Climate-Resilient Health Care Promotes Public Health, Equity, and Climate Justice

From January 2023 through early November, 25 weather and climate disaster events exceeding $1 billion in losses devastated U.S. communities.¹ This is the highest number of such events ever recorded in one year. As climate change leads to more frequent and severe weather events, as well as other climate emergencies, people and communities will continue to face more injuries, illnesses, and deaths.² Extreme heat alone is among the deadliest weather hazards, resulting in almost 7,000 additional emergency department visits and almost 2,000 additional heat-related hospital admissions nationwide each summer.³

Health care providers are on the front lines in responding to extreme weather events. Providers must respond to the increased physical and mental health needs of their communities while also preparing to withstand the disruptions that extreme weather events pose to the operation of their facilities and risk to their staff and patients.⁴ This is especially true for lower-resourced providers and those who serve low-income patients and communities of color, as they already bear the disproportionate burden of exposure to climate hazards—and the poor health outcomes that come with it.⁵ For instance, more intense extreme heat events increase energy costs and threaten public health and safety, particularly among outdoor workers, individuals without access to air conditioning, and low-income households that may not be able to afford to run air conditioning even when they have it.⁶

Climate risks to health care infrastructure threaten community health and health care facilities’ financial viability.⁷ For example, increased electricity demands for cooling during extreme heat events can stress power grids, leading to power outages that jeopardize hospitals’ safe storage of medications and vaccines and the use of medical equipment.⁸ Hurricanes and tropical storms, which are increasing in frequency and intensity,⁹ can interfere with access to medical supplies well beyond a directly affected area. For example, consider the national shortage of saline that occurred following the damage that Hurricane Maria caused to a Puerto Rico manufacturing plant that supplied 50 percent of U.S. hospitals with saline bags.¹⁰ Flooding and storms may damage community infrastructure such as bridges and roads, closing transportation routes to and from health care facilities. Facilities may also need to evacuate or close in the event of extreme weather, as when in the summer of 2023, Tropical Storm Hilary flooded a California hospital emergency room¹¹ and Hurricane Idalia forced several Florida hospitals to evacuate and move patients.¹² When some facilities are not fully operational, other health care facilities nearby may become overextended, threatening the quality of patient care.¹³

Following an active 2023 hurricane season, as well as extreme heat and wildfires, policymakers and health care providers must make preparing the health care system for increasing climate emergencies a top and immediate priority. Federal policymakers can better support health care providers in improving their resilience to extreme weather events—especially providers that are underresourced, such as community health centers (CHCs) and rural hospitals. A new Center for American Progress analysis shows that more than 1 in 3 CHC sites are in areas of high relative climate vulnerability. This report highlights opportunities to leverage new funding streams and financing strategies, as well as federal policy recommendations, to address the challenges these critical providers face:

• Ensure longer-term, sustainable funding for CHCs and rural hospitals that is inclusive of investments in health care climate resilience.
• Tailor communications to and build awareness among safety net providers—or providers that primarily serve low-income patients, patients of color, and rural communities—about all existing resources that are available to support climate resilience.
• Center climate justice in federal policy by making sure that funding for health care climate resilience prioritizes the communities and providers that are most vulnerable to climate threats and overburdened by pollution.
• Make health care safety net provider infrastructure a critical component of federal programs that are designed to support community health and climate resilience.
• Ensure that the priorities and budget of the U.S. Department of Health and Human Services (HHS) address the health impacts of climate change.
• Make carbon emission reductions a critical component of all programs aimed at improving the climate resilience of the health care system.
  

While the impacts of climate change are felt across all communities, some populations are particularly vulnerable to and burdened by climate hazards.¹⁴ Communities of color and low-income families are among those most at risk of experiencing the detrimental physical and mental health effects of climate change—and have insufficient infrastructure to withstand extreme weather as well as fewer resources to recover.¹⁵ For example, low-income communities, which are disproportionately also communities of color, and rural communities are more prone to flooding and drought.¹⁶ Low-income communities also often lack tree cover and green spaces, which absorb heat¹⁷ and reduce both temperatures within neighborhoods and the incidence of heat-related illnesses. Hispanic people are more likely to work in weather-exposed industries,¹⁸ such as construction or agriculture, and thus to experience climate-related health issues: One-third of worker heat-related fatalities from 2010 to 2021 were among Hispanic workers.¹⁹ Black people and those with low incomes tend to live in communities with lower air quality, putting them at increased risk of premature death as climate change worsens air pollution and increases the incidence of wildfire smoke.²⁰ In addition to facing climate change threats, communities of color and low-income populations have historically lived in areas where the nation’s worst and most persistent sources of pollution—fossil fuel-burning cars, power plants and industrial facilities, truck hubs, ports, landfills, trash incinerators, and more—have been concentrated.²¹ This has had serious consequences for their health.

