Invisible Infrastructure, Visible Results: A Conservative Case for Clean Indoor Air

American life expectancy has fallen behind that of our peers.¹ The “Make America Healthy Again” (MAHA) movement aims to reverse this slide by attacking the everyday environmental exposures that cause chronic disease. MAHA’s emphasis on creating cleaner environments to generate sturdier bodies that need fewer drugs and procedures can sometimes sit uneasily alongside conservative commitments to deregulation and small government. These seemingly contradictory impulses, however, can be reconciled around the issue of indoor air quality (IAQ).

This essay makes the case for a conservative IAQ agenda based on three core claims. First, poor IAQ results in both chronic illness and the spread of infectious disease. Cleaner air can help Americans live longer and healthier lives. Second, cost-effective solutions—ventilation, filtration, and germicidal ultraviolet light—are simple and have measurable results that can be coordinated around a single performance standard. Third, if the federal government upgrades IAQ in facilities it already runs and funds, it can demonstrably and affordably improve health outcomes without imposing new mandates on the private sector.

Federal buildings are useful policy proving grounds because they are already unusually well observed. When the government operates or finances a building, it also routinely produces data about what happens to the people who use it. This data includes rates of hospital admission, emergency room visits, prescription use, sick leave, disability claims, and, in some cases, mortality. Because of this abundance of data, IAQ is a rare case in which public health policy can be framed in explicitly predictive terms.

Rather than relying on abstract models or subjective reactions, federal buildings can function as real-world laboratories in which prevention is treated as a verifiable claim, not a permanent commitment or act of faith. Federal agencies could specify in advance what health and spending developments they anticipate from improved IAQ, observe whether those expectations are being met using existing administrative data, and then revise their assumptions and actions accordingly. Improving IAQ is a measurable, commonsense intervention compatible with a government that aims to limit spending, regulation, and market interference.

The Cost of Indoor Pollutants and Pathogens

Americans spend roughly 90 percent of their time indoors, inhaling air that often contains higher concentrations of pollutants than the air outside.² We often assume that indoor air is safe, but this is not borne out by the existing epidemiological evidence. Cooking and cleaning generate fumes and can concentrate pollutants, and fine particles from traffic and industry regularly seep indoors. Poor indoor air is therefore one of the invisible ways the built environment makes Americans sicker, poorer, and less resilient than they should be.³

Respiratory conditions are perhaps the most obvious outcome of poor IAQ. For instance, approximately one in twelve Americans, including some 4.9 million children, suffers from asthma, a condition partially caused by airborne pollutants.⁴ Asthma results in roughly 1.4 million emergency department visits per year and causes 13.8 million missed school days, with an estimated healthcare cost of around $82 billion annually.⁵

For adults with chronic obstructive pulmonary disease (COPD), air quality can be the difference between a manageable week and a hospitalization. Each year, COPD kills more than 140,000 Americans and results in nearly $25 billion in healthcare costs.⁶ Viruses such as RSV, influenza, and Covid also spread readily in shared indoor spaces. Real‑world studies show that cleaning indoor air makes the spread of infectious disease and the development of chronic disease less likely. For instance, nursing homes that upgraded their air systems saw fewer respiratory outbreaks, fewer hospital transfers, and lower overall mortality rates.

Respiratory conditions, however, are but one of the myriad negative health impacts of poor IAQ. The same tiny particles that irritate airways also slip into the bloodstream, nudging blood pressure up, and making clots more likely. One study suggests that particulate matter exposure causes cardiac events that result in the death of nearly thirty thousand Americans annually. Moreover, short‑term spikes in PM2.5 track measurable jumps in acute cardiovascular events, raising the probability of long-term mortality risk.⁷

Poor air quality is particularly dangerous during pregnancy and early life. Studies link exposure to air pollution during pregnancy to lower birth weight, preterm delivery, and a higher risk of complications.⁸ Early-life exposure to poor quality air has also been associated with developmental and behavioral problems in children. Good IAQ is therefore crucial for maintaining the health of American children and supporting their ability to perform well academically. In schools as in workplaces, fewer absences translate into better learning outcomes and higher output.

