By Dave Kingsley

     The late Congressman Wilbur Mills, Chairman of the Ways & Means Committee from 1958 to 1974, was arguably one of the most powerful congressmen in the history of the U.S. House of Representatives.  During the 1950s and 60s, Mills guided federal legislation out of which the nursing home system as we know it today was spawned. He was also an ardent segregationist and white supremacist.[i]

    The power of Southern Democrats in guiding the conceptualization and passage of Medicare and Medicaid determines to this very day how citizens will be treated in federal/state funded long-term care. This is too often overlooked in histories of welfare medicine in the United States.[ii]

    In their zeal to protect Jim Crow and plantation capitalism, the one thing that segregationist senators and congressmen fought most ardently against was federal power.  For the immensely powerful Mills and his Southern brethren, preservation of the racial hierarchy of the South was a cri de Coeur. “States’ rights” were synonymous with the right of Southern states to preserve strict apartheid and maintenance of African Americans in subservience and an inferior economic and social status.[iii]

    Sponsorship of the Kerr-Mills Act in 1960 with Senator Kerr of Oklahoma was an early foray for Mills into major long-term care legislation.  This act was also a precursor to Medicaid and, therefore, to welfare medicine in the United States. Several major facets of this initial “poor people’s medical care” was incorporated into Medicaid and have presented disturbing barriers to a fair and just medical system throughout the last six decades.

   The odious feature of “Means testing” in early nursing home related legislation is a significant characteristic of Kerr-Mills. This is a process through which people prove they are poor enough to qualify for government assistance.  Hence, those not poor enough to qualify would need to “spend down” their assets before qualifying for federal/state assistance.

    The concept of the “medically indigent” was introduced into U.S. medical care through Kerr-Mills.  The importance of a stigmatizing medical category – codified into health care law – cannot be underestimated.  Along with state power in and control over Medicaid, recipients are incessantly confronted by bureaucratic barriers and personal indignities that beneficiaries of all other government subsidized medical care avoid.  The United States is the only advanced, industrialized society that places poor people in an inferior medical care status.

    In addition to means testing, state funding with federal matching funds characterized financing of Kerr-Mills.  Southern Democrats could see the handwriting on the wall and maneuvered as much power to the states as possible. Because states do not have the same fiscal resources to fund Medicaid as the federal government, state legislators and bureaucrats treat Medicaid as lower tier medicine.  Funding is lower and medical care is typically inferior.

    The federal government has unlimited resources and the United States has the wealth to fund an alternative system that provides a truly home-like nursing home environment such as the Eden Alternative and Greenhouse models.  However, states’ rights as a philosophical position has not weakened appreciably among conservative states.  Huge federal programs such as Medicare and Social Security represent federal power, which is an anathema to conservatives.

    Furthermore, state power over regulation and state bureaucracies’ propensity for supporting industry opaqueness hampers the public’s perception of how operators and the investors owning them fulfill their obligation. It is much easier for the industry to capture government at the state level and direct the actions of legislators.  Hence, weak federal oversight and the power of trade associations in all 50 states must be attacked by advocates and activists. 

    It is important to include the impact of systemic racism into any plan and narrative for change. The nursing home system as it has evolved cannot be fixed because it’s not broken.  It is working like it was intended to work.[iv]  It is time to demand that all funding and regulation be the responsibility of the federal government.

[i] I have a more expansive discussion of Mill’s influence in the development of the U.S. nursing home system in my chapter, “Implementation of Medicaid-Funded Long-Term Care: The Impact of Prior History on the Development of the Nursing Home Industry,” in Max Skidmore & Biko Koenig (2019) Anti-Poverty Measures in America: Scientism & Other Obstacles.  Washington, D.C.: Westphalia Press.

[ii] Rare exceptions to the failure of social scientists to understand the impact of race on government medical care policy are Jill Quadagno (2005) One Nation: Why the U.S. Has No National Health Insurance. New York:  Oxford University Press; and Gerard Boychuk (2008), National Health Insurance in the United States & Canada.  Washington, D.C.:  Georgetown University Press.  Social science and history that overlooks the fundamental fact that had there been no slavery, no Jim Crow, and no ongoing systemic racism, the U.S. healthcare system would look far different.

[iii] In 1956, Congressman Mills was a signatory to the Southern Manifesto, which was signed by all senators and congressmen from the former states of the traitorous Confederacy.  In the document, the segregationist legislators argued that legally mandated school desegregation, as required by Brown v. Board of Education encroached on the rights of States and of the people.

[iv] I want to thank my colleague and fellow activist/advocate Ester Holzendorf for this conceptualization of systems adversely impacting poor people and racial minorities.


  1. Connecting the abysmal medical services access and delivery system Americans have to live with to racism is a critically important link. More attention needs to be called to this well disguised reality. Americans who label themselves as practicing born again Christians should be livid about this gross inequity. From that perspective, according the the scriptures they profess to honor and live by, the homeless man in the park and Jeff Bezos should have access to the exact same health care and services. Just imagine that!

    • Thanks Kent! The system as it is structured denies equal treatment to low income Americans. The original intent was: 1. maintain state power over any government welfare program, and 2. keep African Americans in an inferior status. Until this is recognized by white liberals, the system will not change and systemic racism will continue to be part of our thinking.

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