Extreme weather events—including hurricanes, flooding, fires, and tornadoes—displaced more than 3.3 million people in 2022.²² Latino and Black households—at 1.8 percent and 2.2 percent, respectively—were more likely to be displaced than white households, at 1.2 percent.²³ And although racial disparities hold, low-income families broadly are more than twice as likely to be displaced as their higher-income counterparts.²⁴ (see Figure 1)

Low-income families and people of color also tend to be displaced for longer periods of time, or are never able to return home, and they have limited access to critical resources such as food, water, medications, and electricity after displacement. This makes their displacement even more severe and life-altering.²⁵ (see Figure 2)

In addition, people of color, low-income families, and people living in rural communities face more barriers to accessing the health care and health-promoting services they need to address the harms of climate change.²⁶ It is crucial, then, that safety net providers are equipped to handle climate emergencies and continue patient care without disruption.

This report focuses on two types of safety net providers: the nearly 1,400 CHCs and the 1,800 rural and critical access hospitals across the country.²⁷ These providers are often located directly in the communities most vulnerable to climate risks: In fact, more than 1 in 3 CHC sites are located in areas of high relative climate vulnerability.²⁸ (see Figure 3)

Additionally, rural hospitals are often the only providers in their regions—making them critical for continued care access during extreme weather events. Among these providers, there are at least 35 critical access hospitals located in the country’s most climate-vulnerable areas.²⁹ (see textbox) Because of the unique roles they play, both CHCs and rural hospitals are ideal locations for at-risk residents to take refuge and receive care during climate emergencies, yet they often face unique challenges addressing and preparing for climate change, whether due to lack of resources, capacity, partnerships, or knowledge and information. Improving climate resilience among safety net providers and the patients they serve can reduce health disparities and improve health equity and strengthen the viability of facilities.

Much of the discussion of climate resilience in the health care sector is focused on emergency and inpatient care settings rather than outpatient care settings such as community health centers. Also known as federally qualified health centers, CHCs are comprehensive nonprofit primary care providers governed by local patient-majority boards; they serve patients regardless of health insurance status or ability to pay. CHCs serve a unique function in their communities: They are trusted health care facilities for patients in medically underserved communities, they provide and connect patients to social services, and they are agents of community empowerment.³⁰ Individuals working in CHCs are particularly well suited to address the health-related impacts of climate change given their familiarity with addressing the other social and economic conditions that affect patients’ health.

Moreover, tackling the health-related impacts of climate change is integral to the congressional vision for CHCs. The federal statute that authorizes the health center program—Section 330 of the Public Health Service Act—requires that CHCs provide “environmental health services.”³¹

Depending on geographic location, CHCs face a variety of climate threats.³² For example, a health center in Louisiana may have to prepare for the disproportionate threat of facing a hurricane, while a health center in Wyoming may have to focus on the risk of wildfire. In rural areas, health centers may have fewer resources—such as more limited staffing and less up-to-date facilities—than health centers in urban settings. However, climate change is causing shifts in weather patterns³³ that are inducing new and unexpected regional extremes throughout the nation, such as the great Texas freeze in 2021. Therefore, all CHCs must begin to prepare for a wider variety of extreme weather events and their impacts on patient health and facility operations. They must integrate proactive climate mitigation and adaptation efforts into long-term strategic planning and throughout all organizational priorities.

