By DAVID INTROCASO
The Problem
From an anthropocentric perspective, the climate crisis is fundamentally a threat to human health and survival.
The US healthcare industry significantly contributes to this threat. US healthcare’s greenhouse gas emissions (GHG) annually account for over 600 million metric tons of carbon dioxide equivalents or ~10% of total US annual GHG emissions.[1] If US healthcare was its own country, it would rank ~12th worldwide in carbon pollution.
Tragically, the industry and the US Department of Health and Human Services (HHS), responsible for regulating the healthcare market, remain committed to climate breakdown.
The Solution
There was a sense of relief in 2020 when the National Academy of Medicine (NAM) announced its commitment to decarbonize the industry. The NAM’s silence had been difficult to understand in part because the National Academy of Sciences had recognized climate-related public health problems as early as 1966. That year, NAM President Dr. Victor Dzau launched the Academy’s Grand Challenge on Climate and Health. The initiative was defined by a scoping paper drafted by Dr. Don Berwick, a former CMS Administrator, and two colleagues. The authors wrote, “as the climate change public health catastrophe smolders, the US Healthcare system largely fiddles.” “Rather than ‘doing no harm,’ healthcare is fueling the carbon fire.” They recommended healthcare leaders “respond effectively to climate change,” by measuring “HEALTH outcomes as much by the environmental and public health impacts of our work as by the outcomes of particular patients.” “The healthcare sector must,” they concluded, “reduce its carbon footprint by 50%, in absolute terms, by 2030 compared to a 2010 baseline.” The recommendation aligned with a United Nations’ 2018 report that concluded reducing GHG emissions by this percent would provide a 50-66% chance that global warming would be limited 1.5°C above pre-industrial levels and thereby avoid irreversible climate tipping points.
In September 2021, Dr. Dzau announced a NAM and HHS co-chaired effort titled the “Action Collaborative on Decarbonizing the US Health Sector.” HHS was prepared because per an early 2021 White House Executive Order titled, “Tackling the Climate Crisis at Home and Abroad,” HHS Secretary Xavier Becerra had announced one month prior the creation of HHS’s Office of Climate Change and Health Equity (OCCHE). During his OCCHE press conference Becerra promised, “we’re going to use every tool at our disposal” to decarbonize the healthcare industry.
Motivations
There are several reasons why decarbonizing the healthcare industry has enormous significance.
With a market cap of upwards of $7.5 trillion, US healthcare, arguably the largest industry in the world’s largest economy, is exceptionally energy intensive being resource heavy in buildings, technology and labor. Equipment, lighting, strict ventilation, plug-in loads and high-occupancy mean hospitals are ovens even when outside temperatures are below freezing.
The industry is equally energy inefficient. The ten-year running average ending in 2025 of hospitals EPA Energy Star certified was 88, or less than 1.5% of an American Hospital Association-estimated 6,100. Operating rooms are particularly energy sinks accounting for ~50% of a hospital’s GHG emissions largely because of significant use of disposable medical supplies.
High entropy healthcare was nowhere near decarbonizing much less accounting for its GHG emissions. While total US GHG emissions decreased by ~5% between 2010 and 2018, healthcare’s increased by ~6%. Research published in 2022 concluded healthcare “lags far behind in terms of [climate] sustainability, management and disclosure,” because “there is no sector-wide push from academic or industry leaders, government . . . regulators . . . or payors.”
Fossil fuel combustion exposes everyone, everywhere to innumerable and unrelenting health harms. Effectively everyone worldwide breathes substandard air accounting for upwards of ~8 million deaths annually. A study published in 2018 concluded 58% of estimated excess US deaths are due to fossil fuel use. A study published in 2022 concluded an equal percent of infectious diseases are aggravated by climate-related hazards and pathways.
GHG emissions pose a meta-problem, an underlying problem about a problem. Absent their removal, every healthcare policy effort to improve access, equity, quality, spending, value and utilization are compromised.
Add to these ironies healthcare’s harm-treat-harm business model disproportionately impacts those HHS is primarily pledged to protect: ~160 million Medicare and Medicaid beneficiaries. The vast majority of Medicare seniors are comorbid and have a diminished ability to thermoregulate. A 2024 study concluded that for all Medicare beneficiaries, “no safe threshold exists for the chronic effect of particulate matter on overall cardiovascular health.” Children, ~45% insured by Medicaid, breathe more air per kilogram, breathe more polluted air due to being closer to the ground and have developing lungs, brains and immune systems. Particularly for these populations, healthcare is itself traumatic. Iatrogenesis is built in. Nevertheless, HHS annually spends ~$1.6 trillion or ~24% of the federal budget to have Medicare and Medicaid patients pay the greatest climate penalty.
According to the latest EPA estimates, the social cost or the monetary value of the net social harm of just three healthcare emissions is as high as $3.5 trillion, or more than twice the combined annual Medicare and Medicaid budgets. Per Daniel Bressler’s pioneering 2021 mortality cost of carbon calculation, healthcare’s annual GHG emissions are responsible for upwards of ~400,000 deaths.
Hope
There was plausible belief the Action Collaborative would achieve success. HHS regulations define the healthcare market. The world’s largest healthcare purchaser, Medicare, is, as the late Princeton economist Uwe Reinhardt liked to say, the market maker. The NAM is considered the ultimate authority on medicine and health, the highest arbiter of medical truth. The Academy had been successful in past efforts that re-defined public health, launched the modern patient safety movement and established quality improvement goals.
