Tag: David Introcaso

HHS’s Independence: If Not Now, When?

Sep 26, 2025

By DAVID INTROCASO

After having worked in DC for sixteen years, in 2013 I created The Healthcare Policy Podcast. The title was in part intended to be sarcastic because healthcare policymaking in DC is very narrowly drawn. Consequently, healthcare delivery is excessively commodified, reductionistic and financialized or in sum anachronistic and ironically lacking purchase. If the policy objective was health, we’d be healthier. We’re not. For example, though anthropogenic warming poses the greatest threat to human health, we’ve no related healthcare policy.

Among more conventional issues, there is no serious policy discussion regarding HHS’s mission “to enhance . . . the well-being of all Americans. That we treat the disease not the person means we define health as simply the absence thereof. The same for excess deaths, comparatively declining life expectancy and compressing morbidity among Medicare beneficiaries who will soon exceed 20% of the population. As for children, HHS’s recent “Make Our Children Healthy Again” report expressed concern about children’s aerobic fitness but was silent about the prevalence of childhood sexual abuse despite Jeffrey Epstein and the Congress’s own serial child molester former House Speaker Dennis Hastert. Bizarrely, the AMA has yet to rescind Speaker Hastert’s 2006 Nathan Davis award for “outstanding contributions to the betterment of public health.” The HHS report was also silent about Medicaid reform even though the program provides healthcare for roughly half of US children. It is similarly remarkable how seldom if ever names like Arrow, Canguilhem, Farmer, Foucault, Illich, Marmot, Starfield and Virchow are discussed in healthcare policy circles.

Now after OBBBA cuts to the Medicaid and Medicare programs, 500 rounds fired into six CDC buildings, one killing a police officer, and seven months of HHS moral obliquity we are confronted with the reality that healthcare policymaking is now unambiguously on the road to nowhere. This may be because, having failed to appreciate Richard Hofstadter, Humphrey Building leadership is busy fomenting a new chapter in anti-intellectualism. We’re left to ask if healthcare enshittification has now been achieved possibly because healthcare policymakers have adopted Mark Manson’s “The Subtle Art of Not Giving a F*ck.”

The good news is the storm and stress about HHS no longer being fit for purpose could be effectively cured if the Congress, along with support from MedPAC, MACPAC and others, would work to free the department from politicization or partisan influence by redefining it as an independent agency. If policymakers exercised more imagination such a simple and obvious reform would have already received serious attention.

The idea of an independent HHS has at least been recognized. Roughly twenty years ago Dr. Arnold Relman, the esteemed former editor of The New England Journal of Medicine, argued healthcare be managed by a “National Health Care Agency” defined as a hybrid public-private entity like, he said, the Federal Reserve. Similarly, HHS would be governed by an independent board whose members would be nominated by the president and confirmed by the Senate for 14-year terms.

Does American Health Care Violate the ICJ’s Recent Climate Advisory Opinion?

Sep 15, 2025

By DAVID INTROCASO

In late July the UN International Court of Justice (ICJ) announced its long-awaited and highly-anticipated climate advisory opinion. The ICJ ruling represents an historic moment in climate accountability.

“Obligations of States in Respect of Climate Change”

In a rare unanimous decision, the ICJ opinion concluded “a clean, healthy and sustainable environment” is in part a precondition for the enjoyment of human rights including the right to life and the right to health. Consequently, the ICJ ruled states including their private actors are obligated to ensure the climate is protected from anthropogenic greenhouse gas emissions (GHGs) and can be held legally culpable by other harmed or unharmed states, groups and individuals for failing to protect the climate.

The 140-page opinion is the result of a 2023 UN resolution that requested the ICJ produce an advisory opinion answering two questions: what are states’ obligations under international law to ensure protecting the climate and what are the legal consequences for causing significant climate harm? In a failed attempt the US State Department opposed the resolution arguing the ICJ can only consider applicable climate treaties such as the 2015 Paris Agreement and to the exclusion of other rules of international law.

In sum, the ICJ found states have substantive, urgent and enforceable obligations under UN climate treaties and international laws to prevent significant harm to the environment from GHG emissions that includes those resulting from fossil fuel use. The court broadly defined fossil fuel use as the adoption of laws, regulatory policies and programs that promote fossil fuel production and consumption via leases, licenses and subsidies.