Recognition of the role health centers must play in responding to and preparing for climate threats is growing, with additional resources being dedicated to these purposes. The National Association for Community Health Centers’ Community Health Access to Reliable Green Energy (CHARGE) Partnership,³⁴ along with Capital Link and Collective Energy, helps guide and finance CHCs in pursuing capital projects to transition to clean energy sources so that they can save money, reduce their carbon footprint, and remain operational. The Biden administration, through the Inflation Reduction Act,³⁵ made changes to the Investment Tax Credit that allow nonprofit organizations to benefit from solar and/or battery storage project incentives. The CHARGE Partnership has set a goal to facilitate building 1,000 clean and resilient microgrids at CHCs over the next 10 years using these resources, 70 percent of which will be in disadvantaged communities.³⁶ These efforts are expected to offset nearly 75,000 tons of carbon each year and save CHCs more than $150 million on project costs. CHCs also can fund solar and/or battery storage projects by applying for the Federal Emergency Management Agency’s (FEMA’s) mitigation funding through local working groups.³⁷

Despite these new investments, CHCs are still struggling to adequately address the climate crisis. Competing priorities—including staffing shortages, technology challenges, out-of-date facilities, and a broad array of patients’ urgent social needs,³⁸ on top of serving some of the hardest-hit communities during the pandemic and facing the revenue threats of Medicaid unwinding—make prioritizing climate threats difficult.³⁹

While total CHC revenues are currently at their highest levels ever,⁴⁰ critical federal grant funding has remained relatively stagnant over the last few years⁴¹ as medical inflation and patient volumes have increased.⁴² The federal Community Health Center Fund is a key financial source helping CHCs cover the cost of providing uncompensated care and expand services,⁴³ but it cannot completely meet existing needs: For example, CHCs rarely have the capital investment dollars necessary to build climate-ready systems and operations, something that often comes with significant upfront costs.⁴⁴

To address some of CHCs’ funding needs, the Senate Committee on Health, Education, Labor, and Pensions has advanced a bill to boost health center funding and set aside additional funding for capital projects that expand services.⁴⁶ This is a welcome proposal but would come at a high cost in the form of cuts to the Public Health and Prevention Fund’s key public health initiatives,⁴⁷ including support for state and local immunization programs, investigation of disease outbreaks, and support for cancer screenings and suicide prevention.⁴⁸ These tradeoffs would hamper national goals of improving health outcomes and reducing disparities.

Rural hospitals, and rural communities generally, face unique challenges in preparing for and responding to extreme weather events.⁴⁹ Rural residents are more likely to be disabled, low income, and older than are urban residents, as well as less healthy and uninsured, and they have fewer available health care providers.⁵⁰

Rural hospitals face labor shortages,⁵¹ rising prices, fewer financial resources,⁵² and low patient volumes⁵³ that result in higher average operational costs. All these things challenge their ability to provide care. In 2023, more than 600 rural hospitals—30 percent of all rural hospitals in the United States—were at financial risk of closing.⁵⁴ Even Critical Access Hospitals (CAHs), which the U.S. Centers for Medicare and Medicaid Services (CMS) has designated as eligible for additional funding and flexibilities to preserve access to essential services, struggle with viability. Although CAHs’ Medicare reimbursements are intended to be at 101 percent of reasonable costs under federal cost-based reimbursement law, due to Medicare budget sequestration, they currently receive 99 percent.⁵⁵ This means, in effect, that CAHs are providing services to Medicare beneficiaries at a loss.⁵⁶

The financial instability of rural hospitals means that they have few resources to put toward infrastructure investments that would strengthen climate resilience, including installing solar panels with battery storage, instituting flood protections, and making other improvements to withstand more extreme weather events. For instance, when a tornado hit Rolling Fork, Mississippi, in March 2023, Sharkey Issaquena Community Hospital lost power, part of its roof, and life-saving equipment; the wind destroyed its emergency room.⁵⁷ Fewer resources and relatively poorer quality infrastructure make it particularly challenging for rural communities such as Rolling Fork to recover from such events.

Despite rural hospitals’ financial struggles, they are often critical economic hubs and anchor institutions in their communities,⁵⁸ acting as major community employers and influencing quality of life. Indeed, addressing adaptation and resilience to climate change provides rural communities with economic opportunities, as evident in the many federal investments through the Inflation Reduction Act,⁵⁹ the CHIPS and Science Act,⁶⁰ the Infrastructure Investment and Jobs Act,⁶¹ and the American Rescue Plan Act.⁶² These investments can support communities as they identify local needs and rebuild rural capacity and assets, including hospitals, so that they can lead in meeting national climate, equity, and environmental goals. Rural hospitals must become central participants in building sustainable, resilient rural communities and helping them leverage new opportunities. But rural hospitals require support that helps them transform into entities that can sustainably play that role.

