Healthcare policy in the climate crisis (United States)
Why the climate crisis is a human health crisis
The World Health Organization (2021) has declared the climate crisis “the single biggest health threat facing humanity.”
The climate crisis threatens human health and well-being in four main ways:
- Burning fossil fuels creates air pollution, which is the largest environmental causes of human mortality. It is associated with 58% of excess deaths in the United States (U.S.) annually, and one in five or over 8.5 million deaths worldwide. The pollutant most responsible for these deaths is fine particulate matter (known as PM2.5), an air pollutant composed of very tiny particles 2.5 microns or smaller. Over 99% of the population worldwide is exposed to unhealthy levels of PM2.5.
- Human-caused warming can increase the severity of over half of known human infectious diseases, including greater risk of arthropod-borne (arthropods include insects, arachnids, and crustaceans), food-borne and water-borne diseases. Some examples are Yellow fever and Zika (arthropod-borne), Salmonella (food-borne), and diarrhea and cholera (water-borne). These diseases disproportionately impact children, pregnant women and the elderly, particularly among minority populations.
- Increasingly warmer air and water temperatures from human-cause greenhouse gas and carbon dioxide emissions will lead to more frequent and extreme heatwaves, hurricanes, wildfires, and other extreme weather, which can cause physical injury or death. For example, over the past 20 years, heat-related mortality among seniors has increased by 54%.
- The climate crisis is a significant contributor to mass biological extinction, known as the Sixth Mass Extinction. Loss of biodiversity impacts human health and survival by destabilizing the ecosystems we depend on for clean air, water, and food. For example, ocean warming is the leading cause of coral reef bleaching, which, in turn, compromises marine food sources upon which millions of people depend.
U.S. healthcare’s contribution to the climate crisis
The healthcare industry’s role is to promote health and well-being and prevent and treat disease. In the U.S., the mission of the U.S. Department of Health and Human Services (HHS) is “to enhance the health and well-being of all Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services”. Healthcare clinicians pledge to “Do no harm”. It is undeniable that the healthcare system is responsible for responding to the negative health impacts of the climate crisis. And yet, the U.S. healthcare system is a major contributor to U.S. greenhouse gas emissions.
- Each year, the U.S. healthcare industry emits approximately 500 million metric tons of greenhouse gas emissions, equivalent to burning over 553 billion pounds of coal. If U.S. healthcare was its own country, it would be ranked 11th or 12th globally.
- These emissions account for approximately 8.5% of total emissions in the U.S. and 25% of global healthcare emissions.
- These emissions are linked to considerable human suffering. For example, the health damage is comparable in magnitude to between 44,000–98,000 deaths each year due to preventable medical errors.
The role of policy in climate healthcare
To date, U.S. healthcare federal policymakers, congressional legislators, and administration regulators – the people responsible for regulating the U.S. healthcare industry – have failed to put forward any policies to reduce the healthcare sector’s carbon footprint.
Federal policymakers have also failed to improve climate-related healthcare delivery. For example, there are no medical diagnosis codes for climate-related health harms, like extreme heat or wildfire smoke. Adding standardized medical codes (coded by the International Classification for Diseases, ICD-10) for climate harms are necessary to plan for and deliver healthcare to people exposed to climate health threats. There are also currently no climate-related treatments, as well as related performance standards to ensure quality of care. What’s more, healthcare programs do not estimate or budget for the health impacts of the climate crisis. For example, they do not adjust patient risk scores for exposure to climate health threats. Neither Medicare and Medicaid, nor commercial health insurance plans, recognize climate-related healthcare in pay-for-value or pay-for-performance reimbursement formulas.
The current U.S. Congressional legislative session (2021–2023) has the power to put forward legislation requiring the healthcare industry to reduce its emissions and address the health impacts of the climate crisis. However, the Congress has so far failed to do so. For example:
- The Food and Drug Administration (FDA), responsible for approving whether medications to treat Americans are safe, ignores the harms from the pharmaceutical industry’s greenhouse emissions in the research and manufacture of these same medications. Tellingly, the smaller-sized pharmaceutical industry emits more than the auto industry. The FDA’s approval processes are designed to protect and treat the health of the public. The health harms from the pharmaceutical industry’s emissions run counter to the agency’s mission. The FDA could fix this by requiring the pharmaceutical industry to meet emission reduction goals as part of the agency’s approval processes. Congress had the opportunity in 2022 to do this, but failed to act.
