<Li> Facilities that received funding were also required to provide a' reasonable volume' of free care each year for those residents in the facility's area who needed care but could not afford to pay . Hospitals were initially required to provide uncompensated care for 20 years after receiving funding . The federal money was also only provided in cases where the state and local municipality were willing and able to match the federal grant or loan, so that the federal portion only accounted for one third of the total construction or renovation cost . </Li> <Li> The states and localities were also required to prove the economic viability of the facility in question . This excluded the poorest municipalities from the Hill--Burton program; the majority of funding went to middle class areas . It also served to prop up hospitals that were economically nonviable, retarding the development wrought by market forces . Once Medicare and Medicaid were enacted, participation in those programs was added to the list of requirements for access to Hill--Burton funding . </Li> <P> The reality, however, did not nearly meet the written requirement of the law . 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 . This did not improve until the early 1970s, when lawyers representing poor people began suing hospitals for not abiding by the law . Hill - Burton was set to expire in June 1973, but it was extended for one year in the last hour . In 1975, the Act was amended and became Title XVI of the Public Health Service Act . 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 . Still, it was not until 1979 that compliance levels were defined . </P>

One problem with the free care requirement under hill-burton was that it