At least partially funded by the healthcare industry, the Action Collaborative consisted of ~50 senior industry executives and academics. Work was defined by a steering committee led by industry powerholders Kaiser Permanente, UnitedHealth Group, Cardinal Health and Medtronic along with the American Hospital and American Medical associations and the Biotechnology Innovation Organization (BIO).
The first and ultimately only sign of legitimate Collaborative “action” was an essay published in late 2022 titled, “Mandatory Reporting of Emissions to Achieve Net-Zero Health Care.” It was not unanticipated because co-author, Don Berwick, argued during the Collaborative’s 2021 kick-off, “the [Collaborative] effort needed to employ metrics quantifying GHG emissions.” “Without [them],” he said, “we’re dead.” The four Action Collaborative authors recommended healthcare be required to publicly report whole-organization GHG emissions; the Greenhouse Gas Protocol be exploited; and, HHS be required to partner with the EPA to modify its Energy Star program to include Scope 3 supply chain emissions. They also proposed The Joint Commission (TJC) incorporate decarbonization metrics into their accreditation surveys; decarbonizing efforts inform Medicare and Medicaid value-based payments and quality performance benchmarking; and, public reporting be independently verified.
Reality
Five months later in May 2023, the Action Collaborative held its annual virtual meeting that was defined by TJC’s CEO Dr. Jon Perlin’s presentation.
TJC and other CMS-contracted accrediting organizations are required to comprehensively survey hospitals and other healthcare entities to determine whether they meet quality and safety standards or moreover meet Medicare and Medicaid Conditions of Participation (COP). These include maintaining a hospital’s physical plant such that the safety and well-being of patients are assured. Accreditation is voluntary but is required if healthcare providers want to participate in Medicare and Medicaid.
Perlin explained the TJC convened a panel to draft sustainability or climate-related hospital accreditation standards. Informed by Berwick’s COP recommendation, Perlin identified four standards. Most importantly, hospitals measure three or more of the following: energy use; purchased energy; anesthetic gas use; pressurized metered dose inhaler use; fleet vehicle fuel consumption; and, solid waste disposal. Perlin admitted these standards in sum set a low bar, that requested information was readily available and that there was a business case for carbon accounting.
Perlin explained further TJC’s proposed standards were put “out for public review.” As a convenience survey, unsurprisingly, they did not receive “a terribly warm reception,” Perlin said. “Because of the turbulence that has been articulated here, we are going to,” he concluded, “launch these [standards] initially as extra credit.”
Perlin’s decision was brilliant. It provided political cover for Secretary Becerra who could point to TJC’s voluntary sustainability program to justify or excuse HHS inaction. In turn, Perlin could point to regulatory inaction to affirm TJC’s sustainability certification. In addition, as voluntary, it did not threaten TJC’s dominant position in the hospital accreditation market. Three years later TJC’s voluntary certification employs the same criteria. TJC’s website currently lists 30 certified hospitals. It appears none were Energy Star certified in 2025 for energy efficiency.
No one objected. Instead, the meeting’s facilitator, then UnitedHealth Group CEO, Andrew Witty, stated with calculated insincerity, “I hope some of that push back you’re receiving over time can recede.”
Perlin’s decision, analogous to John Sununu’s Noordwijk moment, combined with Witty’s insouciance, effectively ended the Action Collaborative’s effort.
The following year’s public meeting was cringe-worthy. After being introduced as the Action Collaborative’s new co-chair, former Senator Bill Frist, a majority stock holder in the ~$90 billion hospital chain HCA founded by his father, immediately stole a page from the manufacturing doubt playbook. “There still is not a clear understanding of what can be done,” Frist said, “in terms of . . .what we can do from a public health model in terms of identifying the root causes” of climate breakdown.
Don Berwick immediately followed. He took a different tack. He strenuously admonished his colleagues stating in part, “The clock is ticking . . . stuff needs to be done now, not later. Stop complaining; the excuses about mandates and cost and business case won’t do the job. Nature is unforgiving. She does not care about the discomfort that we have to go through in order to stop the global warming and the time for resistance, the time for complaining, it’s over. Measure and report GHG emissions especially, there has been strong resistance even in this collaborative to public reporting and transparency about emissions but it’s the only thing that counts.”
Soon after the Action Collaborative’s 2024 meeting, HHS OCCHE staff published an essay summarizing healthcare’s GHG emissions tracking and reporting to date. They concluded with blunted affect, “the extent to which health systems are sharing emissions data publicly has remained uncertain.”
The HHS/NAM fleeting effort to decarbonize the industry was indeed over. In Phase 2 of the NAM’s Grand Climate Challenge, 2024-2025, HHS and NAM leadership would betray their institutional responsibilities by defaulting to “interested organizations” or a “coalition of the willing.” The Action Collaborative would now play domestique “supporting organizations across the nation on their climate and health journey” by, “cultivating,” “engaging,” “facilitating,” “leading,” “leveraging,” “mobilizing,” and “serving.”
Discussion
Under Secretary Becerra, HHS’s effort to decarbonize healthcare amounted to passive obstructionism or at best an exercise in performative guilt….
Part 2 will be on THCB soon
David Introcaso is a healthcare research and policy consultant based in Washington, D.C