States must act using “all means at their disposal” that includes adopting appropriate legal and regulatory measures, acquiring and analyzing scientific and technological information and risk and impact assessments, meeting a duty of cessation and acting in good faith that includes a duty to cooperate and collaborate internationally. The ruling also allows for legal action to protect future generations. The court rejected the argument attributing harm on a case-by-case basis is unachievable stating it is “scientifically possible” to determine each state’s current and historical emissions. Without naming the US, the ICJ affirmed states not party to UN treaties must still meet their equivalent responsibilities under international law. (Columbia’s Sabin Center Climate Change Law Blog has examined at length the ICJ opinion.)

US Healthcare’s Contribution to Anthropogenic Warming

Because the ICJ recognizes an inherent link between anthropogenic warming and human rights, the opinion implies the right to health cannot be secured without addressing US health care’s own climate obligations. Meeting these pose a substantial challenge for the industry for several reasons.

US health care significantly contributes to anthropogenic warming. Per Northeastern Professor Matthew Eckelman, the industry accounts for a growing amount GHG emissions currently at over 600 million metric tons of carbon dioxide equivalents (CO2e), or 9-10% of total US emissions and 25% of global healthcare emissions. If US healthcare was its own country it would likely rank 9^th, less than Saudi Arabia but more than Germany.

Two reasons largely explain US healthcare’s carbon footprint. The industry is immense. Despite providing care for 4% of the world’s population, last year it constituted a $5.3 trillion market or roughly half of total global healthcare spending. The industry wastes an enormous amount of energy. Despite spending over $5 billion annually on energy, equivalent to at least 15% of profits, hospitals are significantly energy inefficient because they continue to consume fossil fuels to first generate heat to produce electricity that is dramatically less efficient than using renewable resources that directly generate electricity or work demand. End-use energy inefficiency compounds the problem. For example, only a trivial number of hospitals are EPA Energy Star certified for energy efficiency. For the ten-year period ending in 2024, 85 or 1.4% of over 6,000 hospitals were on average certified.

HHS Again Suspends Disbelief: The Medicaid Program Will Ignore the Greatest Health Threat to Medicaid Beneficiaries

Jul 12, 2023

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%.

The IPCC Confirms Life As We Know It Will Soon Cease to Exist

Nov 6, 2018• 7

By DAVID INTROCASO PhD

THCB readers may recall last year in early June when the Trump administration announced it would withdraw from the 2015 Paris climate accord and earlier this January when the World Economic Forum met to discuss its global risk report that included the chapter, “Our Planet on the Brink,” I discussed in part (here and here) the health care industry’s indifference to global warming (See also my related 3 Quarks Daily essay.) Now comes the United Nation’s Intergovernmental Panel on Climate and Change’s (IPCC’s ) latest report. Once again overwhelming scientific evidence that confirms life as we know it on this planet will soon cease to exist is received with apathetic insouciance.

Created in 1988 the IPCC is considered the world’s definitive scientific body on climate change and co-winner with Al Gore of the 2007 Nobel Peace Prize, finalized in early October its report, “Global Warming of 1.5°C.” The 2015 Paris accord called for the report. It was prepared by nearly one hundred scientists who analyzed thousands of the most recent scientific evidence. The report’s summary was accepted by over 180 countries including the American and Saudi Arabia delegation during the IPCC’s meeting recently concluded in South Korea.

What is newsworthy about the IPCC report is its conclusion that keeping or holding temperature increases below 2°C, the goal of the Paris agreement, would not avoid the catastrophic effects of global warming. At 1.5°C life on this planet would suffer serious or dire harm, at 2°C catastrophic harm. Specifically, the report compared the impact between a 1.5°C (2.7°F) increase in temperature with a 2°C (3.6°F) increase (The earth has already warmed by 1°C since the pre-industrial era). Among numerous other findings, should temperatures increase to 1.5°C, the report found of 105,000 species studied, four percent of vertebrates (that include us), eight percent of plants and six percent of insects would lose half of their climatically-determined geographic range. At 2°C, the percents double to triple. Global crop yields will decline significantly. At 1.5°C we will lose 70 to 90 percent of coral reefs, at 2°C there will be a 99 percent loss. At 1.5°C Marine fishery losses or the global annual catch loss would be 1.5 million tons, at 2°C they double.

Will Senate Republicans Get 50 Votes to Repeal the ACA?

