There has been growing attention on the failure of key markets to keep pace with climate change, including the housing, insurance, and utilities markets, and the dire consequences for communities across the country. The healthcare market, however, has received less attention. 

While significant progress has been made over the past two decades in expanding healthcare insurance coverage through the Affordable Care Act, Medicaid expansion, and Medicare enhancements made through the Inflation Reduction Act, the service delivery system is in a state of crisis in many parts of the country. There are a multitude of reasons for this, ranging from an aging workforce, burnout from the COVID-19 pandemic, the criminalization of care (e.g., abortion and transgender care bans), and insufficient insurance reimbursement rates paired with a growing population of people living with significant physical and mental health challenges. This has been exacerbated by a growing trend in hospital and practice consolidations and closures, largely by profit-driven corporate buyouts and private equity acquisitions.¹ The result is that access to healthcare services is being constrained in a way that limits community resilience to climate change.

The effects of climate change and climate disasters on health are well-documented. Extreme heat, for example, increases the risks arising from cardiovascular disease, obesity, and diabetes, and jeopardizes maternal health, leading to a greater likelihood of preterm births and low birth weight. Babies born prematurely face a higher risk of lung problems, including asthma. The aftermath of floods can expose residents to pollutants and pathogens. Wildfires and poor air quality pose significant threats to those living with asthma and other respiratory conditions. Climate change increases the prevalence of infectious diseases and vector-borne illnesses, and the multiple stressors brought about by climate change affect mental health, causing anxiety, depression, and other behavioral health challenges.²

To foster climate resilience, particularly among Black, Indigenous, and People of Color (BIPOC) communities that frequently experience higher rates of chronic and other health conditions,³ ensuring reliable access to healthcare services to manage and treat these kinds of pre-existing conditions is critical to mitigate the impacts of climate-related disasters and events. Yet, as residents of communities in the Southeast and Appalachia ravaged by Hurricanes Helene and Milton can attest, and as is discussed below, the healthcare markets in many of these communities have been decimated in recent years.

Limited Access to Healthcare in the Face of Climate Change

Access to healthcare services is largely dependent upon two factors: affordability and availability.

Rising healthcare costs present formidable barriers to those without health insurance. Those without employer-based coverage and lacking the means to pay for Affordable Care Act premiums (ACA, immigrants unable to access coverage through the ACA, and some low-income individuals living in states that have not yet expanded Medicaid are forced to forego needed healthcare services because of the extraordinary costs of care. That means that they are unable to receive treatment for chronic and other health conditions that increase their vulnerability to extreme climate conditions and climate disasters.  

The Affordable Care Act, enacted in 2010, dramatically reduced uninsured rates and limited out-of-pocket healthcare costs across the U.S. In 2010, prior to passage of the ACA, 16 percent of the U.S. population was uninsured. The ACA provided premium assistance to low- and middle-income households with incomes up to 400 percent of the Federal Poverty Level to make healthcare insurance more affordable. The American Rescue Plan, passed during the COVID-19 pandemic, removed the cap on premium subsidy assistance and expanded ACA subsidies for two years. The Inflation Reduction Act of 2022 (IRA) extended these enhanced subsidies through 2025. As a result, the uninsured rate fell to just over 7 percent in the U.S. in 2023.⁴  However, about 50 percent of undocumented immigrants and 18 percent of immigrants with legal status remain uninsured because they are excluded from the benefits of the legislation.⁵ 

In addition, 10 states have yet to expand Medicaid to those with incomes up to 138 percent of the Federal Poverty Level, equivalent to about $43,000 for a family of four. These states are Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. If Medicaid were to be expanded in these states, an estimated 2.3 million people would benefit, including BIPOC and young people who are more likely to be uninsured. In 2022, the uninsured rate for low-income, non-elderly people in non-Medicaid expansion states was twice (30 percent) what it was in those states that have expanded Medicaid (15 percent).⁶ 

The second component of healthcare access is provider availability. Provider shortages across the country are a growing problem. According to the Association of American Medical Colleges, a shortage of 86,000 physicians is expected in the U.S. by 2036, based on current healthcare utilization rates. That figure, however, does not include currently underserved communities. If these communities, many of which are in rural and low-income communities, are taken into account, the anticipated provider shortage increases to over 200,000 physicians. Moreover, 15 million Americans live in “Medically Underserved Areas” with a shortage of primary care providers, and there are nearly 7,500 “Primary Care Health Professional Shortage Areas” in the U.S. in need of approximately 13,000 primary care providers. An estimated 80 percent of counties across the country lack an infectious disease specialist, a particular need with growing concerns about higher transmission rates brought about by climate change, and over 30% of Black Americans live in a “cardiology desert.”⁷ 

Anti-immigrant discrimination is also now limiting access. Although the vast majority of hospitals are required to provide emergency services to everyone, regardless of legal status or ability to pay, Florida and Texas recently passed laws requiring hospitals in those states to ask patients seeking care about their immigration status.⁸ While not a denial of legally-required care, such policies clearly have a chilling effect on immigrants specifically and People of Color more generally who are in need of emergency medical care.