Such support must come in the form of financial investments, technical assistance, expertise, and education to allow rural hospitals to engage in community planning, identify funding programs to meet their goals, apply for and manage new funding, execute projects, and track outcomes.⁶³ Both health and economic policies and incentives are necessary. CMS, as a prominent payer of rural hospital services, should identify mechanisms through which rural hospitals can address the challenges of extreme weather as the agency implements new programs to preserve access to health care services in rural areas. For instance, CMS should explore ways to make health care resilience and decarbonization conditions of participation for all payment models; new models designed for particularly vulnerable safety net providers, such as the rural emergency hospital designation, should come with an additional payment increase to put toward climate resilience implementation.⁶⁴ Proposed legislation to upgrade rural hospitals’ physical infrastructure and technical assistance capabilities—such as the Save America’s Rural Hospitals Act,⁶⁵ the Hospital Revitalization Act,⁶⁶ the Rural Hospital Technical Assistance Program Act,⁶⁷ and the Medicare Rural Hospital Flexibility program⁶⁸—are opportunities to provide resources that allow hospitals to improve resilience as they improve financial stability, enhance physical infrastructure, provide technical assistance, and support workforce development.

Although health care providers face many financial and capacity barriers,⁶⁹ the Inflation Reduction Act offers incentives, including billions of dollars in grants and loans, that providers can use to create resilient infrastructure and reduce carbon emissions—mutually reinforcing goals, since reducing carbon pollution can improve resilience by helping mitigate climate change and minimize service disruptions. Most hospitals and community health centers are tax exempt, and therefore eligible for the Inflation Reduction Act’s refundable tax credits for renewable energy.⁷⁰

The HHS Office of Climate Change and Health Equity (OCCHE) has developed a “Compendium of Federal Resources for Health Sector Emissions Reduction and Resilience” as well as a “Quickfinder for Leveraging the IRA for the Health Sector.”⁷¹ Both have resources and tools, including a section on “Financial Resources, Funding Opportunities and In-Kind Supports,” to support health care facilities in building resilience and reducing emissions. In addition, OCCHE and the Administration for Strategic Preparedness and Response have developed a “Climate and Health Outlook Portal” that includes interactive county-level maps of heat, wildfire, and drought forecasts for the current month to assist emergency response and health care professionals in planning for potential extreme weather impacts and to educate the public.⁷² Additionally, among the White House’s “National Climate Resilience Framework” recommendations is enhancing the resilience of safety net providers.⁷³ The Biden administration has committed to supporting these providers in leveraging Inflation Reduction Act investments through programs such as the CHARGE Partnership. Private sector partners are also investing in hospital and health center technical assistance and renewable energy projects.⁷⁴

Investments in resilience and reducing carbon emissions can help safety net providers save money and improve care. Investing in renewable energy and storing it onsite in a microgrid would allow health care facilities to be prepared for power failures, as well as to save money that can be invested elsewhere, such as in patient care.⁷⁵ Rural hospitals located in communities with fewer than 50,000 people can also apply through a local U.S. Department of Agriculture (USDA) Rural Development Office for the Rural Energy for America Program.⁷⁶ According to the American Health Care Association and National Center for Assisted Living, one hospital used program funding to purchase and install wind generation equipment, and it is “now generating more energy than it uses,”⁷⁷ enabling investments in other improvements. This example demonstrates an added benefit to onsite energy generation: Hospitals can sell excess energy back to the local utility company, which helps decarbonize the main energy supply in their region.⁷⁸

Health care organizations that serve at-risk communities struggle with a variety of barriers to improving climate resilience, including insufficient knowledge, funding, and investment capacity—and are at various stages of understanding and overcoming these barriers. Policymakers can close critical gaps by ensuring that providers—particularly community health centers and rural hospitals—are armed with the knowledge and resources necessary to protect their communities and by making sure resources reach the most disadvantaged communities.

