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ABSTRACT |��The health sector accounts for approximately 8.5 percent of US greenhouse gas emissions, and hospital care makes up the greatest portion of the sector’s emissions. As the impacts of climate change intensify, it is imperative that the health sector reduces its emissions. Tracking and reporting annual building energy use and emissions data is a critical first step toward reducing emissions. Across the United States, there are various federal, state, and local reporting requirements along with voluntary commitments that organizations have made to regularly disclose their emissions. This discussion paper summarizes reporting requirements and provides, for the first time to our knowledge, an estimate of the total number and percent of US hospitals that are required to or are voluntarily reporting their emissions on a regular basis. These data provide insight into the current state of health sector decarbonization and the nationwide programs that are holding them accountable.

Background

As the impacts of climate change mount and pose greater threats to human health, it is imperative that the health sector, which accounts for approximately 8.5 percent of US greenhouse gas (GHG) emissions, enhances its climate resilience and reduces its emissions (Eckelman, et al., 2020). Within the health sector, hospital care makes up the greatest portion of the sector’s emissions at 35 percent, and according to the American Hospital Association (AHA), there were 6,120 total hospitals nationwide as of 2022 (AHA, 2024; AHRQ, 2022).

A critical and foundational step in health sector emissions reduction is the tracking and public reporting of annual GHG emissions related to health care delivery (Downar, et al., 2021). A number of health systems have been estimating and tracking their GHG emissions privately in the interest of their organizational sustainability and cost-savings goals. The Environmental Protection Agency (EPA) tracks that approximately 3,500 hospitals use the EPA ENERGY STAR Portfolio Manager to estimate GHG emissions and energy use through a practice known as benchmarking (EPA, n.d.a; EPA and HHS, 2023). However, the extent to which health systems are sharing emissions data publicly has remained uncertain. With the growing interest in climate action in the health sector, as well as more broadly across all sectors, there is increasing need for health care delivery organizations to share their emissions estimates publicly for transparency, accountability, and standardization of the practice. The recent introduction of a voluntary Decarbonization and Resilience Initiative from the Centers for Medicare & Medicaid (CMS) Innovation Center offering technical assistance on decarbonization and, for the first time, collecting voluntarily submitted emissions data also demonstrates interest in GHG reporting at the US Department of Health and Human Services (HHS).

The Greenhouse Gas Protocol, a globally-accepted reporting standard, defines three categories, or “scopes,” of GHG emissions. Scope 1 constitutes direct emissions from the organization’s facilities; Scope 2 comes indirectly from energy uses that generate GHG emissions; and Scope 3 comprises emissions associated with supply chains, client use of products, and organizational investments (WBCSD and WRI, n.d.). Portfolio Manager incorporates facility data from on-site fuel combustion (Scope 1) and purchased utilities (Scope 2) to produce a value of Energy Use Intensity (EUI) in units of kBtu/ft², which is a measure of total energy consumed by a building in one year relative to the gross floor area of the building (EPA, n.d.b). Energy consumption by fuel type is used to calculate GHG emissions in Portfolio Manager, highlighting the value of publicly reported EUI data to understand facility-level emissions (EPA, 2023a).

More specific information is required on the degree to which organizations are reporting their emissions data either through federal, state, or local requirements or through voluntary initiatives where individual organizations commit to transparency. Public disclosure of emissions data is mandated by federal regulation for some organizations, and increasingly states and municipalities are also passing mandates for reporting. Federal agencies are also required to estimate and publicly disclose GHG emissions associated with their operations under Executive Order 14057 (EO 14057), which is relevant to the health sector for those agencies with health care delivery operations (EOP, 2021). Last, public disclosure of GHG emissions can be the result of voluntary actions and commitments. This discussion paper aims to summarize data on the cumulative extent of public reporting of annual GHG emissions and/or energy use data by hospital facilities across the United States and identify additional reporting rules and requirements that are pending or soon to come into effect.

Methods

Data on reporting hospitals were first identified from federal reporting sources. The authors sequentially analyzed data from the EPA Greenhouse Gas Reporting Program (GHGRP) and the EPA National Emissions Inventory (NEI), data from agencies with federal hospitals that fall under EO 14057 (i.e., Defense Health Agency (DHA), the Veterans Health Administration (VHA), and the Indian Health Service (IHS)), and data from the HHS Office of Climate Change & Health Equity (OCCHE) on organizations that have made public commitments to report emissions through the White House/HHS Health Sector Climate Pledge. State and local reporting requirements were identified using a map of benchmarking policies from the Institute for Market Transformation (IMT, 2023). Data from Health Care Without Harm (HCWH) on organizations that have voluntarily committed to reporting in the United Nations’ Race to Zero initiative were included, as well. Reporting is not limited to hospitals, so data were collected on all facility types from the sources described above. These data were then filtered and summated in RStudio for each dataset individually, de-duplicated, and then added together to estimate the total number of hospitals publicly reporting.

