By DAVID INTROCASO

This is Part 2 of David Introcaso’s review of the attempt by the Biden admin to do something about the massive carbon footprint of the US health care system. If you haven’t read part 1, start here.

Discussion

Under Secretary Becerra, HHS’s effort to decarbonize healthcare amounted to passive obstructionism or at best an exercise in performative guilt.

Inarguably, the climate crisis constitutes a permanent Public Health Emergency (PHE). Yet, Becerra refused to declare one. His Surgeon General, Dr. Vivek Murthy, whose job was to generate debate and build consensus concerning significant public health issues, failed to make climate breakdown or healthcare’s contribution to it a priority. HHS never signed an agreement with the EPA nor with the Department of Energy. It was striking Becerra failed to say anything about the Securities and Exchange Commissions’ 2022 proposed climate disclosure rule despite knowing the highly-leveraged healthcare industry faces significant climate-related financial risk exposure. 

Because Becerra also failed to obtain Congressional funding for OCCHE, until it was eliminated in 2025 OCCHE was largely relegated to producing monthly “Climate and Health Outlook” reports that attempted to identify where the next climate disaster would threaten the public’s health.

Per a White House call to action, in April 2022 Becerra announced a voluntary climate pledge program that constituted patented greenwashing. Pledgees would self-report, were not required to use Energy Star and the program lacked oversight and enforcement.   

A month later Becerra announced an Office of Environmental Justice. It too was never funded. The OEJ did produce an Environmental Justice Index that scored by census track environmental, health and social vulnerability. Possibly a good idea in theory but in reality, as a potential climate redlining tool it threatened to formally sanction climate apartheid. 

The 2021 White House EO also directed major agencies to develop climate resilience plans. Becerra would have been wise to ignore the directive.  Instead, HHS published a Climate Action Plan that pledged to make a “concerted effort to enhance resilience.” It’s worth noting building resilience is now widely promoted despite presenting insurmountable and distressing problems. Resilience requires ceaseless adaptation to and recovery from an endless cycle of climate-charged disasters. Because resilience assumes climate harms are endemic, they are made acceptable. People are forced to live in permanent danger because there is no alternative to ecocide capitalism. Resilience teaches apathy, hopelessness and fatalism. It is anti-human agency, a form of subjectification. As value free, it is an attractive political policy allowing for infinite deferral. Resilience allows institutions like HHS to abdicate responsibility, apologizes for exploitative resource use and licenses a disaster-ridden world. Refusing to envision any alternative future, resilience is nihilism. 

Becerra could have at minimum calculated healthcare’s annual carbon footprint. Either on its own or in cooperation with the EPA, HHS could have at least conducted source attribution, sentinel site or randomized stratified sampling studies, exploited proxy data, etc. 

More productively, Becerra could have exploited the 1946 Administrative Procedures Act’s “good cause” exemption.  This would have allowed Becerra to publish an interim final regulatory rule, that would take effect immediately, requiring hospitals under COP to at minimum publicly report Energy Star scores.

CMS’ effort was non-existent.

The agency never offered any climate-related discussion in its strategic framework, quality strategy or health equity documents. CMS could have as Berwick and others recommended exploit Medicare’s value-based programming, that financially incentivizes hospitals to in part reduce harm, by tying emission reductions to reimbursement. 

As HHS political leadership was preparing to exit in 2024, CMS concocted a proposed decarbonization and resilience initiative. The voluntary rule, a glaring oxymoron, would allow a limited number of hospitals participating in a five-year Medicare demonstration to self-report a small percent of their GHG emissions. The idea died the following year likely because the data collected would not be generalizable.

More generally, from the outset, Dr. Dzau and other Action Collaborative leaders astonishingly argued decarbonizing lacked “a clear business case or financial model.” On principle, the comment or assumption turned the purpose of healthcare on its head. It amounted to perfidy. In practice, leadership literally begged the question. Their circular reasoning amounted to: a business case requires a short-term cash inflow; decarbonizing is a long-term strategy; therefore, there is no business case for decarbonizing healthcare. 