- The PREVENT Pandemics Act, introduced in 2022, was promised to better prepare the U.S. for the next public health emergency. However, it made no mention of the climate emergency, which is an urgent and permanent public health emergency. Climate change, coincidentally, can also increase the risk of pandemics.
- The Inflation Reduction Act of 2022 (IRA) awarded $148 billion to numerous federal departments and agencies to decarbonize – except for the HHS, which regulates the US healthcare sector. The IRA included an estimated $369 billion in clean energy tax credits. For the first time, the IRA made these tax credits available to tax-exempt healthcare providers. This means that hospitals, the biggest emitters of healthcare greenhouse gas pollution, and largely tax-exempt, can use the IRA’s tax credits to reduce their emissions. Non tax-exempt (for-profit) hospitals can also take advantage of these tax credits.
Minority populations and the poor carry a greater disease burden from the climate crisis. For example, a 2021 study showed that regardless of income and geographic location, racial and ethnic minorities are disproportionately exposed to higher levels of 12–14 sources of fine particulate air pollution (PM2.5) resulting from burning fossil fuels.
Children in the U.S., 40% of whom are enrolled in Medicaid, are particularly vulnerable to the health effects linked to fossil fuel pollution. These include: respiratory diseases, 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. According to a 2021 UNICEF study, half of the world’s 2.2 billion children are already at “extremely high risk” to climate crisis impacts, a reality the authors describe as “unimaginably dire”. In UNICEF’s list of countries where children are most at risk, the U.S. ranked 80th out of 163 countries, or worse than every country in the European Union. The U.S. government’s failure to address the climate crisis has been defined as a form of child abuse.
In May 2022, the White House and HHS created the Office of Environmental Justice (OEJ) within the Office of Climate Change and Health Equity (OCCHE). Soon after, the White House and HHS created an Environmental Justice Index (EJI). The EJI will quantify or score the environmental burden on health for every census tract. Census tracts are areas for which the U.S. Census Bureau collects data. A high score of environmental burden would be given to tracts, for example, with worse air quality and water pollution. However, because polluted areas are disproportionately populated by people of color, the EJI runs the risk of being used by insurance and other business sectors to discriminate against racial and ethnic minorities living in tracts with high EJI scores. The EJI, a tool meant to bring about environmental justice, could potentially become a tool for discrimination (redlining).
Consequences if we don’t reduce carbon emissions drastically
Per capita, U.S. emissions are roughly three times the global average. After China, the U.S. is the second largest annual greenhouse gas emitter and number one for largest historical emitter at 25% of total worldwide historical greenhouse emissions. It is likely to remain so.
As of 2023, average global warming is 1.2 degrees Celsius, and 1.4 degrees Celsius in the United States. In late 2022, the UN concluded there is no credible pathway to limit warming to an average of 1.5 degrees Celsius (2.7 degrees Farenheit) above pre-industrial levels – a goal of the 2015 Paris climate accord. Even if all current climate goals are met, the UN projects global warming will increase on average by 2.8 degrees Celsius by 2100.
Yet estimates of the amount of warming are imprecise, and likely under-estimated because climate feedback loops or tipping points, including ones related to rapid loss of Arctic sea ice, thawing permafrost, changing ocean chemistry, and forest die back. These tipping points can kick off climate cascades that can cause irreversible warming. Given the effects of climate tipping points, the Biden administration’s goal to reduce the United State’s greenhouse gas emissions by 50% by 2030 may not be achievable or sufficient.
Research and policy findings
Research has shown that emissions from the U.S. healthcare sector cause considerable harm to public health. A 2016 study found that U.S. healthcare emissions resulted in a loss of 470,000 years of healthy life lost due to disability or death. Estimates of global health harms from US healthcare emissions vary by a factor of three, depending on the emissions pathway. This means that many human lives can be saved if the U.S. healthcare industry rapidly reduces its greenhouse gas emissions.
