Background: Between August 2020-April 2024, U.S. hospitals were mandated to report weekly occupancy to the Department of Health and Human Services (HHS) as part of Covid-19 data tracking efforts, providing unprecedented insight into average daily census and hospital bed supply across nearly all hospitals nationwide. [1] In this analysis, we sought to repurpose this Covid-19 dashboard to describe several U.S. hospital bed occupancy scenarios arising from an aging U.S. population, while varying hospitalization rates and staffed hospital bed supply.
Methods: The aging-adjusted annual number of hospitalizations were calculated by multiplying U.S. Census Bureau population projections [2] for 2025-2035 by an age-adjusted hospitalization rate from the 2019-2020 National Inpatient Sample. [3] These future hospitalizations were used to calculate future hospital census:(hospital census steady state [post-pandemic; May 2023-April 2024]) / (total annual hospitalizations [post-pandemic; 2023-2024]) =(future avg. daily census, year X) / (future annual hospitalizations, year X)Hospital occupancy for each year between 2025-2035 was calculated by dividing average daily census by staffed hospital bed supply. Alternative scenarios modeled aging-adjusted changes in hospitalization rates (-10% to +5% over the next decade) and hospital bed supply (-5% to +10% over the next decade), as described in the Figure 1 legend.
Results: National hospital occupancy ranged from 63-66% (mean 63.9%) between 2009-2019 compared to 72-79% (mean 75.3%) in the year following the end of the Covid-19 Public Health Emergency (PHE; May 2023-April 2024; Figure 1a). The number of staffed hospital beds declined from a pre-pandemic steady state of 802,000 (2009-2019 mean) to a post-PHE steady state of 674,000, while the average daily census steady state remained around 510,000 (Figure 1b). There was substantial state-to-state variation in the post-PHE hospital occupancy steady state (Figure 2).Without changes in the hospitalization rate or staffed hospital bed supply, total annual hospitalizations would increase from 36,174,000 in 2025 to 40,177,000 in 2035 based on an aging population. This would correspond to a national hospital occupancy of ~85% by 2032 for adult beds and by 2035 for adult and pediatric beds combined (Figure 1a).
Conclusions: The U.S. has achieved a new post-pandemic hospital occupancy steady state 11 percentage points higher than it was pre-pandemic. This persistently elevated occupancy appears to be driven by a 16% reduction in the number of staffed U.S. hospital beds rather than by a change in the number of hospitalizations.Experts in developed countries have posited that a national hospital occupancy of 85% constitutes a hospital bed shortage; [4-7] our findings show that the U.S. could reach this dangerous threshold as soon as 2032, with some states at much higher risk than others. These scenarios suggest that an increase in the staffed hospital bed supply by 10%, reduction in the hospitalization rate by 10%, or some combination of the two would offset the aging-associated increase in hospitalizations over the next decade.To avoid substantial excess mortality associated with a national hospital bed shortage, [8,9] future research should investigate the determinants of recent reductions in the staffed hospital bed supply (e.g., tight healthcare labor markets, hospital closures), and explore models to improve national health system resilience (e.g., next day clinics to avoid hospitalizations).
