HHS’s proposed rule pays lip service to addressing the climate crisis, the greatest threat to human health

In April, the U.S. Department of Health and Human Services, the world’s most powerful health care agency — responsible for overseeing the largest industry in the world’s largest economy — offered a pretend proposal for regulating health care’s massive carbon footprint of 550 million metric tons of carbon dioxide-equivalent (CO2e), or greenhouse gas (GHG) emissions. HHS is largely responsible for the health care industry’s carbon pollution because the federal government is the largest health care payer. What HHS proposed for addressing the climate crisis is a regulatory illusion intended to accomplish nothing.

Specifically, the Centers for Medicare & Medicaid Services is proposing in its 2025 inpatient hospital rule to “allow” a small number of hospitals that had been selected to participate in a five-year surgical procedures demonstration to “voluntarily” report the greenhouse gas emissions they directly emit as well as those from the power they purchase, beginning in 2026. Even assuming that all of these hospitals voluntarily report their greenhouse gas emissions, they constitute a trivial amount of one of the world’s largest sources of such emissions, making up nearly 9% of total annual U.S. greenhouse gas emissions and 4.5% of the total worldwide, along with an equal amount of toxic air pollutants. The social cost of health care’s entire carbon footprint is upwards of $3 trillion a year.

I find it appalling that, decades late, HHS vomits up a pretend regulation to address what the World Health Organization has defined as “single biggest health threat facing humanity.” But it can at least be readily explained.

Although President Biden’s 2021 “Executive Order on Tackling the Climate Crisis at Home and Abroad” promised a government-wide approach, HHS has declined to regulate health care’s greenhouse gas emissions. For example, HHS Secretary Xavier Becerra could have exploited fundamental health and safety rules known as Conditions of Participation regulations to publish a regulatory rule that would require hospitals to publicly report these emissions annually.

Instead, HHS’s strategy is simply promising to “mitigate the impacts of environmental factors, including climate change” and to “ensure the security and climate resiliency of HHS facilities.”

Becerra has never delivered a speech explaining the innumerable and unrelenting health harms that greenhouse gas emissions disproportionately inflict on Medicare and Medicaid beneficiaries.  The Office of the Surgeon General, which also falls under HHS’s purview, has not made addressing climate change a priority despite the fact that this office exists to generate debate and build consensus concerning significant public health issues.

HHS’s Office of Climate Change and Health Equity (OCCHE), a product of the 2021 executive order, has not been funded for three years largely because the HHS secretary has repeatedly failed to address its funding in budget testimony before three Congressional committees. The secretary did announce a voluntary climate pledge program in 2022, but its details do not matter since pledges are not required to use accepted sustainability accounting practices.

None of the 13 programs HHS has defined as contributing to Justice40, an initiative that directs federal agencies to deliver 40% of overall climate and related benefits to disadvantaged communities, reduce health care’s greenhouse gas emissions.

CMS has offered no discussion of the issue in its strategic framework, national quality strategy, and health equity framework, nor is there any in the Centers for Medicare and Medicaid Innovation’s strategic vision and priorities.

There are significant oversights in CMS’s proposed 2025 inpatient rule. Among other significant health harms, CMS fails to mention how the climate crisis creates or exacerbates innumerable neurotoxic diseases, well summarized in Clayton Aldern’s recently-published book “The Weight of Nature, How a Changing Climate Changes Our Brains.” The proposed rule fails to define how carbon pollution is a meta problem that exacerbates most other health problems. A 2022 study, for example, concluded that 217 of 375 infectious diseases, or nearly 60%, are aggravated by more than 1,000 climate hazards or pathways.

CMS also fails to convey any sense of alarm or urgency concerning the rapidly destabilizing biosphere. Atmospheric greenhouse gas levels, surface temperatures, ocean heat and acidification, and the loss of Antarctic ice and permafrost all markedly escalated in 2023. These findings led United Nations Secretary General António Guterres to recently state, “Fossil fuel pollution is sending climate chaos off the charts. Sirens are blaring across all major indicators.”

