Introduction and summary

Top medical journals have described the climate crisis as the “greatest threat” to global public health.1 Its impacts include respiratory and allergy-related illnesses; heart disease and cancer; mental health complications; food-, insect-, and water-borne diseases; and death and disability resulting from extreme weather events.2 Cases of illness and death from climate-related threats are rising,3 and these threats’ disproportionate impacts on the﷟ most vulnerable populations in society4—including children, older adults, disabled people, low-income communities, and people of color—are expected to worsen in the coming years.5

Mitigating climate-related health threats will require intentional investments that promote health and equity while addressing the climate crisis, including the health care system’s contribution to the climate crisis. Implementation of the Infrastructure Investment and Jobs Act (IIJA),6 the Inflation Reduction Act,7 and the CHIPS and Science Act dedicate billions of dollars toward climate and infrastructure and thus have the potential to shape the conditions that influence health and well-being.8 Expertise at the intersection of health and the environment, as well as coordination across traditionally siloed agencies, helps ensure that these investments truly advance health and equity.9

In 2021, as part of a coordinated, interagency, whole-of-government approach to addressing the climate crisis,10 the Biden administration established the Office of Climate Change and Health Equity (OCCHE)11 within the U.S. Department of Health and Human Services (HHS). OCCHE coordinates efforts across HHS departments in responding to the numerous health threats of climate change and advancing environmental justice.12 To date, however, lack of congressional funding and authorization has left the office without any full-time staff or support to carry out its critical and life-saving work.13 Indeed, although President Joe Biden included $3 million for OCCHE in his fiscal year 2023 budget request,14 Congress did not include the allocation in the final budget, leaving OCCHE unable to hire staff and jeopardizing its ability to protect health, address health disparities that lead to the disproportionate impacts of the climate crisis, and improve the sustainability and resilience of the health care system.

This report describes why OCCHE and its newly established Office of Environmental Justice15 are critical to mitigating the health threats of climate change. With appropriate staffing and authority, the offices should lead efforts to: 1) prioritize health in the federal response to the climate crisis; 2) ensure that HHS maximizes its opportunities to address the climate crisis; and 3) improve coordination to capitalize on knowledge, expertise, and strengths across the federal government. The report acknowledges the initial steps that OCCHE has taken toward its goals and outlines four priority areas of focus for it moving forward:

  1. Strengthen holistic resiliency and response efforts within the health care and public health sectors.
  2. Align strategies, resources, and levers to support the health care sector in decarbonizing.
  3. Orchestrate and support efforts to close information gaps, synthesize data, and identify practical applications of information.
  4. Coordinate efforts to develop communication and education on climate-related health threats.

Finally, the report highlights the urgency of permanently authorizing OCCHE and providing it the dedicated funding and staff to achieve its goals.

OCCHE can advance climate goals

OCCHE must provide the connective tissue necessary to harness resources, leverage authorities, and coordinate expertise across HHS and the federal government to protect the public from the health and environmental justice impacts of the climate crisis.

Background on OCCHE

OCCHE was established on August 31, 2021, within the Office of the Assistant Secretary for Health. With no full-time staff, OCCHE relies on HHS employees who are temporarily assigned to the office. It currently provides leadership to working groups and subcommittees both within HHS and across the federal government, such as the Extreme Heat Interagency Working Group and the HHS Climate and Health Equity Working Group. Through partnerships across the federal government, with other countries, and with the health care sector, the office has compiled resources for the health care sector to improve resiliency and reduce emissions; used forecasting data to demonstrate the risk of climate to health; and established the Office of Environmental Justice, which supported the development of the Environmental Justice Index to identify communities at greatest risk.16

OCCHE must ensure that the all-of-government response to climate change prioritizes health

Climate change affects the social and environmental determinants of health, and its physical and mental health effects vary based on vulnerability.17 It exacerbates health disparities, as the communities that face health inequities are often also those most vulnerable to climate and environmental hazards.18 For example, wildfires fueled by severe heat and drought worsen air quality and exacerbate respiratory diseases, such as asthma and chronic obstructive pulmonary disease, which disproportionately affect communities of color that are already more likely to be exposed to air quality worsened by pollution.19

HHS must work to safeguard the public from the health impacts of climate change and reduce the health disparities that are exacerbated by it.

