The safety-net role of public hospitals has evolved since 1700s when the first U.S. public hospital sheltered and provided medical healthcare to the poor. Until the late 20th century, public hospitals represented the "poor house" that undertook social welfare roles. The "poor house" also provided secondarily medical care, specifically during epidemics. For this reason, these "poor houses" were later known as "pest" houses. Following this phase was the "practitioner period" during which, the then welfare oriented urban public hospitals changed their focus to medical care and formalized nursing care. This new phase was highlighted by the private physicians providing care to patients outside their private practices into inpatient hospital settings. To put into practice the demands of the Flexner Report published in 1910, public hospitals later benefited from the best medical care technology to hire full-time staff members, instruct medical and nursing students during the "academic period". The privatization of public hospitals was often contemplated during this period and stalled once an infectious disease outbreak such as influenza in 1918, tuberculosis in the early 1900s, and the polio epidemic in the 1950s hit the U.S.. At this time, with the goal to improve people's health and welfare by allowing for effective health planning and the creation of neighborhood health centers, health policies like the Social Security Act were enacted. This was followed by Medicare and Medicaid Act in 1965 that gave poor people in the U.S., access to inpatient and outpatient medical care from public hospitals after racial segregation ended in the South. With their mandate to care for low income patients, the public hospital started engaging in leadership roles in the communities they care for since the 1980s.