by David Introcaso
Arguably the greatest global health policy failure has been the US Department of Health and Human Services’ (HHS) refusal to promulgate any regulations to first mitigate and then eliminate the healthcare industry’s significant carbon footprint.
With US healthcare spending projected to equal $4.9 trillion this year, HHS is effectively responsible for regulating more than half of the $9 trillion global healthcare market. Because of its size as well as infamous fragmentation and waste, US healthcare’s estimated 553 million metric tons of annual greenhouse gas (GHG) emissions account for approximately 25% of global healthcare GHGs. If it was its own state, US healthcare would easily rank within the top 10% of the highest GHG polluting countries.
The health harms associated with GHG emissions and an equal amount of air pollution constitute an immense public health crisis and pose the greatest threat to patient safety. These harms are innumerable and unrelenting and impact everyone, everywhere, always. Presently, they are largely defined as toxic air pollution resulting from fossil fuel combustion, climate-charged extreme weather events and vector borne diseases.
Per the World Health Organization (WHO), 99% of the world’s population is exposed to PM2.5, or fine particulate matter, 2.5 microns in diameter or less, substantially the result of fossil fuel combustion. As the world’s leading environmental health risk, the effect is over eight million global deaths annually. Children are disproportionally victimized because they breathe more air per kilogram of body weight, breathe more polluted air being closer to the ground and have undeveloped lungs, brains and immune systems. For seniors, a recent study published in British Medical Journal concluded that no safe threshold exists for the chronic effect of PM2.5 on their overall cardiovascular health.
Per the US National Oceanic and Atmospheric Administration (NOAA), for the five year period ending in 2022 the average cost of billion-dollar climate-charged disaster events, that include drought, flooding, extreme heat, hurricanes, tornados and wildfires, equaled $119 billion, triple the average annual cost since 1980.
Concerning vector borne diseases, a study published in Nature Climate Change in 2022 concluded that 58%, or 217 of 375 infectious diseases, are aggravated by more than one thousand climate hazards or pathways.
Those who pay the greatest climate penalty in the US are Medicare and Medicaid beneficiaries and minoritized populations more generally – despite the fact that these populations on balance contribute the least to anthropocentric warming. Per a study published last year in PLOS Climate, in 2019 the highest earning 10% of US households were responsible for 40% of total GHG emissions while the bottom 70% of households were responsible for 30%. The study also found increasing GHG emission inequality across economic and racial lines. The US, with just 4% of the world’s population, is accountable for the greatest percent of excess global GHG emissions, or those in excess of the planetary boundary of 350 ppm atmospheric CO2 concentration, at 40%.
US healthcare’s current social cost of GHG emissions (SC-GHG), defined as an estimate of societal costs or benefits resulting from externalized or unpaid GHG emissions and calculated as the per metric ton dollar value of just three healthcare GHGs: CO2; methane (CH4); and, nitrous oxide (N2O), is estimated as high as $3 trillion annually. It is worth noting the Environmental Protection Agency (EPA) does not calculate a SC-GHG for anesthetic gases that comparatively have far greater global warming potential (GWP). For example, the anesthetic gas desflurane’s GWP is 2,540 times greater than CO2.
Over the past three presidential administrations or since 2009, HHS has neither promulgated any regulatory rules to curb healthcare’s GHG emissions nor any to improve climate-related healthcare delivery. For example, HHS can at any time publish a rule requiring hospitals to publicly report their GHG emissions – an easy lift since well over half of hospitals use the EPA’s Energy Star program that performs this calculation. Last year, only 37 or substantially less than 1% of hospitals were Energy Star certified for energy efficiency.
Concerning care delivery, climate breakdown does not factor in patient risk adjustment, quality measurement or value-based payments and because the International Classification of Diseases (ICD-10), used by physicians to classify and code diagnoses, ignores climate breakdown, cause of death is never climate-related. To its credit the Obama administration did spend three years drafting a 400-page encyclopedic study titled, The Impacts of Climate Change on Human Health: A Scientific Assessment, published in April 2016.
