Adding A Climate Lens To Health Policy In The United States

Reduction in greenhouse gas emissions is part of an urgent prescription for health across the planet. Global greenhouse gas emissions must be reduced by nearly half during the next decade to maintain a global temperature rise to “well below 2°C” above the preindustrial baseline, which requires a 7.6 percent reduction in global emissions per year.¹ The planet has already warmed 1°C since 1880;² warming beyond 2°C puts human health at serious risk. Efforts to address greenhouse gas emissions, often referred to as decarbonization because carbon dioxide is the predominant gas causing climate change, must involve building resilience to climate change, especially for vulnerable populations. Here we describe how to apply a climate lens to health policy, which is a way to assess climate change–driven health risks and integrate them into policies and other actions to protect patient health and optimize health care resilience. We present some challenges that climate change creates for population health and health care delivery. We then discuss a set of opportunities—actions that policy makers and other key health care stakeholders can take to improve health care’s overall operational and financial resilience to climate change.

Challenges

Although climate change is often seen only as a problem for health, it also puts health care access, quality, and financial viability at risk. The human-produced greenhouse gases that cause climate change contribute to more frequent and dangerous heat waves and other extreme weather events (for example, flooding, hurricanes, and wildfires), as evidenced by the unprecedented 2020 wildfire season in the western US, with increasing likelihood that these events will overlap and spur cascading failures.^3–5

Access, Quality, And Cost

Climate change–intensified extreme weather events hamper access to and quality of care for patients and providers alike and can result in major financial losses to health care systems.^3,6,7 Of 158 hospital evacuations between 2000 and 2017, nearly three-quarters were for climate-sensitive events, and more than half required evacuation of more than 100 patients.⁸ Almost 250 hospitals simultaneously lost power in intentional power outages in California because of wildfire prevention measures, and climate change stands to make wildfires and power outages more frequent.^3,7 These disruptions often result in significant hospital losses and worse patient outcomes, and they can ultimately lead to higher costs for both payers and patients.^9–11 For example, one study estimated a 62 percent increase in the mortality rate in Puerto Rico after Hurricane Maria compared with the prior year.¹⁰ Another study of ten climate-sensitive events from 2012 revealed that associated hospital admissions, emergency department and outpatient visits, home health care, and medication use totaled more than $1.5 billion.¹²Exhibit 1 and online appendix exhibit 1 contain further details.¹³

Health Equity

The effects of climate change also amplify disparities in access to and quality of care along racial, ethnic, gender, and socioeconomic lines.¹⁴ Poor people (for example, those in the lowest US income quartile) and people of color, in particular, tend to be at greatest risk for health harms from climate change while often contributing the least to greenhouse gas emissions.^14,15 For example, Blacks in the US are 52 percent more likely to reside in areas that are prone to heat-related risks, as are non-Hispanic Asians (32 percent) and Hispanics (21 percent), compared with non-Hispanic Whites.¹⁶ These climate-related population health risks exacerbate existing health disparities that arise, in part, from differential access to health care and quality of care received, which have been well documented for many vulnerable populations.¹⁴

Opportunities To Apply A Climate Lens To Health Policy

In this section we apply a climate lens to analyzing the public health infrastructure of our nation, noting initiatives where the need for better evidence, governance, and funding could improve population health. We then specifically consider health care delivery, including health care infrastructure (for example, hospitals, medical records), people (for example, health care workforce), and finances (for example, payment models). For each specific element of the delivery system, we also make policy suggestions.

Public Health Infrastructure

Only 5 percent of all US climate resilience investments went to the health care sector in 2016.¹⁷ This anemic investment in climate-related public health capacity has allowed preventable climate-related morbidity and mortality to occur. In Arizona, a lack of public health funding has greatly impeded the state’s efforts to protect health; annual heat-related deaths have more than doubled in the past ten years.¹⁸ Unfortunately, there have been no clear gains in such funding across the US since 2016.^17,19 To begin to address this shortfall, we identify infrastructure investments to bolster public health capacity for climate resilience and improve patient outcomes.