GHGRP, NEI, and state and local datasets included data on facilities of different property types. Some data sources used North American Industry Classification System (NAICS) codes to identify property types, and codes beginning with 622 were used to identify hospitals. The NEI dataset, which does not require GHG emissions reporting for all facilities, was also filtered to only include those reporting GHGs. In sources where Portfolio Manager property types were used, the property types “Hospital (General Medical & Surgical)” and “Other—Specialty Hospital” were selected to identify hospitals. A select few data sources did not include either NAICS codes or Portfolio Manager property types. For datasets from Massachusetts, Chula Vista, CA, Brisbane, CA, and Austin, TX, hospitals were identified by searching for building names and owners that included the word “hospital” or “medical center.”

The list of organizations, including multi-hospital systems, that have signed on to the White House/HHS Health Sector Climate Pledge was used to find location data for all pledge signee hospitals. Pledge hospitals as of April 2024 were identified by reviewing the websites of each pledge signee. The list of organizations that have signed on to the Race to Zero included only one US organization that was not also a White House/HHS Health Sector Climate Pledge signee. The hospital locations for that organization were identified by reviewing their website.

Location data across all datasets were reviewed and duplicates were systematically removed.

Results

Hospitals Responding to Federal Requirements

At the federal level, there are a few key programs that require reporting of GHG emissions and other emissions by specified facilities, including some hospitals. GHGRP mandates reporting of GHG data and other relevant information from facilities that exceed 25,000 metric tons of CO₂��emission per year (EPA, 2024). GHGRP data is available from 2010 through 2022, with approximately 34 hospitals reporting as emission sources for the year 2022 (EPA, 2022). NEI provides air pollutant emissions estimates for point sources (including health care facilities), nonpoint sources, onroad sources, nonroad sources, and fire sources (EPA, 2023b). The EPA Air Emissions Reporting Rule specifies the emissions reporting thresholds for state and local air agencies that classify certain facilities as point sources (EPA, 2008). NEI data on point sources has been published every three years from 2008 to 2020. Point source data on 364 hospitals not already identified in the GHGRP dataset were identified in the 2020 NEI dataset (EPA, 2020).

In 2021, President Biden signed EO 14057, which aims to achieve a 100 percent carbon pollution-free electricity sector by 2035 and net-zero emissions across the economy by 2050. The Executive Order outlines government-wide goals to achieve these targets, including a net-zero emissions building portfolio by 2035 and reducing Scope 1 and Scope 2 GHG emissions by 65 percent by 2030, relative to 2008 levels. Additionally, agencies set specific targets to reach the goals set forth in the Executive Order, and report annually on their progress toward these targets (EOP, 2021). Among the entities affected by this order, there are 222 federal hospitals, including those within the DHA, the IHS, and the VHA that were not already identified in any other dataset in this analysis (DHA, 2024; IHS, 2023; VA, 2024).

Hospitals Responding to State and Local Requirements

Currently, four states—Massachusetts, California, Washington, and Oregon—and the District of Columbia require certain buildings to annually report GHG emissions and/or energy use and make this data publicly available. Four additional states— New Jersey, Maryland, Minnesota, and Colorado—have implemented state-wide benchmarking programs, although they have not shared data from facilities covered by these programs. Among the states with publicly reported emissions and energy use data, 228 hospitals that were not already identified in the GHGRP, NEI, and federal hospital datasets were identified in the most recent year of data shared by each state.

At the local (e.g., city) level, 46 benchmarking policies across 17 states have been identified. Of these, 29 localities make annual GHG emissions and/or energy use data publicly available. Altogether, 171 hospitals that were not already identified in the GHGRP, NEI, federal hospital, and state-level datasets were identified in the most recent year of data shared by these localities.

Voluntary Commitments

Signees of the White House/HHS Health Sector Climate Pledge commit to publicly accounting for annual progress on organizational emissions reduction. Many organizations that have signed the pledge publicly share emissions data through other reporting requirements detailed in this analysis, but not all pledge signee hospitals fall under those requirements, so their data should be shared on a voluntary basis. As of April 2024, 139 organizations, representing 943 hospitals, had signed the pledge (HHS OCCHE, 2024). This number includes 756 hospitals that were not already identified in any other dataset in this analysis.

The Race to Zero is a global United Nations campaign that aims to reduce global emissions by 50 percent by 2030 and member organizations commit to publicly reporting annual progress on emissions reduction targets. According to HCWH, the health care partner for the Race to Zero, over 60 health care organizations, representing 14,000 hospitals and health centers across 26 countries are members of the Race to Zero (HCWH, n.d.). There are nine US health care organizations, including three hospitals that were not already identified in any other dataset in this analysis, participating in this campaign.

Current Totals

Based on the data collected above, an estimated 1,778 hospitals (or 29 percent of all hospitals) across the United States are required to or are voluntarily committed to publicly report GHG emissions and/or energy use data. All reporting programs and the number of hospitals reporting under each program are further outlined in Tables 1–3.