Shortly before President Trump was sworn in, the Centers for Disease Control (CDC) canceled its first ever climate and public health summit scheduled for February 2017. Under a Trump administration that worked diligently to weaken environmental protections, HHS continued to ignore healthcare’s carbon addiction.
One week after the Biden administration took office in 2021, the White House issued an executive order (EO) to “tackle the climate crisis” that directed HHS to create an Office of Climate Change and Health Equity (OCCHE). When the OCCHE was launched that August, HHS Secretary Xavier Becerra pledged to “use everything, every tool at our disposal to address the climate crisis.” Largely because Secretary Becerra has repeatedly failed to argue for OCCHE funding in Congressional budget hearing testimony or ever deliver a speech discussing significant health co-benefits associated with mitigating GHG emissions, the OCCHE remains unfunded and measurably ineffective.
Rather than tackling the problem by exercising its regulatory authority, HHS abandoned its responsibility to enhance our health and wellbeing by defaulting to industry self-regulation and building climate resilience.
One month after the office was stood up, OCCHE partnered with the National Academy of Medicine (NAM) to create an “action collaborative” to decarbonize healthcare. Industry funded and dominated, the collaborative, working behind closed doors, has generated no reports, no policy recommendations and consequently no expectations.
In 2022 HHS Secretary Becerra announced a voluntary climate pledge program. Essentially a grift, pledge details are irrelevant because pledgees are not required to use any accepted sustainability accounting practices, moreover the Greenhouse Gas Protocol. HHS also announced in 2022 an Environmental Justice Index (EJI) that assigns an environmental score by US census tract. Though likely well intended, since EJI scores will inevitably be exploited by financial institutions including insurance carriers, the index will in practice constitute climate redlining literally institutionalizing climate apartheid.
The stated “purpose” of HHS’s 2021 “Climate Action Plan” is “to enhance resilience and adaptation to climate change.” As a cause not a solution, resilience wrongly assumes climate disaster is endemic, a fait accompli. Outside of our control climate breakdown is therefore acceptable. Think: TINA. Because resilience licenses a climate disaster-ridden world, there is no climate crisis. Resilience as policy rationalizes the CDC’s Building Resilience Against Climate Events (BRACE) program that funds state health officials to prepare for climate disasters as well as the OCCHE’s Climate and Health Outlook program that simply forecasts what climate disasters will harm us this month. The June report identified flooding, hurricanes, tick borne diseases, tornadoes and wildfires. Resilience in effect is a form of subjectification, a policy that negates human agency.
This past December HHS published a supplemental climate report, authored by Assistant Secretary Admiral Rachel Levine, recently elected to the NAM for her contributions to pediatric medicine. The report doubled down on the policy noting resilience over 70 times. As for exercising its regulatory authority, HHS again scrupulously avoided responsibility by vaguely stating the department “planned” to “explore” “incentivizing . . . emissions reduction.”
Last September the White House issued a fact sheet that identified “new actions” to reduce GHG emissions. Among others, the Office of Management and Budget (OMB) was directed to work with federal agencies to calculate the SC-GHG of federal programs that presumably includes Medicare and Medicaid. This past March, the Securities and Exchange Commission (SEC) published its highly-anticipated final climate disclosure rule that requires publicly-traded companies to disclose their GHG emissions and related financial risk exposure – that for the highly financially leveraged healthcare industry is considerable. To date, HHS has not discussed much less publicly acknowledged either effort.
In May HHS proposed addressing the “single biggest health threat facing humanity” by “allowing” a small number of hospitals selected to participate in a five-year Medicare payment demonstration do what they can do at any time, i.e., voluntarily disclose their GHG emissions.
We are suffering greatest climate disruption in human history. Since 2000 atmospheric concentrations of CO2 and methane (CH4), a far more potent GHG, have significantly increased. Because GHG emissions and temperature increase are highly correlated, the past 12 consecutive months have not surprisingly been the warmest on record. The earth itself is becoming a sacrifice zone and we are becoming less consumers of healthcare and more consumed by it. Nevertheless, HHS, responsible for regulating the largest industry in the world’s largest economy, an industry that remains uncommitted to eliminating its GHG emissions, should be leading the way in decarbonizing the US. Instead, HHS continues to waste precious time.
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