How To Solve HHS’s Failure To Address The Climate Crisis

From an anthropocentric perspective the climate crisis is fundamentally a threat to human health if not survival. The World Health Organization defines it as “the single biggest health threat facing humanity.” Logic dictates that the Department of Health and Human Services (HHS) take the lead in mitigating climate-related health harms. President Joe Biden immediately recognized this reality in a January 2021 executive order that stated because the US has a “narrow moment” to take action he directed HHS to, in sum, decrease climate-related risks among the elderly, children, and people with disabilities.

However, after two rule-making cycles, the Centers for Medicare and Medicaid Services (CMS) has failed to take any regulatory action requiring Medicare and Medicaid providers to reduce their considerable carbon footprint. CMS’s last 2023 opportunity was via the hospital inpatient prospective payment rule finalized August 1.

While other proposed 2023 regulatory rules, for example, the hospital outpatient prospective payment rule and physician fee schedule, ignored the climate crisis, CMS did recognize the problem in the agency’s proposed inpatient rule. Buried in the May rule was a one-page Request for Information (RFI) titled, “Current Assessment of Climate Change Impacts on Outcomes, Care, and Health Equity.” The RFI recognized the obvious reality that the health care industry must, CMS tepidly stated, “more fully explore how to effectively prepare for climate threats.” Among other questions, the RFI asked if hospitals have “public aims for GHG [greenhouse gas] emissions reduction” and more substantively sought input regarding what Medicare reporting and payment incentives would drive emissions reductions.

We are experiencing record heat—extreme temperatures that had been predicted for 2050 are occurring today. We are also experiencing drought and wildfires outside the historical envelope. In addition, 58 percent (218 of 375) of infectious diseases are aggravated or worsened by more than 1,000 climate hazards or pathways. As all of these disproportionately harm Medicare and Medicaid beneficiaries, commenters, including myself, argued, CMS should create a hospital decarbonization value-based purchasing (VBP) program.

Why Decarbonize Hospitals?

The health care industry annually dumps approximately 550 million metric tons of carbon dioxide equivalents into the atmosphere. These total approximately 8.5 percent of total US GHG emissions. If US health care was its own country, it would rank 13th in the world in GHG emissions, ahead of the UK. Hospitals account for the largest share of industry GHG pollution. After food service facilities, their average energy intensity is 2.6 times greater than other buildings. Hospitals are also significantly wasteful. On average, they are 2.2 times more energy intensive than European hospitals.

On a per capita basis, US health care emits far more GHG pollution than any other country’s health care sector. With 4.25 percent of the world’s population in the US, this country’s industry emits approximately 25 percent of total global health care emissions. Health damage resulting from the industry’s GHG pollution, including deaths comparable in magnitude to the 98,000 associated with medical errors, helps explain this country’s comparatively poor health care performance rankings.

Today, 93 percent of Americans breathe substandard air largely due to fossil fuel combustion. Associated deaths have recently been recalculated to total eight million annually, twice previous estimates; one in five early deaths globally are estimated to result from pollution stemming from fossil fuel combustion. Nearly 60 percent of US excess deaths have been attributed to fossil fuel use. Conditions Medicare beneficiaries face because of fossil fuels include heart disease and stroke, many types of cancer, respiratory diseases, Alzheimer’s, and Parkinson’s, among others.

Duke’s Distinguished Professor of Earth Sciences, Drew Shindell, concluded in recent congressional testimony that human health damages resulting from coal use alone—which accounts for more than 20.0 percent of US electrical generation (in the UK it is 1.6 percent)—are so great that coal use would be a money-loser even if coal-fired power was free. Shindell analogized coal’s use in powering health care to operating a federally qualified health center for the purpose of distributing cigarettes. Shindell also argued decarbonizing the US economy would pay for itself just in the resulting public health benefits.

