The Gap
The strongest national benchmark is now several years old. It documents a severe infrastructure burden, but it is not a current, all-in valuation of what American healthcare facilities need to repair, replace, modernize, and prepare for the future.
$243B
A Facility Health Inc. analysis commissioned by ASHE estimated that approximately 41% of major healthcare facility assets were in deferred status, representing about $243 billion in work needed at that time.
$391B
The same analysis projected that the amount needed could grow to approximately $391 billion over ten years if deferred maintenance continued increasing at the reported rate.
53%
Industry benchmarking reported that deferred maintenance levels had risen to roughly 53% by late 2024. This is directional evidence from a sampled portfolio—not a complete national census.
79% / 43%
In the 2024 ASHE Hospital Operations Survey, 79% of respondents reported receiving less than half of the deferred-maintenance funding they requested, and 43% received 10% or less.
The $243 billion figure is often repeated without its date, scope, or methodology. It should not be treated as a current estimate, and it should not be casually added to the $391 billion projection as though the two figures describe separate backlogs.
A credible current estimate would need to account for continued asset deterioration, construction and labor costs, geographic variation, changes in the healthcare facility base, and additional requirements involving resilience, seismic compliance, modernization, temporary systems, and construction inside occupied hospitals. Those categories can overlap, which means simply adding every available estimate together would be misleading.
The direction of travel is clear even though the current national total is not:
Deferred maintenance measures work that has already been delayed. It does not necessarily capture every system approaching replacement, every building requiring major renewal, every resilience improvement, every code-triggered upgrade, or the engineering and validation work required before a project can attract funding.
The total infrastructure challenge includes both the backlog already accumulated and the predictable renewal of systems that are still operating today but nearing the end of their service lives.
The United States does not currently maintain a complete, transparent, regularly updated assessment of healthcare facility infrastructure condition and capital need.
Available information is fragmented across industry surveys, private facility-condition databases, public capital plans, bond disclosures, government records, hospital master plans, academic research, and individual project announcements. Different sources use different definitions, scopes, and time horizons.
Healthcare depends on physical infrastructure every hour of every day, yet the country cannot say with confidence what condition that infrastructure is in or what will be required to renew it.
A modern assessment should distinguish existing deferred maintenance from near-term capital renewal, long-term replacement, resilience, modernization, and regulatory requirements. It should report condition by system type, facility type, ownership, geography, and operational risk—and make its methods transparent enough to be repeated over time.
It should also identify where otherwise viable projects are stalled because hospitals lack predevelopment engineering, validation, matching funds, or access to the right institutional partners.
Just The Bones intends to begin with a transparent national evidence review and an updated, clearly qualified estimate of healthcare infrastructure need. The work will start from the recognized 2021 benchmark, use documented cost information and clearly labeled assumptions, identify overlap and uncertainty, and show how every conclusion was reached.
It will not be presented as a new national facility-condition assessment. Its purpose will be to establish a defensible current range, identify what remains unknown, and demonstrate the need for a new primary national study. Planned deliverables include a source-controlled research workbook, a public white paper, a concise executive brief, and external technical review.
2021 benchmark: Facility Health Inc. analysis commissioned by the American Society for Health Care Engineering, as reported by Health Facilities Management, Sept. 3, 2021.
Later condition trend: Brightly/FHI benchmarking discussed in Health Facilities Management, May 30, 2025.
Funding survey: ASHE/HFM 2024 Hospital Operations Survey, reported by Health Facilities Management in December 2024. A complete source-controlled evidence library is in development.