The negative economic impacts of poor IAQ are difficult to overstate. High rates of chronic disease cause increases in Medicaid and Medicare spending. Infections lead to sick days, staffing shortages, and higher rates of overtime. Employers lose productivity and, if people fall out of the labor force entirely, the government loses money twice over. Air quality is not the sole cause of these problems, but it is a reversible contributor to harms we already spend hundreds of billions of dollars trying to combat.⁹

This is an economic problem on a global scale. The World Bank estimates that annual global losses from exposure to fine particulate matter (PM2.5) total approximately $8.1 trillion—about 6.1 percent of global GDP—driven largely by premature mortality, with additional costs from morbidity.¹⁰ In the United States, recent synthesis work reaches similar conclusions, finding that air pollution imposes economic losses on the order of hundreds of billions of dollars each year. One widely cited estimate places the total cost in 2014 at roughly $790 billion, or about 5 percent of U.S. GDP,¹¹ and there is little evidence that these burdens have meaningfully declined in the decade since.

While these figures are not limited to indoor exposures, they indicate the scale of the problem. Because indoor environments often concentrate the harms of poor air quality, even modest improvements indoors can have economically significant effects.

A Short History of Indoor Air Policy

In the first half of the twentieth century, tuberculosis, known to be a disease of poverty and overcrowding, remained a major cause of mortality in the United States. Patients were treated in facilities that prioritized air circulation and time spent outdoors.¹² During the 1918–1920 influenza pandemic, Americans were reminded in dramatic fashion that shared indoor air could harbor deadly viruses.¹³ As infectious disease prevention and treatment improved, however, building priorities shifted toward controlling energy use and improving insulation rather than diffusing airborne pathogens.

After World War II, buildings were designed to create a firm barrier between conditioned indoor air and unconditioned outdoor air. American cities embraced sealed, mechanically ventilated towers with glass curtain walls, deep floor plates, and centralized systems that treated outdoor air as a cost rather than a resource.¹⁴ During the 1970s oil embargo, tight building envelopes reduced fuel costs but concentrated pollutants indoors. Workers complained of headaches, irritation, fatigue, and dizziness, a cluster of symptoms that became known as “sick building syndrome.”

By the early 1990s, Congress, along with several federal agencies, was considering a national framework for improving IAQ. In 1991, an IAQ bill drafted rules and guidance for employers, builders, and public institutions.¹⁵ Plans for implementation, systems of oversight, and performance metrics were never settled, however. Paperwork and committees were abundant, but pressure to deliver clean air in indoor spaces was decidedly lacking.

During the same period, the professional consensus standards produced by the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ashrae) began to dominate policy discussions.¹⁶ In most commercial and institutional buildings, the modern benchmark is ashrae Standard 62.1, which specifies minimum outdoor air ventilation rates and related measures intended to achieve “acceptable” IAQ. In residential settings, Standard 62.2 plays a similar role. These standards are widely incorporated into mechanical codes and building practice and therefore shape what is treated as normal and compliant design.

Unfortunately, “Acceptable IAQ” has mostly been defined in terms of subjective comfort rather than by performance targets explicitly tied to disease outcomes. It is, of course, easier to verify that a design nominally meets a ventilation table than it is to verify that a building is actually reducing illness. Yet such a policy approach incurs costs—and creates extraneous paperwork—without generating verifiable economic benefit.

A Conservative Theory of Prevention

Recently, “prevention” has most often involved broad regulatory mandates, permanent grant programs, and invasive efforts to reshape individual behavior. Conservatives have good reason to distrust this model. It promises to protect health and reduce costs but delivers diffuse authority, weak accountability, and a steady accumulation of rules.

The Covid pandemic sharpened these concerns. Mask mandates, school closures, and shifting guidance provoked backlash because they exposed the flaws in a model of public health that relies on emergency powers and enforced behavioral compliance rather than durable infrastructure and measurable results. A defensible alternative must remain narrow in scope, respect the rights of individuals, and be implemented only when supported by evidence. It should be informed primarily by restraint rather than ambition.