Health care providers are on the front line in responding to the injuries and illnesses brought on by climate change, from heat-related emergency department visits;20 to extreme weather events such as flooding and tornados that have physical and mental health consequences;21 to infectious diseases caused by food, water, and disease-carrying insects and rodents.22 The health care system, then, must lead the response to and mitigation of climate change. Every federal government agency must implement climate-saving measures. Therefore, as the primary agency responsible for public health, human services, and health care, HHS must work to safeguard the public23 from the health impacts of climate change and reduce the health disparities24 that are exacerbated by it.25 OCCHE can lay the groundwork for HHS to take charge of the response in the health sector.

OCCHE must provide critical leadership, coordination, and expertise to coordinate a response to climate change across HHS agencies

The Office of Climate Change and Health Equity should work to ensure that HHS uses its authorities and levers to respond to and mitigate the impacts of climate change on health and health equity. HHS agencies and operating divisions can support health care providers in identifying climate risks and protecting their patients and vulnerable communities; investing in infrastructure to protect communities from harm; reducing the disease burden of health care pollution; conducting research to add to the body of knowledge on the interactions between climate and health; and providing messaging, communications, and technical assistance.26 While a variety of actions may be taking place within HHS, there has been no central coordinating office tasked with connecting and supporting them.27 OCCHE should step formally into this role, identifying a list of priority actions and bringing a coherent vision to the department’s approach by coordinating efforts to address the effects of climate change on health.

As part of OCCHE’s charge to coordinate a response across HHS agencies, it should monitor and support the agencies in meeting the goals outlined in the HHS 2021 Climate Action Plan28—and ensure that the department and its programs are considering the use of all available policy levers, including those related to regulation, purchasing, contracting, grant-making, convening, education, and research. OCCHE should also identify a priority list of mechanisms to respond to and mitigate climate change-related threats within various programs. These mechanisms should be regulatory rather than legislative to ensure they are actionable, timely, and impactful. For example, with the rise in climate-related health emergencies, health care providers are increasingly using diesel for emergency power in compliance with the U.S. Centers for Medicare and Medicaid Services’ (CMS’) 2016 fire and emergency power supply rules.29 Diesel, however, has significant impacts on human health and the environment.30 Updated guidance should allow for cleaner and more climate-resilient generators and renewable energy microgrids, which are self-sufficient power grids that service a limited geographic area, such as a university or hospital campus, and can work in tandem with or independently from a central power grid.31

OCCHE, especially through its Office of Environmental Justice, should hold HHS accountable for the ways in which it is responsible for making sure all its programs prioritize approaches that address the disproportionate health impacts of climate change. In doing this, OCCHE can further the agency’s goal of building capacity to address equity in its programs,32 possibly using assessment tools such as the forthcoming Environmental Justice Scorecard,33 outlined in the HHS Equity Action Plan.

OCCHE’s leadership of the Climate Change and Health Equity Working Group,34 which includes most HHS divisions, and collaboration with federal health systems providers through the Federal Health System Learning Network, demonstrate that there are opportunities to coordinate efforts.35

OCCHE must leverage and coordinate expertise and resources across the federal government

Although there are resources and expertise across the federal government that could be leveraged to address the health impacts of climate change, they are not well known or understood within the health care sector. OCCHE is best equipped to foster the necessary interagency coordination to maximize resources and support the health care industry.

HHS agencies have limited climate expertise and lack the bandwidth or knowledge to integrate climate action into their work.36 They are simply not aware of, or staffed to use, some available policy levers. For example, while the Inflation Reduction Act provides decarbonization funding for health care providers, HHS is not among the 16 federal departments and agencies that receive direct appropriations for decarbonization and is therefore not currently well positioned to support providers. And despite the disproportionate impact of climate-related health threats on disadvantaged communities, only 13 HHS programs are covered under the Justice40 Initiative, which ensures these communities receive the benefits of new and existing federal investments in climate and environmental justice.37 Meanwhile, communities may not be tapping the expertise of health professionals to inform climate-related investments.

