This report is the third in a summer 2024 series of products from the Center for American Progress that will focus on policy recommendations to address the needs of populations that are particularly vulnerable to extreme heat.
Authors’ note: The terms “older adults” and “older people” are used in this report to describe people who have reached a chronological age range, such as above 60 or 65 years old. There is no universal definition of an older adult, and government programs that serve older adults use different age criteria; for example, the Older Americans Act serves people ages 60 and older, while Medicare primarily serves people ages 65 and older. Thus, this report does not rely on a single definition of older adults.
Introduction and summary
Extreme heat is a serious climate and health threat that is rapidly worsening.1 The summer of 2023 was the hottest since recording began in 1850 and, based on a recent study of ancient trees, the hottest summer in the Northern Hemisphere in at least the past 2,000 years.2 In 2023, Earth’s temperature officially exceeded 1.5 degrees Celsius warmer than preindustrial times, a marker climate experts say could lead to catastrophic ecological consequences if sustained.3 Unfortunately, this year’s temperatures have already broken more heat records and are trending hotter than last summer: July 22, 2024, was the hottest day on record according to data from NASA.4 Heat waves are becoming more frequent; more intense; are lasting longer; and are leading to more injuries, illnesses, and deaths than any other weather hazard.5 Based on data from 2016 to 2020, the Center for American Progress estimates that each summer, heat events are responsible for nearly 235,000 emergency department visits, 56,000 hospital admissions, and $1 billion in additional health care costs.6
Read more
Older people are especially vulnerable to harm during heat waves and make up a significant portion of heat-related illnesses and deaths.7 One Virginia Commonwealth University analysis found that Virginia ZIP codes with higher percentages of residents age 65 and above are associated with a 23 percent increased risk in both heat-related emergency room visits and heat-related hospital admissions during heat events.8
People become less efficient at adapting to extreme temperatures as they age. Biological functions meant to release heat and cool the body, such as sweating and blood circulation, generally do not work as well in older bodies, causing them to retain heat.9 Chronic conditions, the use of certain medications, and disabilities can compound age-related risks by impairing biological cooling functions and making it more difficult for older adults to recognize and respond to heat symptoms.10
Nonbiological factors can also compound these risks. Housing quality issues and growing rates of homelessness increase older adults’ exposure to unsafe temperatures, and social isolation can limit older adults’ access to resources and supports during heat emergencies.11 A CAP analysis of data from the U.S. Census Bureau’s Household Pulse Survey finds that energy insecurity—defined as difficulty paying utility bills—is widespread among older adults. Because of social and economic disadvantage, older people of color, older adults with low incomes, and older women face even higher risks.12 Action is urgently needed because the population of older adults is growing: Nearly 1 in 4 Americans is projected to be age 65 or older by 2050, meaning even more people will be at risk as temperatures continue to rise.13
CAP recommends the following federal, state, and local policy actions to address extreme heat and to protect older adults from the harshest impacts of climate change:
- Explicitly incorporate climate- and heat-related solutions within aging policies and programs:
- Better leverage “the aging network” to reduce older adults’ heat risk.
- Reauthorize foundational aging legislation, such as the Older Americans Act and the Elder Justice Act, at enhanced and sufficient levels to better support and incorporate a climate lens into aging programs and infrastructure.
- Improve coordination among health care systems, public health agencies, and aging and disability networks to address climate risks.
- Ensure health care systems and insurers can meet the unique needs of older adults during extreme weather:
- Policymakers should amend existing health care emergency preparedness requirements to require planning for long-term heat and cold emergencies.
- The U.S. Centers for Medicare and Medicaid Services (CMS) should encourage states to address climate-related health risks using new Medicaid program flexibilities intended to address social factors that affect health outcomes.
- CMS should strengthen oversight and transparency of Medicare Advantage plans and encourage inclusion of supplemental benefits to improve health outcomes for enrollees exposed to extreme heat.
- Articulate and integrate the needs of older adults into climate preparedness and resilience interventions and policy solutions.
- Accelerate efforts to reduce emissions and pollution through greater clean energy use, including increased uptake of the Biden-Harris administration’s climate investments:
- Prioritize older adults in efforts to create energy-efficient homes and communities.
- Require that health care providers, including long-term facilities where a subset of older adults reside, aggressively reduce energy use and emissions.
America’s population is aging, and older adults are among those at greatest risk from extreme heat
A recent international study by climate experts, economists, and sociologists found that by 2050, more than 200 million older people globally—many of whom are in the United States—will be exposed to extreme heat.14 Adults ages 65 and older account for roughly 58 million Americans—nearly 18 percent of the U.S. population.15 That number is expected to grow by 23 percent to 82 million people by 2050.16 Older adults are among those most vulnerable to extreme heat: More than 80 percent of U.S. heat-related fatalities annually are adults over age 60.17 A 2023 Lancet report found that heat-related deaths in older adults increased by 88 percent between 2018 and 2022 compared with 2000 to 2004.18 These numbers, along with heat-related injuries and illnesses, are likely undercounted due to inaccurate recording and slow reporting.19
While extreme heat is dangerous for all older adults in America, residents of some regions of the country are at greater risk than others. Hotspots in coastal areas of Florida, central and southwest Texas, parts of Oklahoma, pockets of the Midwest (notably Kansas and Nebraska), central Arkansas, coastal and bayou Louisiana, and western Mississippi20 are experiencing both significant population aging and rapidly warming climates. Other regions are vulnerable to increasing temperatures because of high shares of older adults and the lack of heat-ready infrastructure. Maine, for example, has the highest percentage of adults over 65 in the United States but slightly more than half of homes have air conditioning—compared with the national average of 90 percent.21
Virginia ZIP codes with higher percentages of residents age 65 and above are associated with a 23 percent increased risk in both heat-related emergency room visits and heat-related hospital admissions during heat events.
