The health care industry focuses on healing. Yet its pursuit of that mission can cause harm. The harm caused by medical errors is well known. Largely unknown is the hidden harm caused by the industry’s greenhouse gas emissions.
An estimated 10% of all U.S. greenhouse gas emissions come from the health care industry. Largely due to fine particulate matter (particles smaller than 2.5 microns, known as PM2.5), which result from burning fossil fuels, the industry’s carbon emissions account for approximately 100,000 US deaths annually and approximately three times that number worldwide.
A report published in May by the Natural Resources Defense Council concluded that burning fossil fuels causes $800 billion in health care spending annually, a cost disproportionately borne by the Medicare and Medicaid programs and its beneficiaries.
The full extent of health care’s contribution to greenhouse gas emissions is not known. Compared to other major industries, the health care industry also significantly publicly underreports its greenhouse gas emissions.
Discussions of how to address this problem have appeared recently in the BMJ, in Health Affairs, and in two April letters to HHS Secretary Xavier Becerra. One, sent by Health Voices for Climate Action, was signed by 65 academic and health professional and advocacy organizations. The other was sent by Rep. Richard Neal (D-Mass.), chairman of the House Ways and Means Committee.
These discussions were prompted by several things. First and foremost, the government should not be in the business of paying health care systems to harm Americans’ health, particularly Medicare and Medicaid beneficiaries. With biodiversity collapsing, glaciers and permafrost melting, floods and fires raging, and animal-borne diseases multiplying, United Nations Secretary General Antonio Guterres was forced to conclude in his recent “The State of the Planet” speech, “the state of the planet is broken” and “nature needs a bailout.”
Guterres’s dire assessment was reinforced by a recent report from the International Energy Agency that drew the sobering conclusion that limiting global warming to the UN’s recommended 1.5°C would require the equivalent of installing the world’s current largest solar park every day until 2030.
Renewable energy made up only 12 percent of U.S. energy consumption in 2020 despite the fact their cost has declined dramatically. The cost solar power, for example, has dropped by 89% over the past decade making it one-third the price of coal. If the U.S., which has emitted 25% of all greenhouse gas emissions since 1751, plans to win global cooperation in combatting climate change, addressing health care industry emissions would certainly help to build trust.
Becerra can — and should — require hospitals that receive funding from Medicare or Medicaid to publicly disclose their greenhouse gas emissions via Conditions of Participation (CoP) regulations. Doing so would require a trivial effort by hospitals and give them several advantages.
Hospitals that are reimbursed by Medicare and Medicaid are currently required by law to meet Conditions of Participation. One section of the conditions requires hospitals to maintain an effective, hospital-wide, and data-driven quality assessment and performance improvement program — a program that reflects the complexity of the hospital’s organization and services, involves all hospital departments and services including contracted services and is focused on indicators related to improved health outcomes and the prevention of medical errors.
Requiring hospitals to accurately report their greenhouse gas emissions falls neatly under Conditions of Participation because the health harms they cause constitute a medical error and reducing hospital greenhouse gas emissions are directly related to improved health outcomes.
Making a regulatory change to hospitals’ Conditions of Participation typically involves a year-long notice of proposed rulemaking process. Becerra could, however, require hospitals to begin reporting emissions beginning as early as January 1, 2022, by publishing an interim final rule under the Administrative Procedure Act’s good cause exception. This exception allows federal agencies to avoid the notice-and-comment process if it is “impracticable, unnecessary or contrary to the public interest.”
Considering the fact the level of carbon dioxide in the atmosphere is higher today than it has been in 4.5 million years, is rising at a faster rate than at any other time over the past 66 million years, and that the planet is absorbing twice as much heat as it did just 15 years ago, modifying the Conditions of Participation to require hospitals to report their greenhouse gas emissions via the traditional notice of proposed rulemaking process would clearly be beyond “impracticable” and is “contrary to the public interest.”
As for this process being “unnecessary,” public reporting would an easy lift because most hospitals already track their annual energy use. Approximately 65% of hospitals use the EPA’s Energy Star Portfolio Manager benchmarking tool, which is considered the industry standard. It is used by companies that manage approximately 25% of commercial floorspace nationwide and its use is associated with declines in energy use and expense. Most hospitals track their energy use largely under the American Hospital Association’s American Society for Healthcare Engineering program, with whom the EPA partners.
Though hospitals use the benchmarking tool to reduce energy consumption, it can also automatically calculate greenhouse gas emissions.
Some hospitals report energy use because nearly 40 jurisdictions, — and that number is rising — require them to do so. For example, Washington state requires commercial buildings to work toward meeting a 2035 target for reducing greenhouse gas emissions, and 60% of New York City buildings are required to significantly reduce their emissions by 2030. The U.S. Securities and Exchange Commission is currently soliciting public comment to determine what emissions-related information it will require companies to publicly report.
Given the fact that U.S. health care is excessively energy intensive — its greenhouse gas emissions are more than three times per capita that of the United Kingdom — suggests that hospitals have substantial opportunities to improve energy efficiency, reduce emissions, and improve the health of all Americans.
Requiring hospitals to publicly report their greenhouse gas emissions constitutes sound policy for several additional reasons. It would directly address the Biden administration’s stated interest in advancing health equity because environmental factors play a significantly larger role in explaining health disparities than medical care.
The climate crisis disproportionately affects Medicare and Medicaid beneficiaries. A 2019 study estimated that Medicare and Medicaid incurred two-thirds of the health-care costs associated with 10 climate disasters in 2012, ranging from wildfires in Colorado and Washington to the impacts of Hurricane Sandy and harmful algal blooms on the Florida coast. The relentless increase in costly climate crisis disasters — the U.S. experienced a record 22 of them in 2020 that each cost $1 billion or more — means the resulting health harm and expense will increase indefinitely.
Health care industry reporting that drives energy efficiency and in turn reductions in greenhouse gas emissions directly translates to improved population and public health both here and abroad. Public reporting also creates an opportunity for providers to compete for patients as well as improve clinician recruitment and retention. Reporting will improve industry transparency and make it more climate resilient. It can also aid in allowing a capital-intensive industry to obtain more favorable financing since greater use of renewables is associated with lower investment risk. Specific benefits aside, public reporting moves us closer to the ultimate goal of a survivable climate.
Perhaps most important, public reporting enables the next step: requiring hospitals to develop and implement plans to decarbonize in a timely manner. Here, regulators have an opportunity to leverage lessons from health systems overseas, most notably the U.K.’s National Health Service. Since 2008, it has reduced its carbon footprint by an estimated 62% compared to the international standard baseline of 1990 emissions with no deterioration in the quality of care delivered.
The climate crisis presents the single greatest threat to humanity in this century. The Biden administration has appropriately called for an all-of-government approach to address it. The health care industry’s bloated carbon footprint contributes significantly to climate change. Requiring hospitals to publicly report their emissions, and do something about them, is a logical step forward. Becerra’s refusal to require them to do that would be incomprehensible.
David Introcaso, a vice president for regulatory policy at Strategic Health Care in Washington, D.C., has done environmental and health care policy research for the U.S. Congress, the Department of Health and Human Services, and a range of non-profit and for-profit clients. Walt Vernon is principal and CEO of Mazzetti, an international engineering firm based in San Francisco, where he focuses on planning and designing health care facilities. The views expressed here are the authors and do not necessarily represent those of the companies or organizations with which they are affiliated.
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