OCCHE is poised to capitalize on the knowledge, expertise, and strengths across the federal government, building the connective tissue needed to support alignment, coordination, and integration among agencies.38 Through this coordination, OCCHE could support the health care industry in efforts to prepare for and reduce the impact of climate change on health—for example, by ensuring providers are aware of federal funding for decarbonization. OCCHE’s coordination and leadership of the Interagency Working Group on Extreme Heat, along with the National Oceanic and Atmospheric Administration (NOAA) and the U.S. Environmental Protection Agency (EPA), serve as a model for additional climate and health interagency coordination, if funded.39

OCCHE should focus on four priority areas

There are four priority areas in which OCCHE should support federal agencies to prepare for and respond to the health implications of climate change. This section offers initial actions based on resource constraints, but with additional resources, OCCHE’s role could be expanded.

1. Strengthen holistic resiliency and response efforts within the health care and public health sectors

The increasing threat of severe weather events, often as a result of climate change, puts patients and health providers at increasing risk of disruption of services.40 These events can halt normal care operations by disrupting power or water supplies, preventing timely delivery of medical supplies, or forcing closure or evacuation of care sites, as well as increase the need for health services as affected communities suffer physically and mentally. Given health providers’ critical role in recovery, they must prepare for climate threats by building resilient and adaptable systems. For example, hospitals should identify vulnerabilities where their supply chain could be disrupted by a climate emergency and develop contingency plans to ensure key supplies remain available for patient care, whether by stockpiling, resource sharing, or seeking out alternative suppliers. Public health agencies responsible for protecting population health and reducing illness are also vital to ensuring communities are able to adapt to the adverse impacts of climate change. During a climate emergency, they must be able to monitor food and water safety, coordinate mental health resources, ensure air quality, monitor and control infectious disease outbreaks, and provide education to communities on how to stay safe and healthy.

Given health providers’ critical role in recovery, they must prepare for climate threats by building resilient and adaptable systems.

Coordinating across HHS operating divisions, OCCHE can develop holistic, community-based resiliency and recovery strategies that incorporate the health care, public health, and social services sectors. The U.S. Centers for Disease Control and Prevention’s (CDC’s) Climate and Health Program and the Administration for Strategic Preparedness and Response’s (ASPR’s) Hospital Preparedness Program and Regional Disaster Health Response System Pilot are successful federal initiatives that encourage local collaboration.41 OCCHE can align and maximize these opportunities and build collaboratives where health systems, public health agencies, community-based organizations, and environmental justice advocates work together to identify strategies that build resilient communities, similar to the EPA’s Environmental Justice Collaborative Problem-Solving Cooperative Agreement Program.42 OCCHE’s ability to facilitate collaboration is well evidenced by its leadership43 of the Climate Change and Health Equity Working Group, through which it provided input into HHS’s 2021 Climate Action Plan.44

In alignment with efforts to expand data and evidence, OCCHE should coordinate with HHS agencies—such as the Agency for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), and others—to develop evaluation tools for health care providers and public health agencies to assess progress in preparing for climate threats. These tools could aid in establishing benchmarks of preparedness and assessments that determine gaps in adaptation implementation. During an emergency, affected communities need reliable strategies that protect health, such as hospitals performing efficient credentialing of visiting emergency health care personnel to quickly ramp up capacity or public health agencies deploying interventions that reduce the risk of disease from compromised water sources. Benchmarking and assessments can help identify the concrete steps needed to ensure preparedness. OCCHE can then support health providers and public health agencies by providing informed guidance and coordinating technical assistance efforts on the implementation of effective resiliency and adaptation strategies. OCCHE should also explore the levers available within HHS to incentivize and motivate adaptation planning and implementation. For example, OCCHE could work with CMS to include resiliency planning in emergency preparedness requirements for participating Medicare and Medicaid providers.45

OCCHE also has a critical role to play in ensuring accessibility to resources needed to build systems that can withstand health threats. OCCHE should coordinate existing funding opportunities available across the federal government that health care providers, public health agencies, and community-based organizations, particularly those serving marginalized and disproportionately affected communities, can utilize to advance resiliency and adaptation strategies. OCCHE has already compiled a list of federal resources,46 but with more funding, it could help align these opportunities with technical assistance programs. For example, quality improvement organizations (QIO), which are charged with improving health care quality for Medicare beneficiaries whose health is disproportionately harmed by climate change,47 could help providers build climate resiliency.48 QIOs already support a variety of health care facility types in meeting complex Medicare standards and conditions and are well suited to incorporate climate resiliency and emissions reduction.