US children, half of whom are Medicaid enrollees, are especially vulnerable to fossil fuel-related pollution, in part because they have higher respiratory rates. They breathe everything we burn. A recently published review article in the New England Journal of Medicine found that, from in utero through adolescence, every child worldwide is exposed to at least one climate-related health hazard. Beyond respiratory diseases, these include preterm and low weight birth, infant death, hypertension, kidney disease, immune-system dysregulation, structural and functional changes to the brain, and a constellation of mental and behavioral health diagnoses. A UNICEF study published last year concluded that half the world’s 2.2 billion children are already at “extremely high risk” from climate crisis impacts. The authors termed this reality, “unimaginably dire.” In UNICEF’s ranking of countries by climate-related risk to children, the US ranked 80th out of 163 countries, or worse than every European Union country.

CMS’ decision not to address the climate crisis in the inpatient rule—the same decision CMS made in the agency’s May Affordable Care Act qualified health plan (QHP) final rule that similarly sought input on how QHPs could take responsibility for reducing their GHG pollution—is mystifying because CMS should be aware that hospitals presently have few, if any, “public aims” to reduce their GHG pollution. As Aaron Bernstein and his colleagues recently discovered using HHS data, only 19 of the largest 50 health care systems have even identified GHG emission reduction targets.

If CMS is looking for “public aims,” they abound. There are innumerable related efforts by subnationals, including more than 50 carbon reduction schemes worldwide. Moreover, the UK’s National Health Service offers not just aims but numerous lessons, having worked over the past decade-plus to reduce emissions by 64 percent per inpatient finished admission despite a 17 percent increase in the country’s population, a doubling of the NHS’s provision of care, and a tripling in health care spending. That CMS does not detail someone to the NHS is another mystery.

CMS is also aware that only a meager number of health care entities signed up to participate in the National Academy of Medicine’s (NAM’s) decarbonization effort (see below) and more recently HHS Secretary Xavier Becerra’s related pledge initiative. Even if participation was significantly greater, these efforts would still constitute textbook “greenwashing,” since participation does not require the use of any uniform and widely accepted accounting protocols, standards, or metrics. Per Emily Senay’s 2018 and 2022 research, it is clear that the health care industry “lags far behind” all other major industries just in calculating and publicly disclosing their GHG pollution.

CMS’s current hospital VBP programming, efforts to reduce hospital-acquired conditions, hospital readmissions, and make value-based payments are relevant to the extent that Harvard’s J. Michael McWilliams argued convincingly in a lengthy 2020 quality improvement assessment that “gains from performance linked payments have generally ranged from absent to modest and have come at great expense.” This is due in part to the fact that CMS measures, he found, only “detect the symptoms of dysfunction, not necessarily the cause.” He concluded, “We need new ideas and new conversations” and a “next generation of initiatives.”

HHS’s Efforts To Date

In compliance with President Biden’s 2021 executive order, a year ago this month Secretary Becerra announced the Office of Climate Change and Health Equity (OCCHE), stating HHS would “use everything, every tool at our disposal” to address the climate crisis. To date, the OCCHE is co-chairing the National Academy of Medicine’s “Action Collaborative on Decarbonizing the US Health Sector” that began work in 2020. The NAM-OCCHE collaborative does not include National Academy of Engineering support, is largely composed of established interests including the American Hospital Association, the American Medical Association, the Biotechnology Innovation Organization, Medtronic, the Pharmaceutical Research and Manufacturers of America, and UnitedHealth Group; the collaborative does not work transparently and appears uninterested in making policy recommendations. The collaborative’s status can be summed up by NAM President Victor Dzau’s concluding comment in a recent Modern Healthcare interview: “In 2023, we’ll see where we are as a group.”

Secretary Becerra in late May announced the creation of the Office of Environmental Justice (OEJ) that would in part address the climate crisis. The OEJ will reside within the unfunded OCCHE. It is worth noting that the HHS Office of Civil Rights, established in 1967, has never addressed the fact that minority populations are both disproportionately exposed and less resilient to climate crisis health harms. Also, in late June, HHS announced a short list of resources, including a webinar series and an educational forum—“to support the health sector,” the White House statement read, “in transitioning to clean energy.”

