CMS and the Masquerade of Equality
In summarizing Professor Jedediah Purdy’s recent book, Two Cheers for Politics, The New Yorker’s Adam Gopnik recently wrote, “He [Purdy] is angry at the elites who supervise the bureaucratic capitalist state on behalf of their overlords while keeping up an elaborate masquerade of equality of opportunity.”
“Keeping up the masquerade of equality” accurately defines CMS’s continuing pretense to value or prioritize health equity. Earlier this month, CMS published a request for information (RFI), titled, “Make Your Voice Heard, Promoting Efficiency and Equity Within CMS Programs,” soliciting providers, communities and individuals to, in part, comment on how the agency can “further advance health equity” by identifying “policies, programs and practices” “that may help eliminate health disparities.” Comments are due by November 4th. In the accompanying press release, CMS stated, “advancing health equity is core work for CMS,” and that “health equity is embedded within our DNA at CMS and serves as the lens through which we view all our work.”
More of this “CMS-is-committed-to-placing-health-equity-at-the-center-of-our-work” rhetoric can be found in CMS’ 40-page, April “CMS Framework for Health Equity 2022-2032” report. For example, “CMS Framework . . . supports CMS’s ability to assess whether, and to what extent, its programs and policies perpetuate or exacerbate systemic barriers to opportunities and benefits.” The reports five priorities include assessing the causes of disparities and moving to address them. “CMS is committed to,” the report notes, moving “beyond observation and into action, assessing our programs and policies for unintended consequences and making concrete, actionable decisions about our policies, investments, and resource allocations.”
CMS is committed, really?
First, at this point, if for no other reason than we are nearly three years into the COVID pandemic, is anyone really lost on at least the major causes of health and healthcare disparities?
Second, anyone who has done policy worked in DC for more than a week knows that when federal policymakers do not want to do anything, they put out an RFI, tell someone to do a study or hold a meeting. I’ll add, the magic of an agency RFI is that unlike formal regulatory rule making, the agency, here CMS, does not have to make public RFI responses. HHS did the same thing this past spring when the Office of the Assistant Secretary of Health (OASH) released the RFI, “2022 HHS Environmental Justice Strategy and Implementation Plan Draft Outline.”
Moreover - and you’ve heard this from me before - this exercise lends even more evidence to the fact CMS refuses to address, much less recognize, the greatest threat to human health in human history - the climate crisis, that is made substantially worse by the largest industry – healthcare and its largest funder – CMS, in the world’s largest economy – the US.
The RFI makes no mention anywhere of the problem, here moreover the disproportionate health harms inflicted on minority populations and the frail elderly, including in the “advancing health equity” discussion. In CMS’ “Framework,” the climate catastrophe is literally an afterthought. Framework authors wrote, “this [framework] plan also considers the impacts natural disasters (e.g., earthquakes, fires, viral outbreaks) and manmade disasters (e.g., oil spills, lead poisoning, climate change).” That’s it, one mention, no discussion.
To compare, last week the EPA announced it was establishing an office of environmental justice, or more accurately consolidating three smaller related offices, led by a Senate-confirmed administrator reporting directly to the EPA Administer. The redefined office will enjoy a $100 million budget, be staffed by 200 and be merged with the EPA’s Office of Civil Rights. This past May HHS announced it was establishing an Office of Environmental Justice. It will exist within the unfunded Office of Climate Change and Health Equity (OCCHE), meaning it will have a skeletal staff, and its relationship to HHS’s Office of Civil Rights is at least unclear.
Also, late this past week, the World Health Organization along with 65 international cities and governments, 200 global health associations and 100 Nobel Laureates, signed onto a call to action urging governments to agree to a legally binding, i.e., enforceable by the international criminal court, non-proliferation treaty on fossil fuels. The analogy is the 2003 WHO Framework Convention on Tobacco Control. At the United Nations this past Saturday, the President of the Pacific Island nation of Vanuatu, Nikenike Vurobaravu, called for the same.
The legally binding aspect is not farfetched. Coincidentally, in his recent review of three climate-related books, under the titled “Where Will We Live,” in The NY Review of Books, Bill McKibben, cited data showing that today there are approximately 24 million climate-related refugees and by 2050 there could be as many as 1.5 billion. This led McKibben to argue that since the vast majority of these individuals have had or will have had little or nothing to do in causing an increasingly destabilized climate, “you could fairly say the climate crisis is a kind of crime.” This crime, in which the health care industry’s intransigence looks increasingly like that of the oil, gas and electricity industries, disproportionately falls on the US. No country will ever come close to matching upwards of this country’s 40% of total historical worldwide greenhouse gas emissions.