2. Align strategies, resources, and levers to support the health care sector in decarbonizing

The United States leads the world in health care greenhouse gas emissions, making up roughly 27 percent49 of the global health care footprint. This resulted in an estimated 388,000 disability-adjusted life years lost from pollution-related disease in 2016.50 As the health care system focuses on resiliency and response to climate-related health issues, it must take actionable steps to minimize its own contribution to climate change. Such action would improve health, support the resiliency of health care systems51 by minimizing disruptions that result from natural disasters, and provide economic benefits such as cost savings for health care systems.52 For example, hospital microgrids store and utilize renewable energy sources to power facilities, making them more cost-efficient and climate-friendly while also ensuring reliability during climate events as they can operate in the event of central grid failure.53

As the health care system focuses on resiliency and response to climate-related health issues, it must take actionable steps to minimize its own contribution to climate change.

While the health care sector’s interest and progress in reducing greenhouse gases is increasing, the need for a coordinated national effort remains. In 2022, more than 100 health care organizations,54 representing more than 15 percent of U.S. hospitals, signed the voluntary White House/HHS Health Sector Climate Pledge to reduce greenhouse gas emissions by 50 percent by 2030 and President Biden’s goal of net-zero carbon emissions by 2050.55 Although this is a positive first step, only 19 of the 50 largest health care systems have set emission reduction targets so far,56 evidence that a voluntary approach alone will not achieve the goal and that a roadmap is unclear.57 There is no method to measure benchmark performance, eliminate greenwashing,58 and hold the more than 6,000 hospitals59 in the United States accountable.

Funding for OCCHE would support meaningful action to coordinate strategies across the federal government to reduce health care carbon emissions, including providing guidance, identifying opportunities and incentives, and evaluating the cost savings potential of carbon reduction initiatives. As noted in a House Ways and Means Committee report, health care providers may lack the expertise and resources to prioritize climate goals and may need assistance in “deciphering and aggregating the many existing grants and tax credits available to support their work in this space.” The report also notes that the federal government should act “as a convener, a developer, and a guide.”60 For instance, OCCHE should draw on the expertise and resources available through federal partners to educate and provide assistance to nonprofit health care providers, including community health centers and rural hospitals, so that they understand and can tap into incentives available through the Inflation Reduction Act61 to make investments to advance the decarbonization and resilience of the health sector, particularly in communities that shoulder a disproportionate pollution burden.62

As the health care delivery sector lags behind other U.S. economic sectors in calculating and publicly disclosing greenhouse gas pollution,63 the federal government should require the sector to publicly report the sustainability activities it undertakes, using available environmental, social, and governance tools.64 It should require all health care organizations to engage in both carbon reporting through standardized metrics and transparent disclosure65 in order to benchmark and measure progress, develop best practices, and ensure accountability.66 These requirements should be incorporated into existing reporting systems such as the Hospital Inpatient Quality Reporting Program.67 HHS can tap into available resources such as the EPA Energy Star certification68 and the Greenhouse Gas Protocol’s international measurement standards to inform its reporting requirements,69 and OCCHE can partner with QIOs70 or the EPA to help health care systems with reporting and provide technical assistance to improve energy performance.71

With adequate funding, OCCHE could also house a national reporting database for health care sector emissions, which leaders in the field recommend.72 According to some leading health care experts, ultimately HHS should use policy levers such as value-based purchasing, procurement guidelines, pay-for-performance programs, quality measures programs, and facility accreditation to standardize metrics and require emissions reporting to encourage health care providers to reduce their carbon emissions.73

3. Orchestrate and support efforts to close information gaps, synthesize data, and identify practical applications of information

There is substantial evidence available to demonstrate how climate change affects a range of factors that have negative impacts on health, particularly for communities of color. Data relevant to addressing the health impacts of climate change exist within many federal agencies, including the EPA,74 the CDC,75 the NIH,76 and other climate data science programs and state-level tools.77 OCCHE draws on these data—along with data from AHRQ, NOAA, and the Federal Emergency Management Agency (FEMA)—to issue a Climate and Health Outlook series that provides prospective and retrospective analyses and resources.78 However, information gaps exist, and data syntheses are needed for practical application, particularly to identify effective and equitable adaptation and response strategies.79