In this sense, a conservative approach to prevention avoids moral claims about what people “should” do; instead, it should focus on a set of financial and institutional claims about whether a limited intervention reduces downstream spending relative to its cost. This alternative, restrained approach rests on four basic principles:

(1) Limits: the government should act in places it already controls or funds, such as VA hospitals, DoD barracks, nursing homes and hospitals paid by Medicare and Medicaid, Head Start centers, and federal office buildings;

(2) Performance: agencies should pay for results, not cater to particular brands or professional groups, and those results should be straightforward to measure and verify;

(3) Demonstration: the goal of federal projects is to generate evidence that allows private families, businesses, and local governments to copy policies that pay for themselves; and

(4) Evaluation: agencies should state in advance what health and economic effects they expect cleaner air to have in specific settings and treat those expectations as claims to be tested rather than aspirations to be defended. Expansion should be contingent on meeting those benchmarks within a fixed time frame, or else they should be eliminated.

Much of the MAHA agenda has taken the form of reshaping incentives surrounding diet and lifestyle as well as expanding consumer protections by banning or restricting certain food dyes, additives, or chemicals. These efforts reflect a concern about chronic disease, but they also tend to expand regulatory oversight of individual choices and private markets. Sensible federal IAQ policy advances many of MAHA’s core goals—reducing chronic illness, limiting infectious disease, and allowing Americans to live long, healthy, and autonomous lives— without adding new rules for households or businesses. Instead of telling Americans how to conduct their lives, it invisibly changes background conditions, so that preventable illness becomes less likely.

Engineering Air Quality

Engineers typically describe air turnover in enclosed spaces using air changes per hour (ACH), which measures how many times per hour a room’s air volume is replaced through ventilation. While ACH is a useful baseline, it captures only air replacement—not air cleaning. To address this, engineers use equivalent air changes per hour (eACH), which measures how many times per hour the air is effectively cleaned. This cleaning can occur through three mechanisms: introducing outdoor air, filtering recirculated air, or inactivating airborne pathogens, which are each worth discussing in detail.

(1) Ventilation: this process works by bringing in outdoor air and exhausting stale indoor air, typically through fans and ductwork rather than open windows. When outdoor air is relatively clean, increased ventilation can dilute indoor pollutants and virus-laden aerosols. Moving large volumes of air requires significant energy, however, and in many climates that air must also be heated or cooled. As a result, ventilation—when used on its own—is the most capital- and energy-intensive way to increase eACH.

(2) Filtration: Filtration cleans indoor air by repeatedly passing it through filters that capture infectious or harmful particles. High-efficiency filters (MERV 13 and above) remove a large share of fine particles and some droplets with each pass. In buildings with centralized HVAC systems, upgrading filters can increase eACH across the entire structure. Many existing systems, however, cannot accommodate the added resistance of higher-grade filters without costly upgrades. Portable filtration units—such as commercial HEPA cleaners or fan-and-filter setups—avoid this limitation by creating localized recirculation. As a result, they are among the cheapest and most flexible ways to increase eACH in heavily used spaces.

(3) Disinfection: Many airborne pathogens can be inactivated by ultraviolet light. Germicidal UV-C systems replicate the sun’s natural disinfecting effect and concentrate it where it is most effective. Upper-room UV fixtures project light above occupants’ heads; as air circulates through this zone, viruses and bacteria are damaged until they are no longer infectious.

Germicidal UV can deliver large gains in eACH at relatively low cost. Once installed, fixtures operate quietly, use modest amounts of electricity, and require only periodic bulb replacement. Emerging far-UVC technologies are also promising, as they use wavelengths that are safe for limited exposure to human skin and eyes. For near-term policy, however, established upper-room and in-duct UV systems are already mature enough to justify deployment in many settings without meaningfully increasing risk.

Governance, Guardrails, and Oversight

A conservative indoor air quality (IAQ) agenda should begin with firm limits. First, the institutional footprint should be small, and broad regulatory mandates should be avoided. Existing authorities within the Department of Health and Human Services, the Department of Veterans Affairs, the Department of Defense, and the General Services Administration can pilot indoor air upgrades within their own buildings and programs. A light coordinating function—located in the Domestic Policy Council, the Office of Management and Budget, or a temporary task force—can align standards and evaluation methods across agencies without creating a new bureaucracy.