That Action Collaborative leadership believed they could delay decarbonizing suggests they thought the solution amounted to simply reducing industry GHG emissions. Anthropogenic warming cannot be solved by reducing the rate of GHG emissions because climate warming is not a flow problem. It’s a stock problem. As the stock of GHG emissions accumulate in the atmosphere and oceans increases, at any rate of flow, the problem worsens. There is no wait-and-see business case. It’s a given.

Leadership also failed to recognize the most pressing negative externality ever invented had on maintaining insurance for a large-scale physical infrastructure industry. When businesses are no longer able to absorb or transfer insurance risk, credit markets freeze. No one lends money to build or maintain an uninsurable anything. As a result, assets reprice or are left stranded and market failure is achieved. Add to the list of ironies: healthcare becomes its own moral hazard, victim of its own contradiction.    

Surprisingly, the April 2023 public meeting ignored the Inflation Reduction Act (IRA) that was signed into law nine months earlier. The IRA substantially derisked renewable energy investments. Before being largely rescinded in 2025, the IRA’s uncapped energy tax credits, also available to non-profit hospitals, were estimated to be worth upwards of ~$1.2 trillion. The industry left untapped ~$400 billion in related Department of Energy guaranteed loans. Though difficult to calculate, the overriding consensus was the healthcare industry, 18% of the GDP in 2023, largely ignored the IRA.

Leadership also failed to appreciate the comparative superiority of renewable energy resources. They are comparatively more abundant, ubiquitous and efficient. They offer zero marginal cost, present low externalities, distribute economic power and constitute a moral imperative, not moral injury. Healthcare is likely the poster child for the mismatch between the type of energy supply used: heat, and the type of energy service needed: work. Moving a proton 125,000 miles per second by using fire, still the predominate source of energy one million years later, instead of directly converting light or wind to do work to power proton beam therapy, healthcare cyclotrons or superconducting magnets is at a minimum inexcusably energy inefficient.   

Had Action Collaborative leadership bothered to calculate lost opportunity costs, the value of the next-best alternative like cleaner air, they would have been forced to conclude the benefits of improved delivery, quality, outcomes and spending along with industry financial and environmental sustainability were incalculable. 

Conclusion

Action Collaborative leadership obviously believed there was neither a business case nor a moral imperative to decarbonize. Why? The industry was thriving. Between 2021 and 2023 UnitedHealth’s and Medtronic’s stocks traded at historic highs, Cardinal Health’s had increased ~60% and percentage growth of the industry as a whole was twice that of the 2022 GDP and thrice that of the 2023 GDP. 

For HHS, refusal to address intentional iatrogenic harm was at least nothing new. HHS had previously allowed upwards of ~50% of US hemophiliacs to be infected with HIV-tainted blood products during late 1970s and 1980s. CMS did not regulate the mis- and overuse of antipsychotics in nursing homes until ~15 years after an FDA official argued during a 2007 Congressional hearing that upwards of 15,000 skilled nursing homes residents died annually from their off-label use.   

If anything about the Action Collaborative was impressive it had to be leadership’s confidence that their failure to do anything measurable to address at least their own contribution to the greatest human health threat in history, would be effectively ignored by healthcare providers and the public. They guessed correctly. As Orwell phrased it, providers and the public “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.”  Knowing this, Collaborative leadership, except for Don Berwick, were undisturbed by the reality that absent mandated, measurable action HHS would continue to pay the healthcare industry to emit megatons of GHG pollution annually causing worldwide sickness and death. Thinking turned against itself. Collaborative leaders like the characters in “The Zone of Interest,” had mastered the art of willful blindness. Doing so, they ignored the enormity of what evading reality and doing nothing meant. In defining the banality of evil, Hannah Arendt concluded, “morally speaking, it would be hardly less wrong to feel guilty without having done something specific than it is to feel free of all guilt if one is actually guilty of something.”

Ultimately, the Action Collaborative failed to appreciate the intrinsic value of human or any life. One is left to wonder was their impunity nominally tempered by stupidity or was cruelty actually the point.

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