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Many factors have affected, and continue to affect, the development of America’s health care facility infrastructure. Key factors include:

Government investment

A large segment of today’s health care facility infrastructure portfolio can trace its history to the 1946 Hill-Burton Free and Reduced-Cost Health Care Act, which provided federal grants and guaranteed loans for communities to build hospitals.

Government regulations

Government efforts to enhance safety and to protect and improve health play an important role in new construction.

Government reimbursement policies

Health care organizations rely on Medicare, Medicaid and other government reimbursement for much of their revenue, and private payers often follow the lead of Medicare when setting reimbursement policies. Given that these funds are tied to following the Conditions of Participation that often govern building codes, trends in government reimbursement policy affect health care construction.

Environmental concerns

Hospitals require large amounts of energy because they operate around the clock, require advanced medical equipment and must meet strict construction requirements aimed at protecting vulnerable patients. Becoming energy efficient can save hospitals significant money and reduce pollution. In addition, hospitals built with environmental concerns in mind often produce less toxic construction waste and consume less water.

Catastrophic events

Sometimes catastrophic events affect hospital construction. For example, after the 1994 Northridge earthquake in California caused 23 hospitals to suspend some, or all, of their services, the California legislature passed SB 1953, which requires hospitals to meet strict construction standards designed to keep them operational after an earthquake.


Technology has affected construction in numerous ways. For example, new hospitals are built to accommodate robust networking and communications technology, which reduces space requirements needed for record storage, especially with the increasingly standardized reliance on electronic health record systems. Technology also affects decisions regarding renovation. The design of physician office buildings also is affected by technological advancements.


The economy plays a key role in shaping health care infrastructure. Good economic conditions drove new health care facility construction to a peak of 24.9 million square feet in 2008; the recession in following years significantly slowed construction, with only the most critical health care projects moving forward. The construction market has started to recover. However, new construction is only part of the story — maintenance projects often struggle to compete for capital that otherwise could be used for new facilities and equipment.

Health care delivery trends

Among the many health care delivery trends that have affected infrastructure is the move toward patient-centered care. This move has resulted in the design of safer hospitals that promote healing through the purposeful provision of more natural light, improved air quality, reduced noise and easier patient navigation. 

Don D. King, CHFM, BEP, president, Donald King Consulting; Chad Beebe, AIA, FASHE, deputy executive director, ASHE; Joan Suchomel, AIA, ACHA, EDAC, senior vice president, Cannon Design; Peter Bardwell, FAIA, FACHA, principal, BARDWELL+associates LLC; Vincent Della Donna, AIA, ACHA, principal, Healthcare Architect; and Lisa Walt, Ph.D., senior analyst, advocacy, ASHE