Second, programs should operate under clear, public rules about where they apply. Federal IAQ standards should be limited to: (1) buildings owned or directly operated by federal agencies; and (2) facilities participating in explicitly enumerated federal programs, such as Medicare- and Medicaid-certified nursing homes or Head Start childcare centers. Any expansion beyond these categories should require new legislation, not discretionary agency action.

Third, results should be transparent. For participating facilities, the government should report whether eACH targets were met in key spaces, which technologies were deployed, and how infection and hospitalization rates changed relative to pre-intervention baselines. This would make it clear where IAQ investments deliver measurable health and economic benefits.

Finally, programs should include automatic off-ramps. Authorizing language can require pilots to sunset unless reauthorized after a fixed period and condition any expansion on meeting pre-specified outcome thresholds. This ensures that federal action on chronic disease and biosecurity remains narrow, testable, and reversible rather than permanent and expansive.

Importantly, IAQ pilots can rely largely on data the federal government already collects. Medicare and Medicaid claims, VA and tricare records, FEHB data, nursing home assessments, school attendance logs, and federal HR systems already track outcomes such as respiratory illness, hospitalizations, medication use, emergency visits, sick leave, and disability claims. These are precisely the outcomes that should improve with better indoor air.

Because these programs cover tens or hundreds of thousands of people, even modest percentage changes become visible quickly. Existing data systems therefore make it possible to treat prevention as an iterative process—testing predictions, observing results, and adjusting policy—rather than as a one-time investment justified by theory alone.

If IAQ pilots prove effective, the next step should be encouragement rather than compulsion. Agencies can publish designs, performance targets, and evaluation results, giving private builders, landlords, and employers reliable evidence about how ventilation, filtration, and UV perform in ordinary buildings. In this phase, the federal role is informational, not regulatory: reducing uncertainty, clarifying costs and benefits, and lowering risk for early adopters—without expanding regulatory authority or imposing new private sector mandates.

Federal Pilot Strategy

Pilot projects allow the federal government to test whether IAQ improvements deliver their predicted outcomes. Policy should specify in advance the level of improvement required to justify broader adoption. Although the proposed pilots differ in setting and risk profile, they share a common logic: intervene first where outcomes are measurable, attribution is credible, and results can meaningfully inform expansion.

(1) Long‑Term Care and Nursing Homes: Long-term care facilities and nursing homes meet the key criteria for priority IAQ pilot projects. Residents face high risks of morbidity and mortality, especially from rapidly spreading respiratory infections. Because Medicare and Medicaid finance most nursing home care, the Centers for Medicare & Medicaid Services (CMS) already regulates these facilities and collects detailed data on resident health, hospitalizations, and mortality.¹⁷ This allows agencies to make explicit, testable predictions about reductions in infections, hospital transfers, and deaths—and to evaluate those predictions using existing CMS claims and assessment data.

These facilities are also well suited for testing germicidal UV technologies. Many nursing homes have particulate levels so high that portable HEPA filtration alone is unlikely to pay for itself through avoided hospitalizations. By contrast, real-world studies suggest that upper-room UV can modestly reduce respiratory infections and related mortality. When translated into hospitalizations averted, the resulting cost savings per hospitalization appear substantially larger than those from filtration alone.¹⁸ While the evidence remains preliminary, a targeted pilot could generate much firmer conclusions.

(2) Childcare Facilities, Schools, and Federal Workplaces: A childcare and education pilot would focus on settings such as Head Start centers, schools serving federally insured children, and childcare facilities linked to federal workplaces. Federal agencies could do a number of things: supporting upgrades to ventilation and portable filtration in classrooms, cafeterias, and staff rooms; encouraging the use of simple CO₂ and particle monitoring as a proxy for eACH during occupied hours; and linking improvements to attendance data, emergency room visits, and prescription claims in Medicaid and the Children’s Health Insurance Program (CHIP).

In parallel, federal office buildings could serve as demonstration sites for potential IAQ improvements in white‑collar workplaces. Upgrades could be evaluated against HR data on sick leave, short‑term disability, and health claims paid through the Federal Employees Health Benefits (FEHB) program. Private workplaces would then be incentivized to adopt policies because of their demonstrable efficacy and affordability, rendering mandates unnecessary.