A Data-Driven Approach:

An optimal public health response to climate change includes two goals. The first is to identify the most vulnerable in terms of health outcomes, access to care, and modifiable risk factors for intervention. The second is to evaluate public health interventions to determine their efficacy and areas for improvement. For example, heat alerts are one way to inform vulnerable populations of extreme heat risks; however, one study found that heat alert thresholds were set too high in parts of the US. In the Central US, for example, heat alerts were released near 110°F, which is 20 degrees higher than the temperature at which peak hospitalizations occurred (around 90°F).²⁰ In certain areas, lowering temperature thresholds for heat alerts has been shown to result in fewer heat-related illnesses.^20,21

The coordination among diverse partners (for example, public health departments, academia, and federal agencies) and funding to support research required to achieve these two goals is lacking.²² Should more funding be made available, the National Institute for Environmental Health Sciences (NIEHS) and the Centers for Disease Control and Prevention’s (CDC’s) Racial and Ethnic Approaches to Community Health (REACH) program²³ would be well positioned to support collaboration, research, and interventions that can further reduce climate-related risks to health and health care.

National Surveillance For Climate-Related Health Risks:

Another example of the potential for evidence gathering and interagency coordination is our call to establish and fund national real-time surveillance of climate-related health risks. Public health and health care data sources can be linked to create real-time notification for public health departments, providers, and patients for emerging or intensified climate-sensitive diseases. The emergence of Lyme disease, Vibrio, and other climate-sensitive infections in novel locations means that clinicians are facing new diseases that are sometimes difficult to diagnose. Real-time monitoring of climate-related infections will aid clinicians and increase public awareness of these threats. This type of real-time monitoring could also be expanded to other health-harming exposures, such as wildfire smoke or drought-related dust. However, these and other data-driven approaches require support that is not currently available. With adequate support, the National Aeronautics and Space Administration’s remote sensing capacity; the Department of Health and Human Services (HHS) national standardized health data; the CDC’s National Environmental Public Health Tracking Network; or the US Global Change Research Program’s Interagency Crosscutting Group on Climate Change and Human Health, which already spans eleven different federal agencies,²⁴ could advance such efforts.

Coordinated Resilience Planning:

A national strategic climate preparedness plan can bolster the actions of resource-limited local public health departments to more effectively mount responses to climate change–imposed health risks. This plan can, for example, promote the sharing of resources and knowledge to enhance coordination. The CDC’s Building Resilience Against Climate Effects (BRACE) framework and the Public Health Emergency Preparedness Cooperative Agreement are critical platforms ripe for this type of expansion.^25,26 Ultimately, enhanced coordination and other actions aimed at improving the public health response to climate change may be far more effective when coupled with resilience actions in the realm of health care delivery.

Health Care Delivery

Health Care System Decarbonization:

The health care system in the US is a main contributor to greenhouse gases and associated pollution effects. It is estimated that US health care, as a whole, constitutes upwards of 10 percent of all national greenhouse gases, and pollution from health care–associated energy use results in an estimated 405,000 disability-adjusted life-years annually, a burden comparable to that of preventable medical errors.^27–29 A significant driver of health care–associated greenhouse gases is hospitals: In 2012 US hospitals ranked second in major fuel intensity use among all commercial buildings in the US.³⁰

Hospitals often have slim operating margins, and one of the expenses that contributes to limited profitability is energy costs.^31,32 Decarbonizing health care can lower costs, reduce air pollution–associated disease burdens, and combat climate change. Health care systems can take many actions to decarbonize, including low-carbon or net zero emission buildings, zero-carbon electricity, energy efficiency, and renewable power purchase agreements. Although these actions can cut expenses and save lives, initial investments are substantial, such as Boston Medical Center’s $15 million investment in a combined heat and power plant in 2017.³³ These up-front costs may be prohibitive for smaller and rural systems, which had near-record levels of financial insolvency in 2019.³⁴ To overcome such hurdles, Medicare could establish a “green loan” fund for energy efficiency measures that target smaller and rural health care systems—those with the highest financial risk and lowest available investment capital. In addition, Medicare could incentivize decarbonization through tying reimbursements to lower operational carbon intensity.