A review of the healthcare sector’s strategic plans shows little focus on the growing health impacts and costs of the climate crisis. For example:
- The U.S. Department of Health and Human Services (HHS) strategic plan for 2022–2026 describes their work to address complex health issues, but it is missing the largest and most complex health issue: the climate crisis. Among related organizations that fail to address the climate crisis are the HHS Office of the Surgeon General, responsible for influencing public health policy and public opinion; the Administration for Children and Families; the Assistant Secretary for Planning and Evaluation; the HHS Office of Global Affairs; the HHS Office of Minority Health; the Medicare Payment Advisory Commission (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC), two groups given authority by Congress to make recommendations for improving Medicare and Medicaid; the National Quality Forum; and the Patient Centered Outcomes Research Institute (with one minor exception).
- People eligible for Medicare and Medicaid (beneficiaries) are disproportionately harmed by the climate crisis. Despite this, the Centers for Medicare & Medicaid Services (CMS), responsible for caring for over 150 million Medicare and Medicaid beneficiaries, did not discuss the climate crisis in its 2022 Strategic Plan, or in its Diversity, Equity, and Inclusion Strategic Plan. More significantly, over the past two years (2022 and 2023), CMS failed to require healthcare providers to eliminate, reduce or even publicly report their greenhouse gas emissions, or to improve climate-related healthcare delivery.
- It is unclear whether the CMS fully registers the impacts of the climate crisis. In its 2023 proposed hospital inpatient rule, the CMS has described the climate crisis as periodic “catastrophic events”, “disasters”, or “emergencies”, and has proposed plans for “assisting the community and patients to […] recover from” these events. Yet the climate crisis is not a series of events, limited in time and place. It is an overarching or mega-problem, which compromises or makes moot all other efforts to improve healthcare delivery. The climate crisis compromises everyone’s health, everywhere, always. Over 90% of Americans breathe fossil fuel polluted air that accounts for nearly 58% of excess US deaths. No one completely “recovers” from the cumulative burdens of the climate crisis.
- In January 2021, President Biden gave an Executive order that, in part, directed the HHS to create an Office of Climate Change and Health Equity (OCCHE). The OCCHE was stood up in August 2021. However, Congress has not yet funded the OCCHE, which has compromised its ability to tackle the climate crisis. The OCCHE’s efforts to date have largely been limited to providing resources for healthcare organizations, including a 39-page primer on actions they can take to decarbonize. The OCCHE also co-chaired with the National Academy of Medicine (NAM) an action collaborative to decarbonize the healthcare industry. The collaborative, which is largely composed of industry interests, works behind closed doors and is scheduled to wind down this year. The collaborative has yet to produce policy recommendations, educational materials, or any findings.
- HHS Office of Civil Rights (OCR), created in 1967, enforces civil rights laws, such as teh 1964 Civil Rights Act to protect against discrimination. However, the OCR has never recognized the discriminatory effects of the healthcare industry’s emissions on minority populations. Similarly, HHS’s Health Resources Service Administration (HRSA) is responsible for regulating Federally Qualified Health Centers (FQHCs), which provide care for 30 million minority and poor patients. To date, the HRSA has similarly not taken climate action via its Advancing Health Center Excellence program.
Addressing U.S. healthcare’s emissions
Policies to reduce the US healthcare industry’s GHG emissions can be readily put in place. There are no technological or economic barriers, but continues to be a lack of political will. The federal government can take these actions:
- The HHS Secretary can require hospitals that receive Medicare and Medicaid funding to publicly report their emissions with widely used, standardized metrics.
- The HHS Secretary can similarly require hospitals to publicly announce time-bound plans to reduce their emissions.
These actions can be accomplished if the HHS Secretary amends Medicare and Medicaid’s Conditions of Participation (CoP) regulations, which hospitals reimbursed by Medicare and Medicaid are legally required to meet. Under CoP, hospitals are required, in part, to maintain a hospital-wide quality assessment and performance improvement program for improving health outcomes and preventing medical errors. Requiring hospitals to report their emissions fits could be added to CoP regulations because reducing emissions improves health outcomes, and the harms from emissions have been argued to be a medical error. While it normally takes over a year to change Conditions of Participation, the HHS Secretary can make the changes immediately by publishing an interim final rule under the Administrative Procedure Act’s good cause exception. This exception allows federal agencies to shorten the process for changing rules if the agency has a “good cause”. The urgent action on climate change needed to “secure a liveable future for all” is undoubtedly a good cause.