Future Requirements

The US Securities and Exchange Commission (SEC) released a final rule in March 2024 called “The Enhancement and Standardization of Climate-Related Disclosures for Investors,” that will require some publicly traded companies in the United States to report annual GHG emissions and to report on risks their company faces due to climate change and risks created by the company’s contributions to climate change (SEC, 2022). Under the rule, large-accelerated filers and accelerated filers will be required to report their Scope 1 and Scope 2 emissions if their emissions are material (SEC, 2024). According to Senay and colleagues (2023), 26 percent of US hospitals are owned by for-profit health care organizations and may be affected by the rule. A proposed amendment to the Federal Acquisition Regulation would also require certain federal contractors to set science-based targets to reduce their GHG emissions and disclose their GHG emissions and climate-related financial risk (87 FR 68312) (DOD, GSA, and NASA, 2022). If finalized, this regulation could further increase public reporting among health care organizations to the degree they are suppliers to the US government.

Some states and localities have recently introduced reporting policies that have only just begun or have not yet taken effect but could have substantial impacts on the number of hospitals required to publicly report annual data. These include Maryland, Minnesota, Washington, Detroit, MI, Madison, WI, and Honolulu, HI. States and localities that only began reporting programs in 2023 (and therefore did not have reporting data publicly available when this analysis was conducted) include New Jersey, Miami, FL, and Oak Park, IL. In 2023, California also passed into law SB-253 and SB-261, which will create more rigorous state-level reporting requirements. CA SB-253 will require that, beginning in 2026, all US companies with annual revenues over $1 billion that do business in California must report, receive third-party verification, and publicly share emissions data (Wiener et al., 2023). CA SB-261 will require that, beginning in 2026, all US companies with annual revenues over $500 million that do business in California must create a climate-related financial risk report that includes information on climate-related financial risk created by the company and actions being taken to decrease or adapt to climate-related financial risk, which will create more rigorous state-level reporting requirements (Stern et al., 2023).

When all ��the pending regulations and legislation noted here go into effect, it is expected that the total number of additional hospitals in the country that will be ��publicly reporting will increase significantly.

Discussion

This is the first analysis to comprehensively capture all the hospitals in the United States that are either currently required to publicly disclose their GHG emissions or have voluntarily committed to doing so at present. As stated previously, estimating, tracking, and disclosing health care sector GHG emissions are essential first steps to ultimately reducing the sector’s significant emissions.

The estimate of 29 percent of the nation’s hospitals is significant, especially considering that evidence suggests social norms can be altered by a large minority (Centola et al., 2018; Xie et al., 2011). Furthermore, the number of hospitals reporting will decidedly increase with the additional number of federal, state, and local emission disclosure programs that are soon starting ��and are therefore not included in this estimate. As an increasing proportion of the nation’s health care system gains knowledge and experience in tracking its GHG emissions, its ability to take actions to reduce them will also grow. The gains in knowledge and experience will also facilitate the spread of emissions tracking and reporting to other parts of the sector not currently required or committed to report.

There are a number of limitations to this initial analysis. While efforts were made to locate all hospitals in the United States that are reporting emissions or energy use data, documentation of these programs is not uniform, so it is possible that some hospitals were missed in this analysis. It is also likely that some duplicates were not removed due to human error in the de-duplication process. Moreover, misclassification of facility property types as hospitals and differences in the most recent year of data available among programs may have contributed error in the estimated number of hospitals reporting. Public reporting by hospitals under voluntary initiatives was not verified, although the health systems they fall under have publicly stated their commitment to doing so. It is also worth noting that even hospitals that fall under public reporting mandates could opt for the non-compliance penalties rather than report their emissions. However, most programs still publicly document non-compliance in their datasets. With these considerations in mind, it is important to emphasize that this number is solely an initial estimate, and further research will hopefully develop more definitive information.

This analysis is only focused on US hospitals. While hospital energy intensity is generally greater than other health care providing facilities, a more complete study would include other provider types. Furthermore, this analysis is mostly limited to reporting of direct and purchased emissions (Scopes 1 and 2), but the majority of emissions in the sector comes from Scope 3 emissions. Further studies are required to estimate the current reporting activities of stakeholders in the value chain.

The estimate that 29 percent of US hospitals are required to or are voluntarily publicly reporting their GHG emissions, coupled with multiple relevant pending regulations and legislation, suggests important progress toward transparency and accountability regarding GHG emissions within the health care sector. While the goal of reducing the impacts of climate change requires not just reporting but also sharp reduction of GHG emissions, this analysis has documented that a large minority of hospitals in the United States are committed to taking these first steps. While more urgency is needed, these efforts are meaningful, and facilities’ efforts to increase sustainability should be further fueled by financial resources made available by the Biden administration’s Inflation Reduction Act, as well as tools and technical assistance from federal agencies and private entities. The authors recommend that future work focus on interventions that will increase disclosures of GHG emissions within the US health sector and accelerate action on decarbonization.

Join the conversation!

Tracking and reporting annual building energy use and emissions data is a critical first step toward reducing emissions.��A new #NAMPerspectives discussion paper provides insight into the current state of health sector decarbonization:��https://doi.org/10.31478/202411c

Authors of a new #NAMPerspectives discussion paper��estimate that 29% of hospitals currently report their emissions data.��Learn more about how��these meaningful first steps are��accelerating��action on decarbonization:��https://doi.org/10.31478/202411c��#HealthCare #ClimateChange��

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