Resilient Infrastructure And Supply Chains:

The Centers for Medicare and Medicaid Services (CMS) has required hospitals to prepare for disasters through the Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers Final Rule in 2016 and the Health Insurance Portability and Accountability Act (HIPAA) of 1996, but these investments must be expanded.^35,36 Given that climate risks vary geographically, optimal hospital planning for climate-resilient health care systems must start with a local assessment of vulnerability to climate hazards (for example, infrastructure improvements such as generators on the roof).⁷ HHS should reverse the downward funding trend of the Hospital Preparedness Program and promote the adoption of climate-resilient building codes and preventative resilience, whereas the Federal Emergency Management Agency could convene federal interagency collaboration on supply chains.³⁷ Both of these interventions would strengthen documented health system infrastructure weaknesses in the face of climate-sensitive extreme events.^3,38,39 Annual assessments by HHS and the National Infrastructure Protection Plan could include locally relevant climate-related risks.

Interoperable Information Flow:

The Health Information Technology for Economic and Clinical Health Act of 2009 has provisions to ensure access to medical records in emergency scenarios.⁴⁰ However, these measures neglect current shortcomings in medical care that commonly arise when climate-sensitive disasters strike, especially around the transfer of patients between institutions. Although cumbersome medical records pose risks to safe interhospital transfers under normal circumstances, they are particularly problematic with transfers in a time of crisis. Having a concise, standardized, easy-to-read, and accurate summary of key points of a patient’s history, current medications, and test results would benefit safe and effective care regardless of the circumstances of transfer.

Climate-Ready Workforce:

The scope of climate risks to health care makes the need for a climate-ready health care workforce clear and urgent.

The scope of climate risks to health care makes the need for a climate-ready health care workforce clear and urgent. Thus, health professionals must have appropriate knowledge of climate change, and the health care workforce must be adaptable to meet the dynamic challenges that climate change poses to health care.

For example, some parts of the country are experiencing increases in climate-sensitive diseases spread by ticks, mosquitos, and water; however, regional shortages of infectious disease specialists persist in some areas at the same time as training slots have gone unfilled.^41,42 In addition, as the climate becomes more unstable, it will increasingly drive and shift disease burdens and displace populations. This is anticipated to alter the demands on the health care workforce, adding to the stress resulting from existing workforce shortages.⁴³ Researching how climate change will affect the overall number of physicians required, the proportion within each specialty, and the necessary geographic distribution will allow for better health care workforce training and recruitment. This knowledge could be integrated into the American Medical Association’s call for a gap analysis based on the cap on CMS Direct Graduate Medical Education resident training slots and on physician workforce needs.⁴⁴ In addition, federal incentives could urge trainees into specialties with shortages and clinicians into needed locations (such as through the US Public Health Service Commissioned Corps).⁴⁵ The NIEHS Worker Training Program could also mobilize supportive health care personnel at times of need, as was done with Hurricane Sandy recovery in the Northeast in 2012.⁴⁶

The health care workforce will also need to be increasingly adaptable, especially in light of current workforce shortages. Clinical training can place a greater emphasis on having a breadth of skills that allows for better adaptability of practice around disasters. Practitioners will also need to be aware of how climate change may influence their ability to deliver care, from disaster-related mental health impacts to extreme heat exposure. Emerging literature reveals that heat may compromise providers’ ability to think clearly and work efficiently, which is particularly important in non-climate-controlled conditions (for example, home visits or prehospital consultations).^47,48 The US Public Health Service Ready Reserve Corps could be a mechanism to assist with adaptability through surge capacity.⁴⁹

Climate change will also increasingly shape the clinical encounter. For example, some medications, including diuretics, anticholinergics, and psychotropics, may increase an individual’s risk of suffering heat-related illness.⁵⁰ In these cases, prescribers should consider alternative medications, appropriately counsel patients about heat risks, and screen for risk factors such as lack of access to cooling or outdoor work. Support for this body of work may come from the Health Resources and Services Administration (HRSA), given the disproportionate health burdens on the most disadvantaged (for example, integrate a climate lens into HRSA’s Health Center Program, aimed at providing primary care in medically underserved areas).⁵¹ Much more research is needed to understand the clinical care implications of climate risks and to establish core climate change knowledge for each medical discipline. Such knowledge will ultimately need to be incorporated into clinical training pathways and into licensure and board exams, which can accelerate clinical implementation.

Payers

Payers have mostly not taken proactive measures to address climate risks to the health of the populations they serve, and health insurance companies are among those least likely to disclose climate risk in the insurance industry.⁵² With the bar set so low, there is enormous opportunity for improvement.