Heat-related illnesses and deaths are preventable.22 Furthermore, the health dangers heat poses are closely tied to social and systemic disadvantage. For example, a 2022 heat wave in Europe that killed roughly 61,000 people led to 56 percent more deaths among older women than older men.23 Studies show that the risk of heat-related mortality and illness is elevated among Black, Latino, and Indigenous people.24 For example, though heat-related cardiovascular deaths are projected to increase by 162 percent by the period of 2036 to 2065 compared with 2008 to 2019, the increase among Black adults is expected to be 4.6 times greater than that of white adults.25 Poverty is also associated with worse health outcomes during heat waves, which aligns with a 2021 nationwide study finding that in 76 percent of 1,056 counties, low-income neighborhoods were significantly hotter than higher-income neighborhoods.26 In summary, older people of color, older adults with low incomes, and older women face even higher risks than their peers.
A variety of factors contribute to older adults being among the populations at greatest risk from extreme heat: Health status, energy insecurity, housing quality issues, and social isolation all play a key role and serve as important intervention points for policy change.
Health status
Internal mechanisms meant to regulate body temperature are even less efficient in older adults with chronic conditions such as diabetes or cardiovascular, respiratory, or autoimmune diseases.27 According to the National Council on Aging, nearly 95 percent of adults older than 60 have at least one chronic condition; most have two or more.28 The leading chronic condition among older adults is hypertension. Older adults’ use of medications such as diuretics that treat hypertension, medications used to treat mental health conditions, or medications for conditions such as chronic obstructive pulmonary disease can further reduce sweating, cause dehydration, and therefore increase the risk of heat exhaustion.29
Disabilities also complicate heat tolerance in older adults. Physical and mental disabilities can make it difficult to prepare for heat waves and identify heat symptoms and can limit people’s ability to protect themselves. Cognitive impairment, a disability more common in older adults, can have serious implications for worsening heat-related health outcomes.30 For example, dementia is a risk factor for hospitalizations and fatalities during heat waves: People with Alzheimer’s disease are 6 percent more likely to die on a hot day.31 Extreme heat can also exacerbate mental health conditions by triggering confusion, delirium, and agitation in severe cases, and some antidepressants can make people more sensitive to heat.32 Vulnerable groups of older adults, such as those who are Black or living in poor neighborhoods, also face accelerated cognitive declines from extreme heat.33
Mobility limitations, also more common in older adults, can affect heat-related health outcomes.34 Decreased mobility and greater risk of complications from infectious diseases such as COVID-19 limit the ability to secure safe shelter or access resources such as cooling centers during heat events and may leave people in homes with unsafe indoor temperatures.35 Mobility issues, as well as difficulties with hearing, vision, or independent living, can even affect older adults’ capacity to receive critical information about extreme heat and to plan in advance to stay cool at home.36
Because of the biological, physical, and cognitive challenges older adults face, they are more likely to heavily rely on electricity access for life-sustaining care at home. This makes older adults particularly vulnerable during power outages brought on by heat waves and the mounting pressure placed on electrical grids.37 Older adults may rely on insulin or other critical medications that must be stored at cool or refrigerated temperatures, or they may use electricity-dependent durable medical equipment such as oxygen concentrators or mobility equipment.38 However, with increasing temperatures and aging energy infrastructure, the vast majority of the country now faces energy reliability challenges.39 Weather-related power outages are becoming more frequent and are lasting longer, with recent data showing interruptions lasting an average of 5 1/2 hours, a two-hour increase from 2013.40 For some cities, just the threat of a major power outage presents significant risk: A study found that a two-day blackout in a city such as Phoenix would lead to roughly half the population requiring emergency care and 13,000 people dying.41 These impacts would most certainly be felt by older adults first and worst. In July 2024, Hurricane Beryl’s landfall in Texas caused a massive power outage, and a heat wave followed.42 The storm’s effects left many older adults, especially those with chronic conditions and disabilities, in dangerous situations: One 71-year-old woman died after her oxygen machine stopped working during the outage.43
A two-day blackout in a city such as Phoenix would lead to roughly half the population requiring emergency care and 13,000 people dying.