HHS’s efforts to date can be understood by the fact that the Government Accountability Office (GAO) in March added HHS “leadership and coordination of public health emergencies” to its High Risk List. GAO auditors concluded in part that it is doubtful whether HHS is prepared to respond to “extreme weather events.

Exploit Regulatory Rulemaking

CMS VBP programming is authorized under Section 1886(o) of the Social Security Act. The law directs the HHS secretary to create Medicare hospital VBP programming through measures and related performance standards. Based on these standards, hospitals receive a performance score and a value-based incentive payment. Similarly, 2015 legislation created physician or Medicare Part B VBP programming.

A hospital decarbonization VBP program can be readily accomplished by exploiting the Environmental Protection Agency’s (EPA’s) Energy Star Portfolio Manager program. After a hospital provides the requisite data, Energy Star would calculate a weather-normalized and operations-normalized consumption estimate. Energy Star would then compute an energy use intensity score and then compare it to a predicted energy use score by peer group. A hospital’s resulting energy efficiency ratio, with lower ratios demonstrating more energy efficiency, is what HHS could use to determine value-based payments. Considering the health benefits derived from decarbonizing hospitals, value-based payments should not be zero sum.

Launched by the EPA and the Department of Energy in 1992, Energy Star, has over the past 30 years, led to a reduction in billions of tons of GHG pollution by approximately 40 percent of Fortune 500 companies. Over a year ago, we argued in STAT that Secretary Becerra should exploit the good cause exception under the Administrative Procedure Act. This would allow the secretary to quickly publish an interim final rule that would modify performance improvement criteria under Medicare and Medicaid Conditions of Participation (42 CFR 482.21), requiring hospitals to publicly report their GHG pollution via the Energy Star tool and to publicly report auditable plans to decarbonize. Approximately two-thirds of hospitals already use Energy Star; HHS could sign a cooperative agreement with the EPA to expedite Energy Star’s use.

Creating a hospital decarbonization program, via any regulatory mechanism, would address or avoid several existing VBP shortcomings McWilliams identified. Gains derived from reducing total US GHG pollution would be significant. Reducing GHG pollution would alleviate underlying health problems, thereby reducing the treatment burden on hospitals and alleviating workforce burnout and shortages. Such a program would have no reporting burden and address health disparities; it would avoid quality measurement gaming, unintended negative consequences, and risk adjustment problems. Decarbonizing the $4 trillion health care industry would have considerable economywide knock-on effects particularly related to supply chain emissions.

More generally, using reimbursement to reduce GHG emissions would end the ethically onerous use of taxpayer dollars to finance social health insurance programs in which providers, through such emissions, significantly and systematically harm beneficiaries. The argument has been made for years that industry GHG pollution constitutes a medical error.

A study by the Medical Society Consortium on Climate Health and others recently concluded GHG pollution health costs today far exceed $800 billion per year. Reducing and eliminating emissions also addresses the fact that having a health care industry linked to fossil fuels is both environmentally and economically unsustainable. Because renewable energy generation and storage costs have substantially declined over the past decade, today it is within the hospital industry’s financial self-interests to go green. As Scott Jacobson, director of the Atmosphere/Energy Program at Stanford and author of Cambridge’s recently published “100 Percent Clean, Renewable Energy and Storage for Everything,” concluded well over a decade ago, the only obstacles to supplying the world’s energy needs with renewable energy are political.

HHS has an unprecedented opportunity to do nothing less than measurably lower Medicare and Medicaid’s beneficiaries’ burden of disease, improve their care outcomes and safety, advance health equity, address the industry’s financial sustainability, and help heal the planet. If HHS chooses not to exploit this opportunity, one is forced to wonder whether CMS is fit for purpose.