Now 10 Years Old, The Affordable Care Act Made Us Healthier, But Less Prepared For A Pandemic

The Patient Protection and Affordable Care Act, signed into law 10 years ago Monday, not only remade the U.S. health insurance market, it also spurred long-term changes to healthcare real estate.

Most visibly, the law accelerated the decentralization of healthcare facilities, with hospital systems developing more dispersed, multidisciplinary clinics, and private companies ramping up neighborhood healthcare locations. As that has happened, the number of overall hospital beds has declined.

The decentralization trend has been hailed by many healthcare experts, but the current coronavirus outbreak might reveal its weaknesses.

"The bad news is that the number of hospital beds has decreased in the past 10 years because we're healthier and benefit from preventative medicine in our communities," Skender Director of Healthcare Design Jenny Han said.

"The immediate response to the outbreak is the activation of other spaces, such as hospitals that have been shut down, hotels or dorms, and modular hospitals," Han said. "They're being used to increase the number of beds for the number of more critical patients we expect to see, but it's only a temporary measure."

The number of hospital beds has edged down over the last decade, from nearly 942,000 in 2010 to about 924,000 as of 2018, according to the Centers for Disease Control and Prevention and the American Hospital Association. That is a continuation of the decline since 1975, when there were 1.46 million U.S. hospital beds.

As hospital beds have become scarcer, the country's over-80 population — those most vulnerable to COVID-19 — has become more plentiful, growing from 11.2 million in 2010 to 12.7 million in 2018, according to the Census Bureau.

Initiatives are under way nationwide to temporarily expand healthcare facilities. On Monday, New York Gov. Andrew Cuomo issued an emergency order mandating that all hospitals in the state increase their capacity by 50%. New York has the most COVID-19 cases in the country, and has become one of the global epicenters of the coronavirus crisis.

Cuomo estimated Tuesday that the state will need up to 140,000 hospital beds, more than double its current capacity. Its intensive care unit shortage is far worse: It has 3,000 and may need up to 40,000, Cuomo said.

There has been an initial delivery of hospital supplies to the Jacob K. Javits Center in Manhattan, where the Federal Emergency Management Agency is building a 1,000-bed temporary hospital. It will function as a field hospital for COVID-19 patients.

U.S. Navy hospital ships with 1,000-bed capacities are being sent to both New York and Los Angeles. In California, FEMA is building eight temporary facilities statewide totaling 2,000 beds, including a facility in the Santa Clara Convention Center. All of those will be used to treat non-COVID patients to help relieve the pressure on local hospitals. 

Tufts University in Boston is making vacant dorm rooms available to relieve stress on the healthcare system, Middlebury College in Vermont is making some of its buildings available for emergency use, and New Jersey Gov. Phil Murphy has proposed housing patients temporarily in college dorms.

Depending on how the pandemic plays out, healthcare real estate will probably pivot more to anticipate future crises, health experts say — not going back to giant, central hospital campuses, but adapting the decentralized model to new realities as much as possible.

Why Healthcare Spread Out

Decentralization became the norm because of an important feature of the 900-plus-page Affordable Care Act that pushed the industry away from a fee-for-service model and toward the goal of population health, which means better outcomes for a particular population, such as that of a metro area.

The law promotes population health by providing health insurance to more people when it established insurance exchanges for individuals to buy insurance at a lower cost and expanded Medicaid — about 20 million more Americans have insurance now than in 2010. But it also incentivizes preventive care for Medicaid patients, and awards grants to states to develop chronic disease initiatives. 

"One large-scale change we’ve seen is at hospitals, which are modernizing their operations but not necessarily expanding their bed count," said Svigals + Partners Associate Principal Doug Lovegren, who designs healthcare facilities.

The population health principles in the ACA incentivize hospitals to prevent hospitalizations, Lovegren said. Thus many hospital design firms have shifted their focus to ambulatory care facilities, or ambulatory surgery centers, which are being built more in residential communities.

The main reason bed count has leveled off — and even shrank slightly — is because preventive measures have reduced the need for beds in theory, Lovegren said. The theory didn't anticipate a severe spike in demand for beds because of a pandemic.

"One of the original tenets of the ACA was to make healthcare more accessible and affordable," Han said. "So outpatient delivery has taken more routine clinical needs out of downtown academic environments, and created more multidisciplinary clinics both in the suburbs and in the city, but in any case outside of hospital campuses."

But as other factors have allowed the current pandemic to spread widely and quickly — the country's shortage of testing and lack of paid sick leave among them — that leaves the healthcare system at risk of being overwhelmed, Han said.

In the wake of the current outbreak, healthcare design will probably change again, design experts say.

For example, some physical changes in hospitals might be made in the future, if only to accommodate greater stockpiles of personal protection equipment,  said Vivian Ho, the James A. Baker III Institute Chair in Health Economics at Rice University.

"My guess is that hospitals will stockpile PPEs and ask the government to stockpile ventilators," she said. 

It is also possible that more attention will be paid to isolation rooms and air systems, including increased numbers of isolation inpatient and clinic exam rooms and in clinic waiting rooms, Clark Kjos Architects principal Scott Combs said. Portland, Oregon-based Clark Kjos is a specialist in healthcare, designing hospitals, ambulatory care clinics and community health facilities.

Some healthcare facilities are already including isolation rooms and areas.

"After the SARS/MERS and Ebola crises, many larger healthcare institutions responded by considering ways to isolate whole patient units and sections of their emergency departments to contain and isolate groups of patients in newly designed in-patient buildings," Han said. "The way they plan their infrastructure, with separate air handler units, allows them to make sure there is no cross-contamination of air between patients."

Larger clinics can possibly help limit the spread of disease during a pandemic, Lovegren said, though he stresses that the idea is based on project and client experience, and his firm isn't tracking data or surveying the situation in a formal way.

"It's likely a larger group practice has an isolation exam room or two that they can put a suspected case into to limit spread," Lovegren said. "These are generally built for suspected TB cases, and the smaller solo practitioners often didn’t have this type of room in their facility due to cost. It's more common in larger practices."

Ho isn't sure that outpatient centers will be able to play a major role in fighting future pandemics, since the lessons of the current outbreak are still unclear. But the economics of healthcare means that including space set aside for a surge in demand at large hospitals is going to remain unfeasible, she said. 

"Most hospitals are operating on very thin margins, so they will never be able to set aside facilities that just sit empty, waiting for a huge influx of patients," Ho said.

Rather, when the current pandemic runs its course, hospitals are going to lobby the government to be better prepared the next time around, Ho said, such as in rolling out robust testing earlier.

"If testing had been up and running early, we wouldn't be in this space crunch now," she said.