Energy insecurity
Older adults’ ability to protect their health during extreme heat also depends on whether they can afford the cost of staying cool.44 Many older adults struggle with the costs of purchasing, maintaining, and running air conditioning.45 Older adults spend more of their incomes on energy than younger age groups, and low-income older adults are especially burdened by energy costs46—partly because they tend to live in older, less energy-efficient homes.47
A CAP analysis of Household Pulse Survey data from the U.S. Census Bureau examined the incidence of energy insecurity among older adults and found widespread disparities in the ability to afford household energy bills.48 In 2023, nearly 1 in 3 older adults—14.8 million people—were energy insecure, meaning they cut back on basic necessities such as medicine or food in order to pay energy bills; kept their home at unsafe or unhealthy temperatures; or could not pay an energy bill during the prior 12 months. Roughly 1 in 10 older adults—4.9 million people—experienced severe, persistent energy insecurity, reporting that they struggled with energy costs nearly every month during the prior year.
Figure 1 reveals the groups of older adults CAP identified as being most at risk of energy insecurity. More than half of older people (55.9 percent) with annual incomes less than $25,000 were energy insecure in 2023, with nearly 1 in 4 (23.3 percent) reporting persistent, severe energy insecurity. Older adults with disabilities also had high rates of energy insecurity, with almost 1 in 5 (19.7 percent) experiencing severe insecurity. Older people of color—including Black, Hispanic, Asian, and people of other or multiple races—faced higher risks of energy insecurity than their white counterparts. Divorced, widowed, or never-married older adults were at a higher risk than married people, and older women experienced more energy insecurity than men, reflecting their greater overall risk of aging into poverty.49 Finally, the analysis showed older renters were more likely than homeowners to experience energy insecurity, and older people who live in mobile or alternative homes such as RVs, vans, or boats were at far greater risk than people living in traditional housing, whether single or multifamily.
Neighborhood conditions and housing quality
Black, Hispanic, and low-income people in urban areas face greater exposure to extreme heat from urban heat island effects, in which buildings and concrete absorb and release the sun’s heat. They also lack tree cover compared with white residents and people with higher incomes in those same cities.50 This is a direct result of the legacy of redlining in the United States, and these disparities in heat exposure extend to the older adult population.51 Unfortunately, research shows that Black, Hispanic, and lower-income people living in urban areas are also less likely to have reliable air conditioning to mitigate heat risk.52
Older adults represent close to 1 in 3 people who live in manufactured housing nationally.53 While manufactured housing can be an affordable option for older adults, living in manufactured housing can contribute to heat risks, depending on the quality of that housing. One in 5 currently occupied manufactured homes were built before 1980, when U.S. Department of Housing and Urban Development safety codes were established for manufactured homes.54 Risks are higher for people living in these older manufactured homes and compounded when located in high-density parks that lack adequate shade and roof insulation.55 For example, in Maricopa County, Arizona, 30 percent of all indoor heat-related deaths between 2016 and 2020 occurred among people who lived in mobile homes, RVs, and trailers—even though these represented only 5 percent of local housing stock.56 There is a high prevalence of manufactured housing in rural areas, with more than half of all the country’s manufactured housing stock located in rural areas and manufactured housing representing nearly 15 percent of all rural housing.57
Older renters, regardless of the type of housing they live in, may also have elevated exposures to dangerous heat given that in many states and municipalities, landlords are not required to provide cooling and may even have the ability to prevent tenants from obtaining their own air conditioning units.58
Finally, older adults experiencing homelessness are at severe risk from heat. In Maricopa County, for example, people experiencing homelessness face 200 times the risk of heat-related illness or death compared with residents who are securely housed.59 In addition to potential exposure to the elements, homelessness itself physically weighs on the body, accelerating cognitive declines and physical impairments already more common in older adults and further increasing the vulnerability to heat.60 Homelessness is growing faster among adults ages 50 and older than any other age group, and the number of older adults experiencing homelessness is expected to triple by 2030.61
Learn more
Social connectedness
Older adults’ access to social networks and supports has a direct bearing on the risks they face from extreme heat. Social isolation is a health risk for older adults in general and in heat emergencies specifically: Common interventions designed to protect the public from extreme heat often hinge on social connection.62 For example, public advisories to check on homebound neighbors or family members may not reach socially isolated older adults. Public cooling centers work only if people have the transportation to reach them, and the effectiveness of programs that distribute free or low-cost air conditioning units can rely on whether older adults also receive assistance with installation. One in 4 people ages 65 and older experience social isolation, defined as having few social relationships or infrequent social contact with others.63 Older adults with mental health conditions, including anxiety and depression, or cognitive impairment can be at heightened risk for social isolation.64 And because chronic exposure to heat can disrupt sleep patterns and lead to increased stress, depression, anxiety, and cognitive impairment, extreme heat can itself exacerbate existing mental health conditions and deepen social isolation among already vulnerable older adults.65
Recommendations
To mitigate the impacts of extreme heat on older adults, policymakers must leverage strategies that cut across many sectors, including housing, health care, and community supports. State and federal agencies must also align and use all the policy levers at their disposal to reduce the emissions that cause extreme heat and adapt the existing infrastructure serving older adults to improve resilience to heat.