In addition to reducing energy waste or improving energy efficiency, reducing the healthcare industry’s emissions involves switching to renewable energy sources like solar and wind. This would also be in the industry’s financial interests, since renewable energy is increasingly cheaper. Renewable or green energy resources are also more energy-efficient, reliable, and safe.
What more might we need to know?
We need to move fast. To date, federal policy makers responsible for regulating the healthcare industry have failed to reduce the industry’s greenhouse gas emissions, and to improve healthcare related to the climate crisis. Over the next ten years, both non-profit and for-profit hospitals and other healthcare providers can make use of IRA tax credits to decarbonize. A large percentage of healthcare providers are vulnerable to flooding, particularly those along the Atlantic and Gulf coasts. Recent regulations allow them to work independently to develop renewable energy for emergency power. However, considering the rapid need for deep emission cuts by 2030, gradual progress is not enough. Winning slowly is the same as losing.
No Miracles Needed: How Today’s Technology Can Save Our Climate and Clean Our Air by Mark Z. Jacobson, published in 2022 by Cambridge University Press.
Planetary Health: Protecting Nature to Protect Ourselves, edited by Samuel Myers and Howard Frumkin, published in 2020 by Island Press.
The End of Nature by Bill McKibben, published in 1989 by Random House.
The Great Derangement: Climate Change and the Unthinkable by Amitav Ghosh, published in 2017 by University of Chicago Press.
They Knew: The US Federal Government’s Fifty-Year Role in Causing the Climate Crisis by James Gustave Speth, published in 2021 by MIT Press.
The Physics of Climate Change by Lawrence M. Krauss, published in 2021 by Post Hill Press.
The Uninhabitable Earth: Life After Warming by David Wallace-Wells, published in 2019 by Duggan Books.
Articles and Online Sources
Climate change and health, published on October 30, 2021, by the World Health Organization (WHO).
FDA user fee legislation needs to mitigate the pharmaceutical industry’s carbon pollution, published in STAT on June 8, 2022, by David Introcaso.
FYI: The health care industry is not decarbonizing, published in The Hill on January 5, 2023, by David Introcaso.
HHS’s Environmental Justice Index institutionalizes climate apartheid, published in STAT on March 1, 2023, by David Introcaso.
HHS’s failure to address the health harms of the climate crisis constitutes environmental and institutional racism, published in STAT on March 28, 2022, by David Introcaso.
How the Inflation Reduction Act can help decarbonize the health care industry, published in STAT on September 30, 2022, by David Introcaso.
How To Solve HHS’s Failure To Address The Climate Crisis, published in Health Affairs on September 9, 2022, by David Introcaso.
IRA offers hospitals energy reduction financial incentives, published in Health Facilities Management on April 28, 2023, by Laurel Sheppard.
One billion children at ‘extremely high risk’ of the impacts of the climate crisis – UNICEF, published on August 19, 2021, by the United Nations Children’s Fund (UNICEF).
One small regulatory update can lay out the path toward decarbonization, publised in Health Facilities Management on November 18, 2022, by David Introcaso.
Public reporting: the first step in addressing the health care industry’s bloated carbon footprint, published in STAT on June 29, 2021, by David Introcaso and Walt Vernon.
What would happen if there were no coral reefs?, published in Reef-World on March 1, 2021, by Hannah Hesford.
We’re Awash In Climate Change Data, But Health Damages Remain Undercounted, published in Health Affairs on March 24, 2022, by Stefan Wheat, Jay Lemery, and Vijay S. Limaye.
Sampath B, Jensen M, Lenoci-Edwards J, Little K, Singh H, Sherman JD. Reducing Healthcare Carbon Emissions: A Primer on Measures and Actions for Healthcare Organizations to Mitigate Climate Change. (Prepared by Institute for Healthcare Improvement under Contract No. 75Q80122P00007.) AHRQ Publication No. 22-M011. Rockville, MD: Agency for Healthcare Research and Quality; September 2022.
