1800-1990: Changes In Urban/Rural U.S. Population
Source: U.S. Census Bureau
There has been a very large shift from rural living to urban living throughout the US population from 1800 through 1990. As we discuss this change, we will continue to focus on what this means for seniors and senior healthcare.
In 1800, 94 percent of the US Population lived in a rural setting. This would change, but during this period, mass travel or long-distance travel was primarily by boat. Most families were very self-sufficient and a trip to town was about buying staples, not groceries. In fact, the first grocery store would not open until 1916 – when Piggly Wiggly opened its first store in Memphis.  The idea of living in an urban setting was not a standard way of life in 1800 and it was a lifestyle that would be slow to change. Homesteads and farms had everything that a family needed and people were self-reliant. Even senior care was provided by the family.
Going to town meant walking, riding a horse, or riding in a wagon drawn by a horse. The first automobile was a century away and even going ten miles by horse took most of the day. From 1800-1820 only 6-7 percent of people were living in urban settings. Senior healthcare was a role that the family and doctor shared. The life expectancy of a man ranged from 33 years to 47 in 1900. Old age was something that happened to very few people. Only four percent of people born in 1900 made it to age 85 and 10-12 percent to age 65. Old age and the care of seniors was a rarity. This would change as medical advancements helped people to live longer and more productive lives.
Cities and Their Appeal
One of the things that changed where people lived was the convenience of cities. In the 20th century, railroad and streetcars were a primary way to move long or short distances fairly cheaply. People were no longer dependent upon a horse for transportation, though even in 1850, only 15 percent of the US population lived in an urban setting. The rapid expansion of the west was also slowing. Children were leaving home and moving to the city where they would work a job rather than on the farm. 
In terms of senior care, the depletion of labor – children leaving home – meant that those that remained had to do more and there were fewer people around to care for mom and dad or grandma and grandpa. The family unit was shrinking and the distance between siblings grew. That is a shift that would appear later in the urban setting. Who would take care of mom or dad once the children have all left home? Medicare and Medicaid would not begin until 1965 and the idea of a nursing home as we know it today would begin in the 1970’s. Further, the definition of senior care would begin to become something we recognize today after 1987 when the Nursing Reform Act became law. Before 1965 old people without sufficient means were sent to poorhouses – a place of subpar living standards, abuse, and disease. Those blights in senior care would not be replaced until after the Great Depression – 1929-1939. Then the poorhouse would become a paler version of a board and care home today.  Those events were all things that would happen in the future and after a sufficient percentage of the rural population became urbanized.
In 1860 one fifth of the US Population lived in urban settings and the call of the city was growing stronger. By 1870 more than 25 percent of people were living in cities. By 1900, 40 percent of the US population lived in the cities. In 1920 the ratio would be nearly 50:50. Up to this time, rural areas were without major conveniences such as electricity. The standards of living were different between the city and the country. The Rural Electrification Administration was born in 1934. In 1920 50 percent of urban homes had electricity. That boon opened up the door for further conveniences such as electric washing machines, and small appliances. Life was getting easier in the city. 
By 1960 rural living was greatly diminished. Only 37 percent of the population lived rurally. Part of this shift was the expansion of cities and a new phenomenon called urban sprawl. The invention of the automobile would literally drive changes from rural living to urban living. People could now live in suburbs of a city, drive to work, and drive to the grocery store.
The shift in healthcare reflected this too. It was easier for a doctor to stay in one spot than to make house calls. People began going to the doctor rather than the doctor coming to them. By 1990, 75 percent of the US population lived in an urban location. In 1980 less than one percent of doctors made house calls.
As mentioned, after 1965 when Medicare became law, nursing homes increased and in 1987 they became better managed through changes to the legal system. The first hospice would not begin until 1974 and its presence today is in thanks to the Connecticut Hospice which served as a provider of end-of-life-care for people throughout the New Haven area.
The shift from rural living to urban living was slow and it was fueled by innovation such as the discovery or the assembly line which opened up jobs for the masses. The development of the automobile and the gentrification of urban homes from lacking electricity to becoming the predecessor of modern living. Along the way, the seeds of today’s senior health care were planted, grown, and honed. That shift mirrors the change in the family unit and takes on the burden of an increasing lifespan thanks to advancements in medicine.