Explicitly incorporate climate- and heat-related solutions within aging policies and programs
Local leaders and planners involved with aging policies and programs should connect those efforts to climate resilience and sustainability goals.66 For example, in creating age-friendly housing developments, policymakers should consider relative climate risk (e.g., whether housing will be in neighborhoods with less tree canopy and higher surface temperatures) and the energy burden and resilience of new housing structures.67 Age- and climate-friendly transportation initiatives should ensure that older adults have access to public transportation to cooling centers or that bus stops have shading and seating. Some localities and states are implementing policies that serve older adults under the World Health Organization’s age-friendly communities framework, which lacks a distinct climate dimension.68 To guide climate-based policy action, local and state leaders should use federal tools such as the U.S. Centers for Disease Control and Prevention’s Heat and Health Index, the Department of Health and Human Services (HHS) Office of Climate Change and Health Equity’s (OCCHE) Climate and Health Outlook, the National Integrated Heat Health Information System, and the Federal Emergency Management Agency’s Resilience Analysis and Planning Tool.69
America’s aging and disability networks
America’s aging and disability networks trace their roots to the Older Americans Act (OAA) of 1965, which was signed into law at the same time as Medicare and Medicaid. The OAA’s objective was to provide community-based supports to help people ages 60 and older live independently in their homes and communities. OAA created a national network of state, territorial, Tribal, and local agencies, collectively known as “the aging network,” to deliver these programs and supports. The aging network encompasses:
- 56 state units on aging (SUA), which cover each of the 50 states, the District of Columbia, Guam, Puerto Rico, American Samoa, the Northern Mariana Islands, and the U.S. Virgin Islands
- More than 600 area agencies on aging (AAAs), which are public or nonprofit organizations that coordinate local service delivery for older Americans
- More than 260 Title VI Native American aging programs
- More than 20,000 community service providers, including local senior centers
Roughly 11 million older adults and their caregivers benefit from affordable and accessible OAA-funded community services that the aging network delivers each year. The aging network targets those services to older adults with the greatest economic need—defined as needs resulting from an income level at or below the poverty line—and the greatest social needs. Social needs are defined as needs arising from noneconomic factors, including physical and mental disabilities; language barriers; and cultural, social, or geographical isolation, including isolation caused by racial or ethnic status that restricts the ability of an individual to perform normal daily tasks or threatens their capacity to live independently.
Because of the overlap between services older adults need and the services that people with disabilities need to live independently, the aging network often works together with a parallel disability network. This network includes aging and disability resource centers that provide information and counseling to help older and/or disabled people make informed decisions about and access long-term services and supports. The disability network also includes the Americans with Disabilities Act National Network, assistive technology programs, centers for independent living, protection and advocacy systems, state councils on developmental disabilities, and more.
Programs and services provided by the aging and disability networks complement Medicare and Medicaid by meeting older adults’ nonmedical needs that are nevertheless important for health. These include nutrition supports; case management; chronic disease prevention and management; home modifications; family caregiver support; social engagement; transportation; assistance with Medicare and Medicaid enrollment; and services to prevent the abuse, neglect, and exploitation of older adults and people with disabilities.
Better leverage ‘the aging network’ to reduce older adults’ heat risk
Aging and disability networks are critical for older adults and people with disabilities.70 They occupy an important nexus in response to extreme heat, both in the short term and long term, insofar as they address the “last mile” delivery of services to older adults and people with disabilities and act as first point of contact in extreme heat and other climate disasters.71
Aging and disability networks already provide services such as home-delivered meals or in-home care services to vulnerable older adults and can quickly intervene during extreme heat events and deliver needed assistance. In the longer term, aging and disability networks can also promote greater climate resilience among those they serve by virtue of the networks’ status as trusted messengers. For example, area agencies on aging have worked to promote heat safety and emergency preparedness among vulnerable older adults and to connect people with energy assistance.72 With a growing population of older adults who are facing greater health threats, Congress must provide additional resources to these networks so that they can meet the growing needs related to extreme heat.
Many consumers—including older adults—are not yet aware of government programs that can help them reduce their energy costs through home energy rebates and tax credits.73 For older adults, the awareness gap is complicated by scams and frauds that frequently target them, with home improvement—including energy efficiency—scams becoming among the most common and fastest-growing source of complaints filed with local consumer agencies.74 Against this landscape, aging and disability networks have a unique opportunity to help older consumers understand ways to reduce their energy bills, access free or low-cost weatherization and energy efficiency programs, and avoid scams and unfair or deceptive business practices. The U.S. Department of Energy’s (DOE) Office of State and Community Energy Programs has helpfully published consumer protection best practices for states to consider as they roll out home energy rebate programs.75 As part of the Inflation Reduction Act (IRA) of 2022 grant and other programmatic implementation, federal agencies and states should intentionally engage the Administration on Community Living, state units on aging, area agencies on aging, and other partners in the aging and disability networks early on in planning activities to ensure that these partners can play a meaningful role in protecting consumers, promoting energy savings, and helping older adults stay safe and healthy in their homes.