Selected Research/Scientific Papers
Ceballos, G., Ehrlich, P. R., & Raven, P. H. (2020). Vertebrates on the brink as indicators of biological annihilation and the sixth mass extinction. Proceedings of the National Academy of Sciences of the United States of America, 117(24), 13596–13602. https://doi.org/10.1073/pnas.1922686117
Eckelman, M. J., Huang, K., Lagasse, R., Senay, E., Dubrow, R., & Sherman, J. D. (2020). Health Care Pollution And Public Health Damage In The United States: An Update. Health affairs (Project Hope), 39(12), 2071–2079. https://doi.org/10.1377/hlthaff.2020.01247
Eckelman, M. J., & Sherman, J. (2016). Environmental Impacts of the U.S. Health Care System and Effects on Public Health. PloS one, 11(6), e0157014. https://doi.org/10.1371/journal.pone.0157014
Lelieveld, J., Haines, A., & Pozzer, A. (2018). Age-dependent health risk from ambient air pollution: a modelling and data analysis of childhood mortality in middle-income and low-income countries. The Lancet. Planetary health, 2(7), e292–e300. https://doi.org/10.1016/S2542-5196(18)30147-5
Mora, C., McKenzie, T., Gaw, I. M., Dean, J. M., von Hammerstein, H., Knudson, T. A., Setter, R. O., Smith, C. Z., Webster, K. M., Patz, J. A., & Franklin, E. C. (2022). Over half of known human pathogenic diseases can be aggravated by climate change. Nature climate change, 12(9), 869–875. https://doi.org/10.1038/s41558-022-01426-1
Perera, F., & Nadeau, K. (2022). Climate Change, Fossil-Fuel Pollution, and Children’s Health. The New England journal of medicine, 386(24), 2303–2314. https://doi.org/10.1056/NEJMra2117706
Ripple, W. J., Wolf, C., Lenton, T. M., Gregg, J. W., Natali, S. M., Duffy, P. B., Rockström, J., & Schellnhuber, H. J. (2023). Many risky feedback loops amplify the need for climate action. One Earth, 6(2), 86–91. https://doi.org/10.1016/j.oneear.2023.01.004
Tarabochia-Gast, A. T., Michanowicz, D. R., & Bernstein, A. S. (2022). Flood Risk to Hospitals on the United States Atlantic and Gulf Coasts From Hurricanes and Sea Level Rise. GeoHealth, 6(10), e2022GH000651. https://doi.org/10.1029/2022GH000651
Tessum, C. W., Paolella, D. A., Chambliss, S. E., Apte, J. S., Hill, J. D., & Marshall, J. D. (2021). PM2.5 polluters disproportionately and systemically affect people of color in the United States. Science advances, 7(18), eabf4491. https://doi.org/10.1126/sciadv.abf4491
Van Susteren L. (2021). Editorial Perspective: A parable for climate collapse?. Child and adolescent mental health, 26(3), 269–271. https://doi.org/10.1111/camh.12496
Vohra, K., Vodonos, A., Schwartz, J., Marais, E. A., Sulprizio, M. P., & Mickley, L. J. (2021). Global mortality from outdoor fine particle pollution generated by fossil fuel combustion: Results from GEOS-Chem. Environmental research, 195, 110754. https://doi.org/10.1016/j.envres.2021.110754
Watts, N., Amann, M., Arnell, N., Ayeb-Karlsson, S., Beagley, J., Belesova, K., Boykoff, M., Byass, P., Cai, W., Campbell-Lendrum, D., Capstick, S., Chambers, J., Coleman, S., Dalin, C., Daly, M., Dasandi, N., Dasgupta, S., Davies, M., Di Napoli, C., Dominguez-Salas, P., … Costello, A. (2021). The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. Lancet (London, England), 397(10269), 129–170. https://doi.org/10.1016/S0140-6736(20)32290-X
Yu, W., Ye, T., Zhang, Y., Xu, R., Lei, Y., Chen, Z., Yang, Z., Zhang, Y., Song, J., Yue, X., Li, S., & Guo, Y. (2023). Global estimates of daily ambient fine particulate matter concentrations and unequal spatiotemporal distribution of population exposure: a machine learning modelling study. The Lancet. Planetary health, 7(3), e209–e218. https://doi.org/10.1016/S2542-5196(23)00008-6
May 5, 2023
Author: David Introcaso, PhD
Editor: Colleen Rollins