HHS’s climate nihilism reflects the health care industry’s own. The American Hospital Association doesn’t mention climate change in its 2024 Advocacy Agenda, nor does the American Medical Association’s Advocacy Efforts. The Biotechnology Innovation Organization, Pharmaceutical Research and Manufacturers of America, and other leading biopharma trade associations are generally mum on the issue. This explains why efforts by the industry-led Action Collaborative to decarbonize health care have amounted to producing little more than educational materials.

Health care policy and advocacy organizations that might be expected to support regulating health care’s greenhouse gas emissions, or at least discuss them, do not. For example the Congressionally-created Medicare and Medicaid advisory commissions, MedPAC and MACPAC, have not discussed the climate crisis. Among advocacy organizations, Physicians for Social Responsibility addresses the climate crisis mainly by working to activate health care professionals, but says nothing, at least explicitly, about their own industry’s carbon addiction or what can be described as health care’s harm-treat-harm cycle, in which greenhouse gases emitted from health care harm patients, requiring further treatment. Despite the fact that health care’s greenhouse gas emissions pose an ongoing threat to patients, advocacy groups like Patients for Patient Safety apparently have other priorities.

CMS must be aware that what it is proposing in its 2025 inpatient hospital rule is pointless.

Voluntarily reported data is not generalizable. CMS could acquire generalizable emissions data by simply asking the Environmental Protection Agency, because more than 3,000 hospitals already participate in its Energy Star program.

Ample evidence exists that the health care industry does not on balance voluntarily report greenhouse emissions. Because reporting would be voluntary it is mystery why supply chain emissions are excluded from HHS’s inpatient hospital rule, since they account for 80% of hospitals’ greenhouse gas emissions. The proposed rule goes out of its way to state that HHS has no intention of using “Medicare financing strategies” to decarbonize health care. This certainly suggests that, despite the fact CMS already provides financial incentives to hospitals to reduce adverse events and improve patients’ experiences, HHS will continue to indiscriminately pay hospitals to increase climate-related adverse events and worsen patients’ experiences by allowing them to continue to behave recklessly and negligently and exhibit the worst sort of moral hazard and moral treason.

It is a mystery why CMS also failed to mention the recently finalized Securities and Exchange Commission’s climate disclosure rule, since it directly contradicts CMS. The SEC’s disclosure rule requires publicly traded companies — numerous hospitals fall into this category — to disclose their greenhouse gas emissions and climate-related financial risks. The SEC rule will have a significant impact on health care, an industry that is as financially leveraged as it is carbon dependent. There is pent-up demand for what the SEC rule called “consistent, comparable, and reliable” climate-related data to inform investment decisions. Asset managers are certainly well aware investments take the stairs up but the elevator down.

In Judge Josephine Staton’s 2020 dissent in Juliana v. United States, a case in which 21 children alleged the government “willfully ignored” the dangers of burning of fossil fuels, she concluded that “never before has the U.S. confronted an existential threat that has not only gone unremedied but is actively backed by the government.” Though “the government accepts as fact that the U.S. has reached a [climate] tipping point crying out for a concerted response,” she wrote, the government “insists it has the absolute and unreviewable power to destroy the nation.”

Should HHS affirm Judge Staton’s opinion and finalize the proposed inpatient hospital rule’s decarbonization initiative, its only legitimate purpose will be to serve as an example of what historian and philosopher Hannah Arendt defined as the “banality of evil.” CMS will have propagated a business-as-usual regulatory rule so thoughtless, divorced from reality, and depraved it cannot be, as Arendt phrased, “an expression of anyone’s conscience.” Such a policy could only be crafted by a bureaucracy whose functionaries have mastered the art of not looking.

If HHS chooses to address the incalculable misery and suffering resulting from health care’s massive carbon footprint by allowing a small fraction of hospitals to voluntarily report their emissions for a few years, the country will have assuredly reached an Illichian tipping point where health care constitutes what theologian and social critic Ivan Illich defined as “a sick-making enterprise” and a “major threat to health.”

David Introcaso is a Washington, D.C.-based health care research and policy consultant whose work largely focuses on the climate crisis.