Reauthorize foundational aging legislation at enhanced and sufficient levels to better support and incorporate a climate lens into aging programs and infrastructure
The aging network relies heavily, though not exclusively, on funding from the Older Americans Act (OAA) (OAA) to deliver the supports people ages 60 and older need to stay healthy and remain in their homes and communities as they age. This includes social, nutrition, employment, and health programs. Adequate funding is necessary to ensure the aging network can meet older adults’ needs in the face of both demographic change and climate change. But in recent years, OAA funding has lagged behind both inflation and the growth of the older population, limiting access to even existing aging services.76 OAA funding for fiscal year 2024 was $170 million lower on an inflation-adjusted basis than fiscal year 2014 funding. Over the same period, the country’s 60-plus population increased by 29 percent, from 62 million to 80 million. The lack of investment in this critical social infrastructure serving older adults has concerningly resulted in widespread disparities in access to aging services: Counties with the highest shares of older adults are more likely to be aging services deserts, as are rural counties and counties with high rates of poverty or higher shares of Black residents.77
Along with its reauthorization, policymakers should increase overall funding for OAA to harden the aging services infrastructure, close disparities, and invest in new opportunities that address emerging health needs for older adults in the face of a changing climate. For example, Congress should clarify that Older Americans Act programs, such as the home modifications program, can address cooling and heating, air quality, energy efficiency, and other ways to make older adults’ homes safer, healthier, and more resilient against climate threats.
The Elder Justice Act (EJA) addresses often underreported abuse, neglect, and exploitation of older adults, particularly by funding Adult Protective Services and ombudsman programs for long-term care facilities.78 The Elder Justice Reauthorization and Modernization Act of 2023 would provide $4.5 billion for these services and incorporate new authorities to protect older adults from harm, including a program to address social isolation—a key extreme heat risk factor for older adults.79 Adult Protective Services can help keep older adults safe from extreme heat, including cases of self-neglect in which older adults fail to recognize their risk or take necessary precautions to protect themselves from the dangers of heat. Ombudsman programs funded through the EJA can also help surface heat-related safety hazards for residents of long-term care facilities. The Addressing Social Isolation and Loneliness in Older Adults Act of 2023 would complement the EJA and the OAA and serve as another opportunity to support area agencies on aging or other community-based organizations to conduct outreach to isolated older adults.80
Federal agencies and states should also promote and support efforts to make the aging and disability support infrastructure more green. For example, the DOE could help the country’s aging and disability networks learn about and apply for IRA climate resilience funding for activities that reduce their emissions, including by acquiring clean vehicles for transit fleets or electrifying kitchens used to prepare congregate meals.
Improve coordination among health care systems, public health agencies, and aging and disability networks in addressing climate risks
Given their close connections to community members, health care systems and payers are increasingly turning to aging and disability organizations to assist with meeting the health-related social needs of the communities those health care systems and payers serve, requiring deeper coordination between their organizations.81 The Administration for Community Living’s (ACL) Community Care Hub (CCH) approach helps connect aging and disability networks with health care systems, creating an infrastructure to coordinate and deliver social care services. In 2024, aging and disability networks organized as CCHs received $12 million in new infrastructure and innovation grants to expand service capacity and support health care contracting efforts.82 Technical assistance through these grants could help embed climate into the work of aging and disability networks. Equipping CCHs to identify climate risk factors and signs of heat-related illness and to provide education and guidance on the resources available to stay safe and improve energy efficiency in homes, whether through the health care sector or government programs, can improve the health and safety of older adults during heat emergencies.
The CHRONIC Care Act of 2019 enabled Medicare Advantage plans to expand their supplemental benefit offerings for chronically ill enrollees, including by offering “non-primarily health-related” benefits.83 These benefits can include items such as food to assist chronically ill enrollees in meeting nutritional needs, transportation for nonmedical services, and equipment to improve indoor air quality such as air conditioners. As Medicare Advantage plans pay for air conditioners, aging service providers can encourage or assist older adults in finding out whether their plans offer these new benefits and in following up with their plans about enrollment if offered.
Medicaid contracting provides another opportunity for coordination to address climate risks. Slightly more than half of area agencies on aging contract with a state Medicaid agency to provide services under a state’s Home and Community Based Services (HCBS) waiver and/or with a Medicaid managed care organization that administers the HCBS program for the state.84 As states such as Massachusetts require Medicaid managed care organizations to contract with community-based organizations to provide care coordination and address health-related social needs, those entities should consider contracting with aging and disability networks as community partners in social needs work.85
Ensure health care systems and payers can meet the unique needs of older adults during extreme weather
Health care settings also must be prepared to respond86 to the increased physical and mental health needs of older adults in communities that experience extreme weather events. According to one study, communities across the United States experienced 114 hospital evacuations due to climate-related natural disasters between 2000 and 2017.87 Climate-resilient operations would enable health care settings to continue providing quality care and safe shelter for residents during climate emergencies. These facilities must also understand the impact of climate change on patient health and how they can best meet the health-related social needs of their older patients and other community members as they engage in resilience planning.
Policymakers should amend existing emergency preparedness requirements to require planning for long-term heat and cold emergencies
Nearly 13 percent of people88 use long-term care services at an assisted living facility at some point in their lifetime. Long-term care residents are particularly sensitive to extreme heat due to age and health conditions. Therefore, it is important these facilities have comprehensive emergency preparedness plans that specifically incorporate alternative power sources that can maintain healthy temperatures and remain operational during climate threats and power outages. Only Florida, California, Colorado, and South Dakota require assisted living facilities, which are state-regulated entities, to have an emergency power source.89 Considering the growing risk of climate threats and power disruptions, more states should adopt such regulations.