Gaps exist in understanding the impact of climate change on health care providers and payors, as well as practical ways to prepare for challenges in providing care;80 climate resilience analyses and scenario modeling for vulnerable households; health care sustainability research;81 and the impact of multiple climate hazards on local environmental health disparities, including new and emerging threats. Other gaps exist in areas including building the evidence base for climate mitigation strategies and predicting their impacts on health; identifying best practices for health care decision-makers on the effectiveness of interventions; effective health-based climate communication; and strategies for moving toward a climate-ready health care system.

OCCHE is well equipped to organize and systematize climate and health system data to ensure it is available and transparent so that researchers can use it to fill gaps and local stakeholders and policymakers can use it to inform education and policy initiatives.

Currently, no aligned federal agenda exists to synthesize available climate and health data, identify gaps in the evidence needed to inform practical application, and ensure data are used to inform health policy and program delivery. OCCHE is well equipped to organize and systematize climate and health system data82 to ensure it is available and transparent so that researchers can use it to fill gaps and local stakeholders and policymakers can use it to inform education and policy initiatives.83 OCCHE could identify data needed to update guidance and regulations critical to prepare for, respond to, and recover from climate threats and extreme weather as well as to integrate environmental justice and equity.

4. Coordinate efforts to develop communication and education on climate-related health threats

Although climate science evidence shows that climate change has significant negative impacts on health, environmental justice and health advocates—as well as the general public—need actionable information that translates climate data to convey tangible health impacts. As a leading source of health information, HHS must disseminate information on the connections between climate change, health, and equity to policymakers, providers, and the public. It must signal that it prioritizes climate change and health equity and share information needed to prepare for and respond to climate change-related health threats. OCCHE is well positioned to break down silos of information and resources and coordinate efforts to develop climate and health communication efforts and information resources across the federal government.

The very real health impacts that climate has on everyday life are powerful messages for the public.84 The federal government has made strides in incorporating social determinants of health—factors such as housing, education, employment, and food access—across its programs by considering the impacts that they have on health and equity.85 Climate and environmental factors should also be understood as social determinants of health. OCCHE is already providing information to consumers to help them make healthy decisions,86 so it is a natural fit to convey real-time community health risks of climate events and encourage Americans to protect themselves.

OCCHE should also coordinate actions within HHS programs—such as Health Resources and Service Administration Title VII and Title VIII Programs that train, educate, and support health care professionals, public health practitioners, and health researchers—to ensure they are prepared to investigate, prepare for, and respond to the health impacts of climate change, including surge capacity during natural disasters.87 HHS must work to link climate change to clinical outcomes: Programs could, for instance, include climate and environmental risks in health care screenings for social determinants of health to inform medical decisions and enable providers to deliver higher quality care, particularly in vulnerable communities and health settings. OCCHE also can coordinate with CMS, the U.S. Department of Labor, FEMA, and states to train, support, and protect community first responders.88

Building on its initial efforts to educate providers through webinars and other resources, OCCHE can ensure that climate and health messages are relevant for HHS stakeholders and ensure that HHS agencies are supporting and communicating with the providers and grantees in their networks to educate them on the health harms and inequities associated with climate change. OCCHE could provide information to ensure that health professionals are aware of opportunities to work with community partners to inform IIJA spending on infrastructure investments that support health and equity.89

Conclusion

The changing climate is having grave health consequences for the American public and a disproportionate impact on vulnerable communities. HHS has an essential role to play in protecting the country’s health, and the Office of Climate Change and Health Equity can fill a critical gap of leveraging and coordinating resources within HHS and across the federal government to address climate-related health threats. OCCHE must hold HHS accountable for taking meaningful action and message how urgent it is for HHS and the health sector to build climate resilience and reduce their carbon footprints.90

Acknowledgments

The authors would like to thank the many climate and health scientists and experts, advocates, and current and former federal officials, along with Center for American Progress colleagues, who provided input that informed this report.

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