By 1980, the United States had reached its goal of 4.5 community hospital beds per 1,000 civilian population (National Center for Health Statistics [NCHS], 2002) even though the Hill-Burton program ended in 1974.

President Harry Truman took advantage of reports that the United States had severe capacity deficits in the hospital sector and that many Americans across the country were unable to access acute care services, using them as a stepping stone to create the Hill-Burton Act.

Over time, however, overbuilding of hospitals and unrestrained use of Medicare and Medicaid funding sent health care costs into an uncontrolled upward spiral.

For the first 20 years of the act's existence, there was no regulation in place to define what constituted a "reasonable volume" or to ensure that hospitals were providing any free care at all.

The most significant changes at this point were the addition of some regulatory mechanisms (defining what constitutes the inability to pay) and the move from a 20-year commitment to a requirement to provide free care in perpetuity.