Only Florida, California, Colorado, and South Dakota require assisted living facilities, which are state-regulated entities, to have an emergency power source.
Additionally, CMS must update its emergency preparedness rule, designed to ensure that CMS-regulated health care facilities plan and coordinate sufficiently for power outages and disasters, to reflect climate-related events that threaten the health and safety of older adults.90 For example, 12 Florida nursing home residents died from heat exposure after air conditioners failed during Hurricane Irma in 2017.91 HHS should adopt the National Advisory Committee on Seniors and Disasters’ recommendation to require that long-term care facilities make plans to maintain adequate temperature control during heat emergencies by having emergency power, especially that which uses renewable energy sources.92
CMS should encourage states to address climate-related health risks using new Medicaid program flexibilities intended to address social factors that affect health outcomes
The White House’s November 2023 “U.S. Playbook to Address Social Determinants of Health” highlighted an increased understanding and reaffirmed the commitment at the federal level to address social factors that affect health outcomes.93 Along with the playbook, CMS released a framework that states can use to support Medicaid beneficiaries’ health-related social needs, including recommendations for ways to structure programs, such as Section 1115 waiver demonstrations, that address housing and nutritional insecurity for enrollees in high-need populations.94 After finding that heat caused more than 100 deaths—most of whom were older adults and low-income individuals—in Oregon during a 2021 heat wave on the West Coast, the state became the first to attempt to mitigate climate-related health threats through its Medicaid program.95 Among the supports, Oregon’s Medicaid program will provide 200,000 beneficiaries with air conditioning units, mini refrigerators for storing medications, and portable power supplies to prepare for extreme heat.96 Since the overwhelming majority of older adults live in traditional housing as opposed to institutionalized settings, these supports are critical.97 In addition to Section 1115 demonstration waivers, state Medicaid programs may be able to address health-related social needs through home- and community-based services provided under Money Follows the Person demonstrations, Medicaid managed care arrangements, and other programs.98
CMS should strengthen oversight and transparency of Medicare Advantage plans and encourage inclusion of supplemental benefits to improve health outcomes for enrollees exposed to extreme heat
Medicare Advantage nonmedical supplemental benefits could be effective in improving the health of chronically ill enrollees. The 2021 West Coast heat wave emphasized how critical climate-related supplemental benefits could be for older adults, and in response, Sen. Ron Wyden (D-OR) urged Medicare Advantage plans to pay for air conditioning units that improve indoor air quality.99 However, limited information is available from Medicare Advantage organizations on supplemental benefit offerings, the uptake of those benefits, and how Medicare Advantage plans promote those benefits to populations most in need.100 The limited information available suggests that supplemental benefits are underutilized.101 In order to better understand whether supplemental benefits are effective and are reaching the populations most in need, CMS must strengthen its oversight of Medicare Advantage plans by requiring more granular data reporting of supplemental benefit offerings, eligibility requirements for those benefits, frequency in uptake among beneficiaries, and spending levels by types of beneficiaries.102 CMS could use this information to guide and encourage Medicare Advantage plans to offer enrollees exposed to extreme heat benefits such as air conditioners, heat pumps, or transportation to cooling centers or other public locations with air conditioning during extreme heat events, which is critical since 18 percent of adults older than age 65 do not drive.103
Articulate and integrate the needs of older adults into climate preparedness and resilience interventions and policy solutions
Many communities are able to access funding through the IRA’s community resilience programs to build community resilience hubs, which are important tools for addressing gaps in climate resilience and emergency preparedness for particularly vulnerable communities.104 These centers also advance climate resilience by providing climate-related education and services, in addition to being a safe haven during extreme weather emergencies. An advantage to community resilience centers as climate tools is that they can be more familiar and culturally inclusive, particularly for marginalized groups, than traditional cooling centers, since year-round they are designed to serve a variety of social and community functions.105
These hubs are critical for older adults who, despite the significant evidence to the contrary, generally do not perceive themselves as being at elevated risk from heat.106 This misperception reduces the likelihood that older adults will take proactive steps to protect themselves from heat threats. Community resilience centers can help fill awareness gaps for older adults and provide resources to help. These hubs can also help improve social and communal ties for older adults, reducing feelings of social isolation and depression and improving health outcomes during climate emergencies. As local leaders—often nonprofits in collaboration with local governments—design community resilience centers, they should ensure that, regardless of the model, the centers’ programming, activities, and education target older adults. Older adults should also be empowered as partners in developing and managing community resilience centers.
