BY DAVID INTROCASO

In May the Centers for Medicare and Medicaid Services (CMS) simultaneously published two proposed Medicaid rules (here and here) intended to improve moreover access and quality.  Both discussed at length the agency’s commitment to “addressing health equity.”  The first sentence in both identified health equity as a Medicaid program priority.  The proposed “ensuring access” rule stated CMS “takes a comprehensive approach to . . . better addressing health equity issues in the Medicaid program.”  CMS went on to state “we are working to advance health equity by designing, implementing, and operationalizing policies and programs” by “eliminating avoidable differences in health and quality of life outcomes experienced by people who are disadvantaged or underserved.”

Nevertheless, CMS’ interest in health equity is entirely performative.  It is impossible to believe the agency is legitimately interested in “eliminating avoidable differences” because leadership is well aware the greatest health equity threat to Medicaid – and Medicare – beneficiaries is the climate crisis.  This is because the most climate vulnerable Americans are Medicaid and Medicare populations.  Yet, the climate crisis is never addressed much less mentioned in either proposed Medicaid rule.  The word “climate” never appears in 291 Federal Register pages. 

This is explained by the fact that despite the Biden administration’s “government-wide approach” approach to “tackle” the climate crisis, HHS has refused to address the threat the climate crisis poses by regulating the healthcare industry’s massive carbon footprint.

Children, 36 percent of whom are Medicaid beneficiaries, are uniquely vulnerable.  Fine respirable particles resulting from fossil fuel combustion are particularly harmful because children breathe more air than adults relative to their body weight.  Research published last year concluded the health effects to the fetus, infant and child include preterm and low-weight birth, infant death, hypertension, kidney and lung disease, immune-system dysregulation, structural and functional changes to the brain and a constellation of behavioral health diagnoses.   

Medicare beneficiaries, already compromised due to higher incidence rates of co-morbidities, are at even greater risk related to arthropod-borne, food-borne and water-borne diseases because the climate crisis can increase the severity of over half of known human pathogenic diseases.  Extreme heat episodes are particularly deadly.  Over the past 20 years heat-related mortality among seniors has increased 54%. 

US healthcare, the largest industry in the largest economy in the world, emits approximately 500 million tons of greenhouse gas (GHG) emissions, the equivalent of burning 553 billion pounds of coal annually.  Healthcare’s GHG pollution equals approximately 9% of total US annual and 25% of total global healthcare GHG emissions.  If US healthcare was its own country, it would rank 11^th or 12^th worldwide in GHG pollution.  To truly appreciate how massive healthcare industry emissions are, if every nation emitted US healthcare’s per capita rate of greenhouse gases, the total would approximate the entire global carbon budget to limit warming to 1.5⁰ C by 2030.  Healthcare’s emissions alone have been estimated to be commensurate with upwards of 98,000 US deaths and roughly three times this number globally.  This helps to explain why fossil fuel use constitutes the largest environmental cause of human mortality.  Fossil fuel-related air pollution constitutes 58% of excess annual US deaths and approximately ten million globally.  Associated US healthcare costs have been estimated to exceed $820 billion annually.  Despite all this, the healthcare industry remains solidly uncommitted to decarbonizing.  For example, less than 4% of US hospitals are EPA Energy Star certified. 

CMS’ failure here is consistent with wider agency policy.  The agency’s “Framework for Health Equity, 2022-2032” does not recognize the fact healthcare’s own GHG emissions disproportionately inflict innumerable and unrelenting health harms on HHS beneficiaries.  CMS’ “Strategic Plan” ignores the issue, specifically the plan’s “2023 Strategic Framework.”  So too does CMS’ related 2022 “Diversity, Equity, and Inclusion Strategic Plan.”  Medicaid’s “strategic vision” outlined in 2021also makes no mention of the climate crisis. 

CMS’ Centers for Medicare and Medicaid Innovation (CMMI) has also done nothing to either mitigate industry emissions or work to improve climate-related health care delivery.  During a recent National Academy of Medicine virtual meeting all CMMI Director Liz Fowler could offer was to note the Innovation Center’s recent Medicare Advantage demonstration affords participating plans the option of offering undefined “climate change supports in the future.”   It is worth nothing as well neither is the climate crisis nor health equity an Office of the Surgeon General priority.

There is a great deal that is disturbing about CMS’ continuing fecklessness. 

Among other things, what makes the climate crisis a unique health threat is that it is not just another problem.  As a meta problem it exacerbates all other health conditions. Research published in 2019 concluded fine particulate matter resulting from burning fossil fuels can damage every cell in the human body.  Efforts to improve health equity along with care quality and patient safety absent mitigating GHG emissions are therefore compromised.  Possibly futile when you realize HHS dedicated to “sound, sustained advances in the sciences underlying medicine, public health and social services,” substantially contributes to biological annihilation since the climate crisis is an increasing contributor to the planet’s ongoing and accelerating human-caused sixth mass extinction.

Healthcare professionals take a moral oath to do no harm.  However, instead of fostering a business model rooted in beneficence, HHS instead advances one that operates as a maleficent harm-treat-harm doom loop where health harm is treated in a way that further compounds health harm.  Because health harms resulting from healthcare’s GHG emissions are largely foreseeable, CMS’ regulatory malfeasance can be described as reckless, negligent, the worst sort of moral hazard and moral treason.  The Hippocratic Oath has become an absurdity. 

One would think the world’s most powerful healthcare regulatory body would be particularly concerned that the biosphere is rapidly destabilizing.  Among numerous other realities, ocean heat content is at alarming record levels, the Northern Hemisphere’s summer disaster season is off to an early start made evident by heat waves worldwide, that explains for the first time this past month surface air temperatures worldwide exceeded 1.5°C, and a Canadian wildfire season that already is the worst ever recorded.  Three recent publications in Nature drew three frightening conclusions: 9% of the world’s population already lives outside the “human climate niche;” climate tipping points are being triggered substantially more rapidly than previously understood; and, seven of eight life support earth system boundaries have already been crossed.  In June, UN Secretary General Antonio Gutters was once again forced to raise alarm.  During a press conference in New York City he argued, “The collective response remains pitiful.  We are hurtling toward disaster, eyes wide open.”  “There is too much at risk for us to sit on the side-lines.  Now must be the time for ambition and action.” 

CMS refuses to address the fact that healthcare is a climate destroying industry that leaves HHS guilty of fossil fuel racism.  All this is quintessentially Orwellian.  Orwell’s characterizing Party members in “1984” aptly applies to HHS leadership.  They “could be made to accept the most flagrant violations of reality, because they never fully grasped the enormity of what was demanded of them, and were not sufficiently interested in public events to notice what was happening.”

Dedicated THCB readers may recall among 25 articles I wrote between 2016 and 2018, three concerned the climate crisis.

David Introcaso is a healthcare research and policy consultant based in Washington, D.C