Jun 24, 2017• 2

By DAVID INTROCASO

THCB readers are well aware this coming week Senate Republicans plan to begin debate on passing their amended version of the House-passed American Health Care Act (AHCA), titled the Better Care Reconciliation Act. As of today, June 23rd, immediate reactions by Republican senators to the June 22^nd released discussion draft have been limited largely because members immediately left town after the draft’s release. The Congressional Budget Office’s (CBO’s) score, that will again be influential, is expected this Monday or Tuesday. Senate debate on the legislation will likely begin next Wednesday with a vote expected late Friday or early Saturday morning, or just prior to their week-long July 4^th recess. Here is an assessment of the legislation’s prospects:

What Might We Expect in the MACRA Proposed Rule?

Apr 6, 2016• 1

By DAVID INTROCASO

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Nearly a year ago President Obama signed the Medicare Access and CHIP Reauthorization Act (MACRA) into law. MACRA, among other things, repeals the 1997 Balanced Budget Act’s Sustainable Growth Rate (SGR) formula for calculating annual updates to Medicare Part B physician and other eligible professionals’ payment rates.1 The bill received overwhelming support in both the House and Senate, only 45 out of 529 total votes cast opposed the bill despite the fact the legislation is estimated to add $141 billion to the federal deficit by 2025.2 Support for the legislation can, in part, be attributed to the Congress having grown tired of rescinding SGR mandated payment cuts or passing nearly 20 “doc fix” “patches,” over 18 years. Presently, Medicare physicians are awaiting CMS’s proposed rule that will define how the agency intends to implement the six sections of MACRA Title I, or how the agency will annually update physician performance beginning in 2019 based on the use of the law’s Merit-Based Incentive Payment System (MIPS) and its Alternative Payment Models (APMs) pathway. The proposed rule, expected to be published in the next few weeks, is highly anticipated because the rewards and penalties under either MIPS and APMs can be significant.

CMS Is the Reason We Have so Little Useful ACO Research

Feb 19, 2016• 4

By DAVID INTROCASO

flying cadeucii In his THCB essay, “Why We Have So Little Useful Research on ACOs,” Kip Sullivan correctly notes we know surprisingly little about the ACO program. (While he identifies Medicare, Medicaid and commercial plan ACOs, here I’m referring specifically to the Medicare Shared Savings Program (MSSP) ACOs that account for two-thirds of all ACOs.) Why there is little useful research is however not due to the two reasons Mr. Sullivan proposes. To understand why we lack useful ACO research look no further than the agency that manages the MSSP.

Mr. Sullivan’s explanations are: since ACOs have been defined amorphously or aspirationally they cannot be assessed based on a prescribed set of activities or services; and, policy analysts have been “cavalier” program performance-related evidence. Neither explanation is correct. Medicare ACOs are defined regulatorily in great detail. This fact is made obvious by the, to date, 430-relevant Federal Register pages. Generally defined MSSP ACOs are a model of care delivery that increasingly shifts financial risk from the payer to the provider in order to reduce spending growth and, though less definitively determined, improve care quality and patient health outcomes. An MSSP ACO’s “prescribed activities” are simply to provide beneficiaries all necessary Medicare Part A and B services. To define them beyond that or to expect the same precision or efficacy in delivering timely, comprehensive, population-based health care as administering a single prescription drug, as Mr. Sullivan would like, is impossible. Arguing ACO researchers or stakeholders are “cavalier” about how best to define and measure the program ignores, among other things, the fact CMS received over 1,670 comment letters in response to the agency’s 2011 and 2014 proposed MSSP rules.

What To Make of the Senate Finance Committee’s Chronic Care Policy Options

Feb 11, 2016

By DAVID INTROCASO

flying cadeucii This past December after eight months of formal work the Senate Finance Committee’s “Bipartisan Chronic Care Working Group” released for comment a 30-page memo outlining 23 policy options to improve chronic care quality, patient outcomes and cost efficiency. While the Committee is not endorsing any of the options identified members will likely not stray far from this list when they move to drafting legislative language next month at least in part because members insist the bill must be cost neutral. Committee members and staff should be applauded for their effort to date since both political parties have been disinterested in adding policies to improve the Medicare program. (Last year’s MACRA bill was largely unpaid for and aptly described by Henry Aaron in the New England Journal of Medicine as a log rolling exercise.) On balance, the Committee’s effort should leave Medicare stakeholders cautiously hopeful. While some of the proposed options are obvious and incrementally beneficial, others might aid in innovating care delivery and in advancing CMS’s efforts to improve quality and value payment.