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Rhoads, J. "On Our 250th Birthday, What to Make of President Adams’s Act for the Relief of Sick and Disabled Seamen?" Center for Modern Health. July 2026.

On July 16, 1798, President John Adams signed "An Act for the Relief of Sick and Disabled Seamen," a piece of legislation that had been passed by the Fifth Congress. The act was modest in terms of what it put into place, but it has had a long afterlife in American political argument. It required that twenty cents per month be deducted from the wages of private merchant sailors and paid into a federal fund for their medical care. In modern debates, it is sometimes described as America's first prepaid health plan, or even the first federal health insurance mandate.^1,2

As the United States marks the 250th anniversary of the Declaration of Independence, Adams's 1798 law invites some reflection: for a nation founded on independence, what are we to make of a law that uses this kind of mechanism to solve a healthcare-related problem?

There is some truth in describing the seamen act as a health insurance mandate, but there is also a danger of anachronism. The law did place a requirement on sailors, but the law was not a health insurance mandate as we would understand the phrase today. It was an occupational health program for a particular class of workers whose labor entailed international trade and was in some ways inseparable from national defense and public health.

The context for Adams's law was the early republic's maritime world. In the 1790s, the United States was a fragile commercial nation with a long coastline, a small navy, and a deep dependence on merchant shipping. Sailors carried goods between ports and abroad, and they were considered the reserve of manpower in time of war—something that would have been a recent memory for them. The sailor's life was dangerous. Disease, injury, shipwreck, exposure, and disability were common. When sailors became ill in port, they often lacked family support, local residence, or the means to pay for care. Charitable, benevolent societies existed, but were not especially well-resourced in pre-industrial America.

Public health concerns were also part of the context. Port cities lived in fear of yellow fever and smallpox. Variolation was still new. Philadelphia's devastating yellow fever epidemic in 1793 remained fresh in memory, and the late 1790s brought renewed anxiety about quarantine and the movement of people and goods through busy harbors. The federal government had a direct interest in customs houses, ports, and the seafaring labor force. In that world, the health and welfare of sailors was not a completely private matter; it was arguably even a national defense concern. In Adams's letters and state papers from 1782-1799, maritime issues come up repeatedly (indeed, "seamen" are mentioned 65 times).³

The 1798 act addressed that problem through a simple financing mechanism. Shipmasters were required to withhold twenty cents per month from the wages of seamen and pay the money to federal customs collectors. Those funds would then be used for the "temporary relief and maintenance" of sick or disabled sailors. The president was authorized to direct expenditures, including the establishment or support of hospitals where necessary. So-called Marine Hospitals were established in port cities up and down the coast, from Boston to New Orleans.⁴

The law was compulsory; sailors could not opt out. In that narrow respect, it does resemble a prepaid health arrangement akin to, say, the modern compulsory social health insurance systems of Germany or Japan.

But there are also some important differences. For instance, the act applied to a specific occupation, not the general population. It was tied to the federal government's well-established authority over foreign commerce, customs collection, and maritime affairs. Also, it did not create a universal entitlement to medical care, and did not require every American to buy a private insurance product. It was closer to an occupational assessment or user fee within a federally supervised sector than to a comprehensive national health scheme.

Precedents from the founding era are often conscripted into modern political battles. Just as free-market advocates like to cite examples where the founders acted in ways that seem to us especially market-oriented, advocates of national health insurance like to cite the 1798 act as evidence that modern efforts to expand government into healthcare would have the support of the founders. The better conclusion is that things such as context and scale matter. A twenty-cent monthly deduction from merchant sailors in a port-based economy is simply not on the same scale as a nationwide system governing hundreds of millions of people, billions of dollars, and the full complexity of modern medicine. To invoke Adams's law as a decisive precedent for national health insurance is to read too much into a relatively minor piece of law from a long time ago.

The story of what happened later on is also instructive. The program provided some relief, but for much of the 1800s, the contributions from the wage deductions were insufficient to cover the actual costs of the system. Eventually in 1870, after a critical review, the Marine Hospital Fund was reorganized into a more centralized Marine Hospital Service with a mission of expanding care into quarantine, disease control, and medical inspection. In 1912 it was renamed the United States Public Health Service (USPHS). Today the USPHS is an agency within the Department of Health and Human Service and employs about 6,000 people working in all 50 states and many international locations.

The evolution of Adams’s act into the USPHS is further evidence that the law is best understood as an early, limited, and debatable attempt to address a public health problem, not evidence that the founders believed that the federal government should one day assume responsibility for the medical needs of all citizens. This distinction is worth remembering as America celebrates the 250th anniversary of its independence.

Jared Rhoads is Executive Director of the Center for Modern Health.

References:
1. Laskow, S. "A Little Perspective: Congress First Mandated Health Care in 1798" Smithsonian Magazine. June 28, 2012.
2. Ungar, R. "Congress Passes Socialized Medicine and Mandates Health Insurance -In 1798" Forbes. January 17, 2011.
3. The Works of John Adams, vol. 8 (Letters and State Papers 1782-1799). The Liberty Fund. https://oll.libertyfund.org/titles/adams-the-works-of-john-adams-vol-8-letters-and-state-papers-1782-1799. Accessed July 1, 2026.
4. "Our History." Commissioned Corps of the United States Public Health Service. https://www.usphs.gov/history. Accessed July 2, 2026.