Infrastructure investment is one of the few bipartisan candles still flickering on Capitol Hill. Over the past year, leading Democratic presidential candidates have put forward their own trillion-dollar proposals to boost the country’s infrastructure spending. But the discussion has largely centered around highways and bridges. Politicians have all but ignored one of the country’s most important categories of infrastructure: hospitals.
American hospitals are old. Much of today’s hospital stock was initially built in the decades following World War II, when the 1946 Hill-Burton Act spurred national investment in health care. By the time the program was folded into the larger Public Health Service Act in the 1970s, it subsidized the construction of as much as a third of the nation’s hospital bed capacity. By 1997, nearly 7,000 health care facilities — including hospitals, rehabilitation centers, and clinics — had been constructed with some funding from either the Hill-Burton program or its successor in the Public Health Service Act. Sure, those buildings have been upgraded since their construction, but increasingly, the pace of renovations and repairs is faltering.
The collective investment backslide was partially quantified through a 2017 study by the American Society for Health Care Engineering (ASHE), an affiliate of the American Hospital Association. The study’s authors reported that the median hospital’s “average age of plant” — a financial metric that describes the extent of a building’s depreciation — increased from 8.6 years in 1994 to 11.48 years in 2015.
Many of today’s hospitals may still be around 50 to 100 years from now. It can be difficult for anyone to prioritize so far into the future.
Although average age of plant is an imperfect indicator of a hospital’s physical condition, it’s one of the few metrics available. And according to health care spending consultant Don King, co-author of the ASHE study, the trend captured by the metric is genuine. “We do believe it’s aging,” King said of hospital infrastructure. “There may be some flaws in the measurement system, so we’re not sure about the rate.”
What’s going on? King attributes part of the aging process to a “break-fix” mindset: Instead of conducting preventative maintenance, hospital administrators wait until infrastructure has broken before they repair it. Often, administrators have to choose between long-term facility improvement projects and short-term initiatives that yield visible results quickly. But “the average lifespan of a hospital executive is shorter than the average lifespan of a hospital building,” said David Allison, a specialist in hospital design at Clemson University, noting that many of today’s hospitals may still be around 50 to 100 years from now. It can be difficult for anyone to prioritize so far into the future.
Delaying repairs always carries risk. It takes only one infrastructure system failure to cause serious, tragic disruption to a hospital. In April 2019, nearly four dozen patients were evacuated from a hospital in New Hampshire after its boiler broke, leaving the building without heat or water. On a 90-degree day the previous September, the air conditioning failed at a hospital in Florida. In these worst-case scenarios, patients are forced to go to another hospital or delay scheduled treatment until the facilities are repaired. For someone who arrives at a non-functioning hospital in a critically ill state and who can’t afford transportation to a different hospital, a neglected repair could mean the difference between life and death.
The heightened risk of equipment breakdown isn’t the only downside of aging hospitals. The facilities have subtler ways of causing trouble, even when they work according to design. That’s because many of the principles of health care that were baked into the design of Hill-Burton era hospitals are now outdated. For instance, architects of that era did not know that access to natural light aided patient recovery, and they had no idea that it would one day be commonplace for families to camp out in hospital rooms to show support for their loved ones.
Most of all, however, the architects of mid-20th century hospitals couldn’t have anticipated today’s medical technology. Modern hospitals are packed with complicated, electricity-guzzling machines, connected by mazes of wires and cables. Newer hospitals are built with large gaps between floors to accommodate these cables; older hospital buildings don’t have such space.
The architects of mid-20th century hospitals couldn’t have anticipated today’s medical technology.
Outdated hospitals may also impede future medical innovations. Medical professionals anticipate that next-generation wireless technologies will confer a host of health care advantages: new ways to collect and retrieve electronic medical record data, “smart rooms” that transcribe a doctor’s oral notes, more compact emergency equipment with fewer trailing wires. Heavyset, Hill-Burton era hospitals are ill-equipped for this technological revolution. Take their thick concrete walls, for instance, which tend to absorb Wi-Fi signals, rendering coverage patchy. It’s no use investing in new technology at a hospital that can’t reliably operate it.
This fundamental concern about the state of our hospitals has prompted U.S. representatives Eliot Engel and Peter King to introduce the 21st Century Hospitals Act, a bipartisan bill that would direct the Department of Health and Human Services to conduct a national study of all hospital infrastructure. Such a study would produce more information than age of plant numbers can provide — and quantifying the problem is the first step towards fixing it. The bill was introduced in June 2019, but it has yet to be considered by a committee and remains a long way from being debated on the House floor.
The closest thing we have to a revival of the Hill-Burton Act is the Leading Infrastructure for Tomorrow’s America Act (LIFT America), a bill sponsored by more than 40 congressional Democrats that would set aside billions of dollars to build new health care facilities and renovate existing ones. Additional funds are earmarked for health programs serving American Indians, for community health centers, and for the Centers for Disease Control and Prevention. But with Congress distracted by other matters, the chances of LIFT America — or any hospital infrastructure legislation, for that matter — becoming law are small. The state of the U.S.’s aging hospital facilities is going to get worse before it gets better.
Claire Jarvis is a scientific and technical writer covering the interface of chemistry, biology, and medicine. Her writing has appeared in Chemistry World and The Open Notebook. She can be found on Twitter @StAndrewslynx.