Medicare And Medicaid:

Medicare and Medicaid can promote interventions that mitigate climate and health risks by applying a climate lens to their efforts around clinical quality and the expansion of health-related social needs such as housing and utilities. For example, climate-relevant clinical measures could guide climate-sensitive clinical care, such as pay-for-performance programs that focus on patients with kidney failure, especially during warmer months.⁵³

CMS and other payers have been giving greater attention to health-related social needs and incorporating them into alternative payment models, such as accountable care organizations (ACOs). This provides an opportunity to protect patients from health-harming and deadly climate exposures (for example, extreme heat and poor air quality).⁵⁴ As ACOs get more flexibility to spend funds on nonmedical care, they can decide which social needs can best optimize health outcomes and potentially save money—and which types of patients would benefit the most. Moving to multiyear ACO contracts or other payment programs might make long-term investments even more attractive.

CMS’s Accountable Health Communities Model is an important start in the arena of health-related social needs in its systematic identification of patients with critical needs.⁵⁵ Here, thinking through the implications of climate change would again be useful. A survey recently revealed that of beneficiaries reporting at least one health-related social need, half identified housing insecurity, and a quarter reported the lack of reliable access to basic utilities.⁵⁶ As temperatures rise and air quality degrades, paying attention to these health-related social needs identified through the CMS efforts and intervening on issues such as housing weatherization, adequate and consistent access to utilities to run air conditioning, or even indoor air quality improvement can advance health and potentially save money.^57–59

Payers, especially Medicare and Medicaid, should widen criteria for the identification of vulnerable patients who receive coverage for home cooling devices (for example, air conditioning devices and subsidized electricity) and air filtration systems beyond current waivers and specific Medicare Advantage programs.^60,61 Ensuring coverage for a larger proportion of low-income people at high risk because of comorbid conditions (such as cardiovascular or pulmonary diseases) or residential location (for example, urban heat islands or wildfire-prone regions), as is currently offered by New York State, could reduce heat-related morbidity and mortality in the short term and reduce the financial burden on payers in the long run.^62,63

Incentives For Decarbonization:

Payers could also incentivize lower carbon use in health care through financial incentives or integration into pay-for-performance models. For example, payers could reduce coverage for drugs that have particularly high warming potential (for example, desflurane, a carbon-intensive anesthetic gas) and for which equally effective and less carbon-intensive alternatives are available.⁶⁴ In addition, the rapid transition to telemedicine during the COVID-19 pandemic likely resulted in substantial decreases in carbon emissions.⁶⁵ After a more thorough evaluation of the efficacy of telemedicine visits in comparison with in-person visits, payers could ensure equal remuneration for telemedicine services, subsequently reducing greenhouse gas emissions and air pollution.

Key Knowledge Gaps Requiring Research

An understanding of how climate-sensitive extreme weather events affect health care use, quality, and cost is lacking.

A climate lens for health policy will have greater clarity when unanswered questions are addressed. As examples, much more needs to be known about who is at greatest risk from climate-related exposures (such as heat waves) and what modifiable characteristics contribute to this risk. Such knowledge is intimately tied to understanding which patients are more likely to need access to health care for climate-sensitive conditions and how and when they obtain that care. This type of information allows health systems and payers to pursue risk-benefit calculations and target resources more effectively. Also, an understanding of how climate-sensitive extreme weather events affect health care use, quality, and cost is lacking. This information can drive evidence-based resilience initiatives by guiding strategic investments and policy.

Recent extreme weather events, and hurricanes in particular, have shown that much needs to be learned about climate-proofing health care operations. The best design of a standardized patient summary for interinstitutional transfers has not yet been defined, nor has recent research on standardized patient hand-offs extended into this realm. Hurricanes, such as Hurricane Maria, have resulted in surprising and protracted shortages of critical medical supplies.⁶⁶ Studying the climate vulnerability of the medical supply chain can promote greater resilience. Finally, knowing the carbon footprints of various procedures and treatments is necessary to inform strategic decisions around decarbonization and facilitate the incorporation of decarbonization incentives in payment models.

Conclusion

In the face of the generational threat of climate change, health policy must be discussed, funded, and implemented through a climate lens. Given how little attention has been paid to climate-smart health policy and given that the harms of climate change are already apparent, policy reforms to safeguard health and health care from climate change are necessary and urgent.

NOTES

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