Ensure longer-term sustainable funding, including climate resilience funding, for community health centers and rural hospitals

Safety net providers that have historically been underresourced are facing increasing climate risks to their operations. However, without increased and consistent funding and support, these providers cannot pursue climate risk mitigation and adaptation efforts while remaining operational. Stipulations on receiving longer-term funding should require climate-resilient infrastructure investments,⁸¹ ensuring that CHCs and rural hospitals plan building improvements and expansions that account for the increasing frequency and intensity of disasters, in addition to planning to reduce carbon pollution. The Granting Resources for Eliminating Emissions Now in (GREEN) Hospitals Act,⁸² for instance, would commit $100 billion in federal funding to upgrade health facilities so that they are “more resilient to climate disasters and public health crises,” along with $5 billion for planning grants to fund community assessments and engineering evaluations to ensure that projects meet community needs.

Tailor communications to safety net providers regarding existing resources

Understanding of the impacts that a changing climate and climate-sensitive diseases have on patient health continues to grow throughout the health care sector. However, efforts to embed climate resilience and emission reduction strategies into operations vary significantly, and are often contingent on knowledge, political will, capacity, and resources. In some cases, targeted messaging with language sensitive to local sociopolitical dynamics may motivate health care institutions to undertake resilience planning. Communities that rely heavily on fossil fuels may be hesitant to take on efforts to reduce carbon pollution without first understanding how it will enhance public safety and readiness, reduce climate change threats, and keep them safer during climate disasters.

Moreover, health care providers cannot take full advantage of federal resources to support climate resilience and reduce carbon emissions if they are unaware of the resources available. This is particularly true in cases where resources flow through federal agencies that they are unaccustomed to working with, such as with the Inflation Reduction Act incentives largely flowing through the U.S. Environmental Protection Agency (EPA), a direct technical assistance opportunity through FEMA’s Building Resilient Infrastructure and Communities program, and the USDA’s Rural Partners Network.⁸³ As the national climate resilience framework points out, health care providers need “translators” who can provide them information on funding and technical assistance.⁸⁴ OCCHE has taken on this role and is planning a new program in collaboration with the EPA and the U.S. Department of Energy in early 2024 to help safety net health care organizations learn about and access Inflation Reduction Act resources.⁸⁵

Center climate justice in federal policy efforts

Federal agencies should design programs that incorporate capacity building and technical assistance so that underresourced and understaffed safety net providers can compete for grants against better resourced health care institutions.⁸⁶ HHS should follow the lead of other federal agencies in identifying and prioritizing investments in those safety net providers that are at greatest risk of climate-related health threats. For example, FEMA has identified community disaster resilience zones, census tracts at the highest risk of climate change, that are eligible for increased federal assistance. FEMA’s Building Resilient Infrastructure and Communities program and Flood Mitigation Assistance grant program, as well as the Hazard Mitigation Assistance program it sits within, are Justice40 pilot programs focused on disaster mitigation and resilience.⁸⁷ CMS could mandate that climate risk assessments and resilience planning are included as part of emergency preparedness requirements for providers participating in Medicare and Medicaid programs,⁸⁸ as well as provide grants for health care providers—giving priority to safety net providers—to install renewable energy infrastructure to mitigate and address climate disasters and extreme weather events. OCCHE released a helpful guide for providers in developing climate resilience plans that go beyond traditional emergency preparedness standards.⁸⁹

Incorporate health care safety net provider infrastructure into federal health and climate resilience programs

In addition to tailoring programs specifically for health care providers, the federal government should promote and support multisector collaboration that addresses how these facilities fit into broader local preparedness and response efforts. Through programs such as the EPA’s Environmental Justice Collaborative Problem-Solving Cooperative Agreement Program, the HHS Environmental Justice Community Innovator Challenge,⁹⁰  and the CDC’s Building Resilience Against Climate Effects framework,⁹¹ health systems and public health agencies can partner with community-based organizations and environmental justice advocates to identify strategies that build resilient communities.

When major public investments in renewable energy are financed through the Department of Energy, the department requires developers to develop community benefits plans. Safety net providers should be included in this process because they are essential institutions that add to communities’ capacity to self-organize, identify potential impacts of economic transitions, and advocate for local needs.⁹² As part of their core essential functions, local health departments undertake a community health improvement planning process every three to five years that includes a community health assessment, a process that uses a data-driven strategy to identify community health issues.⁹³ Community engagement is essential to this process, providing a critical opportunity for safety net providers and the community members that they serve to meaningfully engage around climate risks and to surface local priorities and needs.

