From Poorhouses to Front Porches: The History of Group Homes and Assisted Living

Every time a family in Tucson tours a six-bed group home on a quiet street, they are standing at the end of a very long road. It is a road paved with good intentions, terrible mistakes, a few brave people, and a slow, stubborn belief that older and disabled people deserve to live in a home, not a ward.

Understanding that history helps you ask better questions. It also explains why Arizona's care system looks the way it does.

The almshouse era (1700s to early 1900s)

Public poorhouses, also called almshouses, were one historical source of care for impoverished older people—not the only one. The later exclusion of public-institution residents from Old-Age Assistance helped encourage private nursing-home growth. 1

Social Security and the birth of the private care home (1935)

The Social Security Act of 1935 established Old-Age Assistance, a federal-state assistance program. Its exclusion of residents of public institutions from those payments stimulated growth in voluntary and proprietary nursing homes. This was not the same as the later retirement-benefit checks associated with Social Security. 1

Medicare, Medicaid and the nursing home boom (1965 to 1987)

Medicare and Medicaid were enacted in 1965, expanding federal involvement in nursing-home financing and regulation. 1 The Institute of Medicine's 1986 report, Improving the Quality of Care in Nursing Homes, documented serious quality concerns and recommended reforms. 1 Rather than assuming a building's size tells you its quality, ask how a provider protects residents' choices and meets their needs.

Willowbrook and the end of the big institution (1970s)

The story of the developmental disability group home has its own turning point. In 1972, reporter Geraldo Rivera filmed inside Willowbrook State School on Staten Island, New York, showing children and adults with intellectual disabilities living in overcrowded, filthy conditions. The investigative report received a Peabody Award. 1

The report helped draw attention to the contrast between institutional care and community alternatives. 1 Community living developed through a broader history of advocacy and legal change; it did not mean that every large institution closed.

Olmstead: a legal right to live in the community (1999)

In Olmstead v. L.C. (1999), the Supreme Court held that unnecessary segregation of people with disabilities is discrimination under the Americans with Disabilities Act. Community services are required when appropriate to the person's needs, not opposed by the person, and reasonably accommodated by the public entity. This is a qualified right, not an unconditional guarantee of a particular placement. 1

Keren Brown Wilson and the idea of assisted living (1980s)

Keren Brown Wilson is an important voice in the history of modern assisted living. Her peer-reviewed historical account describes a shift beginning in 1979–1985 toward residential environments, consumer-centered care and alternatives to nursing facilities, followed by expansion and quality concerns in the 1990s. Assisted living has multiple roots rather than a single founding story. 1

For families, the useful question is whether a home makes privacy, independence and meaningful choices part of daily life.

Arizona's path

Arizona began its mandatory managed-care Medicaid program, AHCCCS, on October 1, 1982. ALTCS was implemented on December 19, 1988, for people with developmental disabilities and January 1, 1989, for elderly or physically disabled people. 1 Today, eligible ALTCS members may receive services in institutions or home and community-based settings, including assisted living. 1

Arizona defines an assisted living home as serving 10 or fewer residents and an assisted living center as serving 11 or more. These definitions do not establish how many homes Tucson has. 1

What this history means for you

When you tour a home in Tucson, you are judging whether it lives up to a promise that took a century to win:

• Is it a home or a ward? Look for personal belongings, real furniture, and residents who make choices.
• Are residents' rights respected? Ask about privacy, visiting and how complaints are handled.
• Does the person stay part of the community? Outings, family visits and ordinary life matter.

Look for a place that feels like a home and respects the person who will live there. Hold every provider to that standard.

Sources are linked beside the relevant claims above.