up disabled and unable to work.
Because of the devastating impact of the war, veterans benefits were expanded during and after the war, first to stimulate recruitment, and later to avoid sending a flood of disabled soldiers and indigent widows to the poorhouses. This expansion in benefits led to what may have been the first instance of fraud and abuse of a federal benefits program. Thousands of profiteers throughout the country encouraged everyone, eligible or not, to sign up for these new benefits. The deluge of claims overwhelmed the Pension Bureau, slowed down claims processing, and added huge, and unexpected, costs to the veterans' pension program. (Atlantic Monthly, 1890)
Cash assistance wasn't enough in some cases. Eventually, the federal government started building hospitals and homes to provide long term care to disabled soldiers and sailors, where many lived into their old age. In spite of the problems and limitations, veterans benefits succeeded in providing a source of income that kept many veterans and their families out of the poorhouse. The cash payments could also be used to help pay for care in other facilities.
At the end of the century, employers began to take a role in providing assistance for their employees. In 1875, American Express developed the first private employer-sponsored pension program. It wasn't available to all retirees, but was limited to those age 60 and over who were incapacitated and unable to work. The Baltimore and Ohio Railroad inaugurated a pension in 1884 and its example was quickly followed by other railroads. The railroad pensions required no contribution from the employee, but were designed to tie the employee to the employer for life by limiting benefits to employees with very long tenure, as long as 30 years. Other employers created innovative programs, some even provided housing for employees or retirees.
California passed the first state old-age assistance law in 1883. Helen Valeska Bary, who had worked at the California State Department of Social Welfare and later became the 8th employee of the Social Security Administration, recalled,
"Back in 1883 a law had been passed giving money to anybody over sixty who was in need. It provided no system of administration. It could be just given out by the counties and was an open end drain on the State Treasury. That was the first law in this country for what you would say was an old age pension. That went on until 1895 when the country ran into the depression of the '90s and the State Treasury was being drained. By that time, the number of people getting pensions had increased so much that the legislature had to abolish it." (University of California/Berkeley Oral Histories Project: Helen Valeska Bary)
Robert Lansdale, a professor who headed up a study of state old-age assistance programs for the Social Security Administration in 1936, thought that people in the West were particularly sensitive to the need of the poor elderly. He said,
"In Colorado and on the Pacific Coast one found more general concern for old people than was encountered in the East. The social economists who have written the history of the old age pension movement in this country have looked largely to the industrial nations of Europe for origins because that was the source of their own ideology. They have never satisfactorily accounted for the fact that California had a program of state aid for the aged in the 1870's and 1880's and that the first two old age pension laws in this country were passed by Alaska and Arizona in 1914. This early action did not arise in an industrial economy. For want of a better explanation, I ascribe this movement in the West to a concern for the pioneer. In the East, down to the Great Depression, economic success was generally attributed to individual acumen, and failure to personal inadequacies. In the Far West, it appeared to me that there was greater tolerance for the old person who had not "struck it rich," attributable perhaps to the fact that those who had, knew that good luck rather than superior virtue accounted for their success." (Robert T. Lansdale,1960.)