(3) Barracks, Ships, and Training Facilities: The U.S. military has long understood that respiratory outbreaks in basic training, barracks, and ships take units offline and disrupt operations. A defense‑focused IAQ pilot would identify barracks and ships where respiratory spread is most intense, and additionally consider areas like sleeping quarters, mess halls, gyms, and training classrooms where members of the armed forces gather in large numbers; it would upgrade these spaces to meet well-defined eACH targets using a mix of ventilation, filtration, and UV; and it would track outcomes in tricare and Defense Health Agency data, along with unit readiness metrics: sick call visits, training interruptions, and lost duty days.

The national security case is straightforward. High-quality indoor air is a permanent layer of defense that does not depend on perfect compliance with masking, vaccination, or emergency lockdowns. Infrastructure that reduces baseline transmission through ventilation, filtration, and disinfection slows the spread of both familiar and novel pathogens and lowers reliance on disruptive crisis measures. Once installed, it quietly limits the scale and speed of outbreaks in critical institutions.

Covid-19 demonstrated how quickly a novel respiratory virus can overwhelm domestic systems—and how vulnerable countries are when they rely primarily on reactive public health measures. An indoor air strategy grounded in performance standards and real-world evaluation will not eliminate the need for temporary behavioral interventions in extreme cases, but it can flatten outbreak peaks and reduce how often extraordinary measures are required.

From a strategic perspective, this is a bargain. The incremental cost of adding filtration and germicidal UV to existing federal facilities is modest, while the benefits—fewer deaths, less operational disruption, and greater institutional resilience—are large.

The military training pipeline illustrates this logic clearly. Respiratory outbreaks at large basic-training installations are a persistent feature of military life, regularly sidelining trainees and disrupting training cycles in densely populated environments.¹⁹ Because the Department of Defense pays for both medical care and the full cost of recruiting and training each service member, these disruptions create direct, visible losses.

A targeted IAQ program could focus on high-transmission spaces—sleeping bays, corridors, latrines, and mess halls—using a standardized “clean-air stack”: upgraded central filtration where feasible, portable HEPA units in living and instructional spaces, and germicidal UV in the highest-density areas. Repeating building designs allow installation and commissioning costs to be spread across many similar facilities.

If such upgrades cost a few million dollars across a training base but reduce respiratory-related attrition by even one or two percentage points, the savings would quickly outweigh the costs. Each avoided dropout preserves tens of thousands of dollars in sunk recruiting and training expenses, while fewer sick call visits and hospitalizations reduce tricare spending and lost training days. These outcomes can be evaluated within a defined window using existing data.

For these reasons, high-density military housing and training facilities are a canonical use case for a fiscally conservative IAQ agenda. Where the government is the sole payer for both health and productivity losses, and where buildings can be upgraded at scale, indoor air quality is not a luxury but a cost-effective way to buy readiness. Across these venues, the structure is the same: use federal buildings and programs as proving grounds, not as the tip of a new regulatory spear directed at every private landlord in the country.

A Limited but Competent Health State

MAHA promises a country that is stronger, healthier, and more resilient. Achieving that vision does not require indiscriminate expansion of the public health bureaucracy; it requires a federal government that knows where to act—and where to stop. Indoor air quality is an ideal proving ground for this kind of restrained, evidence-based public health policy. If successful, we should see measurable reductions in ambulance runs from nursing homes, respiratory virus outbreaks in barracks and ships, and missed days of school and work. Medicare and Medicaid spending would grow more slowly, and the country would be marginally harder to destabilize by a novel virus.

The alternative is not a neutral baseline but the status quo: a built environment that quietly worsens chronic disease, amplifies outbreaks, and repeatedly forces officials to rely on blunt emergency measures. A serious conservative IAQ agenda offers a better path. It is a domain where commitments to limited government, fiscal prudence, and national strength converge on the same practical approach: use existing federal assets and data to pilot narrowly targeted interventions that reduce disease and disability. Families, employers, and markets can then adopt what works—voluntarily and at their own pace.

This article is an American Affairs online exclusive, published May 20, 2026.

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Notes