In addition to the historic investments through the IRA, policymakers in both the House and Senate have introduced multiple pieces of legislation to prioritize action on heat and its risk on health and safety. Only some of these proposals specifically focus on the needs of older adults. For example, Rep. Bonnie Watson Coleman (D-NJ)’s 2023 Stay Cool Act includes policies to address extreme heat, such as creating new grant programs specifically for protecting seniors during heat emergencies, installing air conditioners in public housing, and increasing the number of community resilience centers and cooling centers.107 The Survival Aid for Emergencies through Medicare Act, introduced by Sen. Edward Markey (D-MA) and Rep. Maxwell Frost (D-FL) in 2023, would help older adults most at risk of harm from extreme heat to pay for home resiliency equipment such as air conditioners, generators, and solar batteries by requiring full coverage through Medicare.108
Legislative solutions designed more broadly to address the adverse consequences of extreme heat may also help some older adults. The Preventing Health Emergencies and Temperature-related Illness and Deaths (HEAT) Act—reintroduced in 2023 by Sens. Markey, Alejandro Padilla (D-CA), and Kyrsten Sinema (D-AZ) in the Senate and by Reps. Suzanne Bonamici (D-OR), Marilyn Strickland (D-WA), and Ruben Gallego (D-AZ) in the House—is one such effort.109 The HEAT Act would establish a $100 million financial assistance program where federal funds can be directed to reduce the health impacts in communities that are more vulnerable to heat or have gaps in heat preparedness. The Weatherization Resilience and Adaptation Program Act, introduced by Rep. Kevin Mullin (D-CA) in 2023, builds on the IRA’s energy efficiency benefits for homeowners by creating a direct assistance program for low-income property owners, including mobile homeowners, to pay for climate-resilience efforts.110 The Excess Urban Heat Mitigation Act of 2023, introduced by Reps. Gallego and Watson Coleman and Sen. Sherrod Brown (D-OH), also builds on IRA investments and would authorize a $240 million grant program over eight years to states and localities to combat the effects of heat islands in urban areas—for example by expanding cooling centers, tree planting, cool roofs, green spaces, and heat education efforts.111 Federal legislators should work to pass these bills as critical steps to mitigating the threat extreme heat poses to all communities, but especially to older adults.
Accelerate efforts to reduce emissions and pollution through greater clean energy use, including increased uptick of the Biden-Harris administration’s climate investments
The Biden-Harris administration is making historic investments and important strides in reducing emissions and moving toward a clean energy economy through policies such as the IRA and the Infrastructure Investment and Jobs Act (IIJA) of 2021.112 IRA investments are already lowering household energy costs, reducing pollution, and protecting communities from the impacts of extreme heat.113 These policies have implications for energy insecure older adults and others who experience racial and income disparities in heat exposure and response.
Read more
Prioritize older adults in efforts to create energy-efficient homes and communities
Older adults are among the populations with the most to gain from opportunities to improve home energy efficiency. Implementing the administration’s climate policies in ways that reach older adults and others most vulnerable in their homes and communities is critical to achieving the ambitious action needed to avoid major climate damage by 2030.
CAP has catalogued many available opportunities to improve home energy efficiency and to prepare for increased heat and other climate-related extreme weather.114 For instance, the IRA offers rebates for making homes more energy efficient; according to the DOE’s modeling, those rebates are projected to save Americans $27 billion to $38 billion on home electricity bills between 2022 and 2030.115 The IRA-supported Home Electrification and Appliance Rebates through the DOE and the Green and Resilient Retrofit Program through the U.S. Department of Housing and Urban Development are just some of these opportunities.116 These investments complement other IIJA-funded programs, such as the DOE’s Weatherization Assistance Program and the Low Income Home Energy Assistance Program (LIHEAP), which assist low-income renters and homeowners with energy costs, repairs, and energy efficiency upgrades.117 LIHEAP cooling programs may be helpful for energy bills as well as installing and repairing air conditioners; however, only 26 states, the District of Columbia, and three territories have LIHEAP cooling programs.118 The American Rescue Plan Act of 2021 more than doubled the usual appropriations for LIHEAP, but Congress subsequently failed to include the program’s supplemental funding of $2 billion in 2023, essentially cutting the program from $6.1 billion in fiscal year 2023 to $4.1 billion in fiscal year 2024.119 States are expected to launch new home energy rebate programs in 2024 that are supported through the IRA. The DOE estimates these rebates will save households up to $1 billion annually in energy bills.120
The IRA also supports communities in reducing heat-related illness and energy costs and improving air quality by eradicating urban heat islands.121 For example, the U.S. Department of Agriculture’s Urban and Community Forestry Assistance Program awards grants to plant trees and to expand green spaces in cities in order to mitigate extreme heat and climate change.122 These investments all fall within the Biden-Harris administration’s Justice40 Initiative, intended to address the legacy of environmental, economic, and racial injustice and institutionalized residential segregation.123
To maximize the impact of these investments, federal, state, and local governments must establish ways to encourage efforts that reduce emissions; improve awareness about federal opportunities in the form of grants, tax credits, and other incentives; and provide technical assistance so that older individuals, service providers, and governments can access resources. As they roll out these programs, the departments of Energy, Housing and Urban Development, and Agriculture as well as other agencies should coordinate with the Administration for Community Living to develop strategies to inform and assist older adults in accessing resources. One concrete opportunity would be for the DOE to join ACL’s Interagency Coordinating Committee (ICC) on Healthy Aging and Age-Friendly Communities.124
Require health care providers, including long-term facilities where a subset of older adults reside, to aggressively reduce energy use and emissions
The health care sector is responsible for significant greenhouse gas (GHG) emissions, with the majority of GHG emissions stemming from indirect emissions, such as through the supply chain.125 Hospitals rank as the second most energy-intensive building types in the United States and regularly emit pollution that compromises public health.126 The consequences of the pollution hospitals emit are most problematic for populations that face an inequitable impact of extreme heat, such as older adults.127 Hospitals feel these consequences: According to preliminary results of a Congressional Budget Office analysis, a day above 95 degrees, compared with a 60- to 65-degree day, results in an average 3 percent increase in emergency department visits and a 6 percent increase in deaths among Medicare beneficiaries.128 With the impact on beneficiaries in mind, HHS must use its authorities and levers to reduce the health care system’s contribution to climate change.129
According to preliminary results of a Congressional Budget Office analysis, a day above 95 degrees, compared with a 60- to 65-degree day, results in an average 3 percent increase in emergency department visits and a 6 percent in deaths among Medicare beneficiaries.
