During the Revolution, government-subsidized health care for the poor was part of the self-government cherished by the rebels who fought the war. Recall that the revolution began in Massachusetts, where one of the Intolerable Acts, the Massachusetts Government Act, restricted the ability of local governments to run their own affairs. After the Revolution, newly independent states retained the poor law, making only modest revisions.

Ironically, the law remained virtually unchanged longer in the United States than it did in Britain. By the time New Deal programs began to augment poor relief in the 1930s—because state and local governments during the Great Depression could no longer fund it alone—the oldest American states had been using the Elizabethan Poor Law, more or less, for 300 years.

The details varied from one state to the other, but four principles of the poor law were the same. First, parents and children were legally required to help each other when they were in need. If they could not, then the local government was legally required to step in. Second, poor relief was a function of that local government—whether a town, municipality, city, county, or parish—and not state or national officials. Third, all those who required aid had to be provided with basic provisions: food, shelter, warmth, and medical care. Fourth, all those in need who were not from the town where they sought care or shelter could be banished, with the intention that they return to their hometowns where they would be guaranteed assistance. Until the Great Depression, most Americans paid for health care out of pocket; it was only if costs were too great that they appealed to poor relief for help.

How the poor law’s four principles were applied varied not only from state to state, but also from one town to the next. The law determining who was from a town (or who had a “settlement” there, in legalese) could be very complicated. The simple version was that if one’s ancestor had owned real estate in the town, one had a settlement there until a more recent ancestor—or, in a woman’s case, her husband—bought land somewhere else. The officials who implemented the poor law in a given area, usually called overseers of the poor, had great discretion in deciding who was in need and how best to keep them fed, clothed, housed, and doctored. Bills stemming from doctor and nurse visits, as well as medicine, were part of what made poor relief the biggest expense for almost every local government at the time of the American Revolution.

Indeed, poor relief was the single largest expense in almost every local-government budget until schools and roadwork caught up in the mid-19th century. Larger towns and cities had enough poor patients to build institutions devoted to the health care of the neediest. By 1826, New York City had a dedicated public hospital for the poor and sick called Bellevue. Bellevue was very much in the tradition of the Elizabethan Poor Law: a local institution, funded by local taxpayers, aimed at local needs.