Feature image: The LEED Silver Inova Women's and Children's Hospital in Falls Church, Virginia. Photo credit: Ana Ka'ahanui.

Following the Global Climate Action Summit held in San Francisco, California, in September 2018, the focus on decarbonization in the U.S. has progressed extremely rapidly. ASHRAE released its Position Document on Building Decarbonization on June 26, 2022. This adds to the American Society of Civil Engineers Structural Engineering Institute’s commitment to net zero greenhouse gas (GHG) emissions from the built environment, which addresses the whole life cycle of new and existing buildings.

These policies set enormous goals, but ones that are needed to turn the curve on GHG emissions (both operational and embodied carbon emissions) in order to reduce current threats to the health and well-being of every species on earth.

The health care sector’s impact on carbon

The health care sector accounts for almost 10% of total energy consumption in all U.S. buildings tracked in the U.S. Energy Information Administration’s 2018 Commercial Building Energy Consumption Survey database. Hospital buildings use more than twice the energy (on a BTU per square foot basis) than any of the other principal uses of the top five energy consumers (the others being office space, mercantile, education and lodging).

Climate damage from the health care sector only grows when accounting for all operational emissions (energy use, refrigerant leaks, anesthetic gases, etc.). This gives the health care sector an outsized share of the responsibility to reduce the impact on climate from the built environment.

This need to reduce health care sector GHG emissions must be met at a time when the high cost of health care is already a burden on U.S. families, and while health care costs factor into people’s decisions about insurance coverage and care-seeking. Health care sector operating margins are small (operating margin measures how much profit a company makes on a dollar of sales after taking into account all operating costs—such as wages and raw materials—but excluding all non-operating costs such as taxes and interest).

This means that investments in decarbonization need to be understood in the context of reductions in overall health care costs, savings that must somehow be shared by all providers. Investments that do not reduce costs can only be made if there is a financial support for this sector to live up to its prime directive—“First, do no harm.”

The reality of net zero emissions

Planning for net zero emissions has resulted in many discussions about the challenges of achieving this goal. Meanwhile, electrifying all new construction has become a mainstay of local policies. This, in turn, has caused a number of voices to express concerns about the current state of grid-related emissions: Other than in Maine, where the grid is already 99% powered by renewable energy, we still have many states that get over 50% of their electricity from burning coal. Adding in considerations for grid capacity and stranded natural gas assets, widespread electrification has a number of technical and logistical barriers. Yet zero emissions by 2050 is the goal, and there is no path to zero unless each piece of the infrastructure puzzle addresses its part of the whole.

Thus, when it comes to building electrification, engineers, architects and owners need to put aside their concerns, and demand that the utility industry, the federal government and municipalities take the necessary actions to do their part in support of our efforts to immediately design and construct all-electric new buildings. In addition, every major retrofit or adaptive reuse project must look for ways to drastically reduce GHG emissions and prepare existing buildings for eventual conversion to all-electric operation by 2050.

During this transition over the next 10 years, projects in regions with “dirty” grids should help displace existing dirty energy sources with clean energy production as part of any new construction project. Since solar photovoltaic systems are currently the cheapest form of electricity production in over half the states in the U.S. (and are projected by the U.S. Department of Energy to be the cheapest form of electricity production in every state some time before 2030), investments in clean energy production capacity with every new construction project can be easily justified.

Paving the way for the health care sector

Moving to all-electric designs for hospitals should be driven in large part by the public health benefits of decarbonization. Other factors that should encourage this sector to decarbonize include managing risk and future-proofing against the cost of carbon emissions. For individual health care providers to realize these savings, “value-based programs” that have already been created by the Center for Medicare and Medicaid Services (CMMS) must recognize the public health benefits and potential cost reductions from decarbonization.

These existing programs reward health care providers with incentive payments for the quality of care they give to people with Medicare. These programs are part of a larger quality strategy to reform how health care is delivered and paid for, and they support three aims: better care for individuals, better health for populations and lower cost. The programs need to be aligned immediately with the global health imperative of climate change mitigation.

Hospitals are a core example of 24/7 facilities where decarbonization requires a significant departure from business as usual. When combined with the regulatory framework of health care construction and an inherent resistance to change in this sector, these factors create barriers to the adoption of systems that promote operational decarbonization. Thus, the health care sector is particularly sensitive to regulatory changes, but also extremely good at responding to new regulatory requirements. Combining payments to health care providers for reducing the adverse health impacts of their operations, along with requiring all-new construction to meet specific decarbonization goals, are both important elements of the path to net zero carbon emissions from this building sector by 2030.

Next steps

Efforts both within and outside the health care industry are needed to make the changes necessary to moving this sector toward responsible decarbonization, including:

1. Updating ASHRAE Standard 189.3, “Design, Construction, and Operation of Sustainable High-Performance Health Care Facilities.”

The “Title, Purpose and Scope” of this standard needs to be immediately aligned with the ASHRAE Position Document on Building Decarbonization. Then, the standard needs to be updated to incorporate strategies to meet ASHRAE’s stated goals: 1) By 2030, all new buildings must be net zero GHG emissions in operation, and embodied carbon of new construction must be reduced by at least 40%, and 2) By 2050, at the latest, all new and existing assets must be net zero GHG emissions across the whole life cycle.

2. Finalizing the National Academy of Medicine’s Building’s policy agenda.

The National Academy of Medicine’s Climate Collaborative should finalize its policy guidance for the U.S. Department of Health and Human Services (HHS), with the stated goal to reduce the climate footprint of U.S. health care by 50% from its current level by 2030. Subsequently, HHS should immediately prioritize and begin implementation of these agenda items.

3. Updating Center for Medicare and Medicaid Services requirements.

While various health care standards (including electric codes NFPA 70 and NFPA 99) have been updated to include a number of considerations relevant to decarbonization efforts, CMMS continues to enforce the requirements of outdated versions of these standards. CMMS should immediately update its Conditions of Participation requirements to reflect current standards.
A value-based program to target decarbonization should be implemented.
A recent letter from Sen. Edward J. Markey to HHS Secretary Xavier Becerra has begun to raise these issues, and CMMS will need this kind of continued leadership from Congress in order to make the required policy changes.

4. Internalizing the social cost of carbon.

All health care providers should immediately factor a social cost of carbon into all their cost benefit analyses. The Federal Interagency Working Group had adopted a cost of $51 per metric ton of carbon dioxide equivalent. However, a couple of months ago, the U.S. EPA proposed increasing that number to $190. In this author’s opinion, using a number—any number— is currently more important than what number is used.

The tug of war between climate change believers and climate change skeptics needs to end. All industry sectors pulling in the same direction is the only way that gets us to a place where, by 2030, all new buildings have net zero operational emissions of GHGs.

Learn more about decarbonization

Turning the health care sector toward decarbonization