In 2023, OCCHE created a resource hub with information on federal resources that hospitals can use to become more energy efficient.130 These resources encourage health systems to leverage IRA tax credits, and OCCHE provides technical assistance—for example, through webinars and programs such as the Catalytic Program—to help health care organizations reduce emissions.131 Congress has not appropriated funding to OCCHE, leaving OCCHE dependent on temporary staff and unable to expand its capacity to coordinate climate actions, harness and develop additional resources, and leverage authorities to address environmental health hazards and support health systems in reducing emissions.132
CMS’ fiscal year 2025 Hospital Inpatient Prospective Payment System rule helpfully included the Decarbonization and Resilience Initiative to promote hospital reporting of greenhouse gas emissions.133 Participation, however, is voluntary. CMS should fully leverage this rule, along with its Hospital Inpatient Quality Reporting Program, to require health care organizations to calculate and report emissions through standardized metrics and transparent disclosure.134 CMS could also explore ways to incorporate emissions reduction into conditions of participation for all payment models.135 Additionally, CMS should act on the National Advisory Committee on Seniors and Disasters’ recommendation to require participating long-term care facilities to have plans to incorporate renewable energy by 2030.136
See also
Conclusion
As extreme heat continues to worsen, policymakers must work to mitigate harms to older adults. These efforts must consider older adults’ unique health conditions, needs, and social conditions—such as energy insecurity, housing quality issues, and social isolation—which elevate their risk of poor health outcomes. Policymakers and community leaders at all levels should use the many levers at their disposal to ensure that efforts intended to reduce emissions, strengthen community resilience to heat, and address energy insecurity are intentionally designed to serve older adults. At the same time, aging policies and programs and climate and resiliency efforts should be better integrated, and aging and disability networks should be better supported and leveraged to address climate risks. Policymakers must also reauthorize and set aside more money for the Older Americans Act and the Elder Justice Act, develop heat preparedness strategies that prioritize older adults, and require health care systems and payers to promote policies that address climate risks.
Acknowledgments
The authors would like to thank the external aging, climate, and health experts who contributed their expertise to this report, along with Casey Doherty, Andrea Ducas, Emily Gee, William Roberts, Kate Petosa, and Jasia Smith for their insights and feedback. The authors would also like to thank Christian Weller for data analysis and Claire Koyle for her thorough fact-checking and support throughout this report’s development.
Methodology
In a study released in 2023, researchers at Virginia Commonwealth University demonstrated that visits to the emergency room or hospital were significantly higher on heat event days than other summer days.137 The analysis was conducted at the level of ZIP Code Tabulation Areas (ZCTAs). In 2024, the researchers completed a follow-up study, the results of which they shared with CAP, to determine the degree to which characteristics of the local population in each ZCTA increased or decreased the risk of emergency department or hospital visits. The study covered the entire state of Virginia for the summers of 2016 to 2020. Data on emergency room visits and hospitalizations came from the Virginia All-Payer Claims Database (APCD). Heat event days were determined by applying the Spatial Synoptic Classification method to meteorological data collected from 15 weather stations that serve the state of Virginia.
Data on the community characteristics of each ZCTA came from the U.S. Census Bureau or APCD and included population density and the percentage of residents who were: 1) younger than age 5, 2) age 65 and above, 3) who were Black but non-Hispanic, 4) who were Hispanic, 5) who had less than a high school education, 6) whose income was less than twice the federal poverty threshold, 7) who worked outdoors, 8) who had a disability, and 9) who were on Medicaid. The Charlson Comorbidity Index, a measure of the prevalence of chronic illnesses, was also obtained for each ZCTA.
The researchers then calculated the degree to which each of these characteristics influenced the risk of emergency room visits or hospitalizations on heat event days. They adjusted for these characteristics by using an advanced statistical technique called multiple mixed-effect Poisson regression and the results were reported as relative risks. In most cases, the relative risks estimated the effect of a 10 percent increase in the prevalence of the characteristic. For example, they showed that a 10 percent increase in the proportion of residents age 65 and above resulted in a 23 percent increase in emergency department visits. The relative risk for population density referred to a 25 point increase in density, and that for the Charlson Comorbidity Index referred to a 0.5 point increase in the index.