Additionally, funding programs such as EPA’s climate pollution reduction grants and the Environmental and Climate Justice grant program⁹⁴ should consider health care along with communities’ social, economic, and environmental contexts as a critical component of resilience.⁹⁵ This collaboration is particularly important given the critical role health care institutions play in the aftermath of a climate emergency as providers of emergency medical services and places of refuge.

Ensure that HHS’ priorities and budget address the health impacts of climate change

HHS did not promulgate any climate-related regulatory rules in 2021, 2022, or 2023.⁹⁶ It must use its authorities and levers—including those related to regulation, purchasing, contracting, grantmaking, convening, education, and research—to safeguard the public from the health impacts of climate change and to reduce the health disparities that climate change exacerbates.⁹⁷ For instance, HHS could train quality improvement organizations, which it charges with improving health care quality for Medicare beneficiaries, to provide technical assistance on building climate resilience.⁹⁸ And CMS’ categorical waiver allowing health care facilities to use renewable-powered microgrids or independent electric grids as required emergency power—instead of diesel-powered sources⁹⁹—is an example of how HHS can utilize its regulatory tools to advance both carbon pollution reductions and climate resilience. Finally, HHS’ Office of the Surgeon General, in collaboration with OCCHE, recently announced Climate Action, Readiness, Equity, a new initiative to help build climate resilience.¹⁰⁰ Initiatives of this nature must specifically support safety net providers, and climate change must be prioritized within strategic planning and health equity action plans, budget requests, and HHS’ Office for Civil Rights.

Incentivize reduction in carbon emissions within climate resilience initiatives

As part of improving resilience and response to climate-related weather events, health care systems across the country must acknowledge the health harms of carbon emissions and take action to reduce their own emissions. The U.S. health care sector emits the highest health care-related greenhouse gas emissions among industrialized nations; its emissions increased 6 percent from 2010 to 2018 and account for approximately 8.5 percent of all domestic emissions.¹⁰¹ In 2018, U.S. health care pollution resulted in approximately 388,000 disability-adjusted life-years, making it as deadly as preventable medical errors.¹⁰² This issue is particularly relevant to safety net providers, whose patient populations are disproportionately harmed by climate change.¹⁰³

Reducing carbon emissions through strategies such as optimizing building energy use, transitioning to sustainable transportation systems, managing anesthetic gas choices and medical device use, and adopting food waste programs¹⁰⁴ would improve community health, minimize disruptions in care,¹⁰⁵ and provide cost savings.¹⁰⁶ Moreover, these actions will eventually become unavoidable as investors, including the federal government, grow more concerned about climate-related financial risks.¹⁰⁷ Although there is no federal requirement for health care systems to report their climate risk or carbon emissions, the U.S. Securities and Exchange Commission has proposed a rule¹⁰⁸—the Enhancement and Standardization of Climate-Related Disclosures for Investors—that would require climate-related financial risk disclosures for publicly traded companies. The proposed rule would create pressure for these disclosures throughout the health care sector;¹⁰⁹ for instance, publicly traded companies may seek disclosures from supply chains and nonprofit business partners to inform their own accounting of emissions for which they are indirectly responsible.

Finally, the Biden administration has proposed an amendment to the Federal Acquisition Regulation that would require suppliers with more than $7.5 million in contracts with the federal government to provide publicly available climate-related disclosures related to their businesses.¹¹⁰ Federal programs and resources aimed at supporting climate resilience should, and ultimately may be required to, incentivize reduction in carbon emissions. All health care systems must reduce emissions, but safety net providers need more support than more affluent providers to do so.

Strengthening safety net providers’ resilience infrastructure and enhancing their capacity to mitigate the health threats of changing climate conditions is vital to advancing health equity in vulnerable communities and improving the sustainability of providers’ operations. This is especially true for community health centers—more than 1 in 3 CHC sites are located in areas of high relative climate vulnerability—as well as rural hospitals, given the unique challenges they face and the role they play in serving disadvantaged communities. Federal policymakers must support them in leveraging existing resources and incentives and should provide them with additional resources so that they are able to invest in and prioritize climate resilience, including through reducing their carbon emissions.