A third growing trend affecting provider availability is a pattern of consolidation within the healthcare industry. Consolidation and mergers have been accelerating over the past 30 years. Between 1998 and 2017, there were a total of 1,573 hospital mergers, followed by another 428 hospital and health system mergers between 2018 and 2023. Mergers, which affect both for-profit and non-profit providers, can be “vertical” – for example, where a hospital buys out multiple physician practices – or “horizontal,” where a healthcare system or group of providers buys other hospitals or practices across various geographic regions. According to 2021 data, three-quarters of all hospitals and half of all physicians across the country are now part of only 635 health organizations.⁹

Attention is now focusing on the role of large corporations, including CVS, Walgreens, United Health, and Walmart, and private equity firms that have entered into the healthcare market. Physician practices acquired by private equity firms increased from 816 in 2012 to 5,779 in 2021. In some areas, private equity-owned practices accounted for more than 50 percent of market share. Notably, when losses accrue to these large, investor-driven ventures, closures are sure to follow, as has been the case in recent months. Walgreens, for example, is closing over 160 primary care clinics it had acquired, and Walmart is shutting down 51 health clinics in five states.¹⁰ 

The result of all of these trends is a diminishing availability of healthcare services, particularly in rural areas. More than 100 rural hospitals have closed over the past decade. Over 30 percent of the country’s rural hospitals are currently at risk of closure, with about half of these described as being at immediate risk of closure. In addition to a growing risk of closures, some rural hospitals seek “conversion” to a Rural Emergency Hospital designation, which allows for enhanced Medicare payments that enable some rural hospitals to keep their doors open by eliminating inpatient services and only providing emergency and some outpatient treatment. Perhaps not coincidentally, the majority of closures have been in non-Medicaid expansion states.¹¹ Apart from closures and conversions, communities are confronting the loss of some services. For example, operating rooms may close. Maternal health services are being dropped in many areas, which is a particular concern considering the effects of maternal health on birth outcomes. Some areas have lost inpatient pediatric services.¹² 

In the communities across the Southeast and Appalachia hard-hit by Hurricanes Helene and Milton, all of these accessibility concerns are stark. As this map shows, there are very few counties along the path of the hurricane that are not entirely designated as Primary Care Health Professional Shortage Areas. As a whole, the region lacks sufficient access to the preventive healthcare services that foster climate resilience. The region has also been at the forefront of rural hospital closures and conversions, as shown here. Simultaneously, many communities in the affected region live in a “maternal care desert,” putting pregnant women and children at greater risk from the health effects of climate change. Meanwhile, the region has some of the poorest health outcomes in the country.

What Is Being Done 

Re-envisioning healthcare as a critical public good upon which lives depend rather than a profit-generating marketplace is a necessary first step to increase climate resilience. Medicare for All, of course, would transform the healthcare market by creating a public single-payer system providing healthcare coverage for everyone. 

In the absence of this kind of transformative action, other legislative proposals aim to address physician shortages to improve healthcare access. The Green New Deal for Health would invest $130 billion in non-profit Federally Qualified Health Centers (also known as community health centers) that provide primary healthcare services to predominantly low-income and BIPOC patients. It also would take steps to prevent healthcare deserts resulting from closures and support workforce development. Proposals to increase investment in Graduate Medical Education (GME) are also being put forward to expand the primary care workforce.¹³ 

At both the state and federal levels, actions are also being taken to reign in profit-driven

healthcare consolidation. At the state level, the Massachusetts State Senate passed a bill increasing oversight on private equity-related healthcare deals, although the legislation was not enacted during the last session. In California, the state legislature passed AB 3129, which required notice and/or approval of private-equity funded healthcare acquisitions by the state Attorney General, but the bill was vetoed by Governor Gavin Newsom earlier this month. Increasing the anti-trust enforcement authority of state Attorneys General is another pathway to undercutting this trend. Legislative proposals at the federal level include the Health Over Wealth Act, which would increase oversight of private equity-owned healthcare facilities, require that they maintain five-reserve to fund patient care in the event of a closure or reduction in service availability, and authorize enforcement actions against companies that create barriers to care. Finally, the Federal Trade Commission, U.S. Department of Justice, and U.S. Department of Health and Human Services launched an investigation earlier this year into the effects of increasing private equity and corporate control in healthcare.¹⁴ 

Conclusion

To increase climate resilience, particularly in frontline and rural communities, the various aspects of market failure in the healthcare industry must be addressed. Lives of millions of Americans are increasingly at risk, not only because of the multiple factors that contribute to poor health – and thereby decrease resilience to climate change – but also because of the failure of the system to provide the preventive and urgent care that they need. Reforming the healthcare system to ensure access to affordable, quality healthcare services for all, regardless of income or immigration status, investing in innovative solutions to bring healthcare services to the communities in need, and considering healthcare as both a right and a public good, outside the profit-driven marketplace, will improve health outcomes, quality of life, and resilience to climate change.

1. For a general discussion of these challenges, see American Medical Association, “AMA president sounds alarm on national physician shortage,” October 25, 2023. ↩︎
2. March of Dimes, “Long-term health effects of preterm birth”, accessed October 4, 2024; U.S. Centers for Disease Control and Prevention, “Effects of Climate Change on Health,” accessed October 4, 2024. ↩︎
3. See, for example, Nambi Ndugga, Latoya Hill, and Samantha Artiga, “Key Data on Health and Health Care by Race and Ethnicity,” June 11, 2024. ↩︎
4. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, “National Uninsured Rate Remained Unchanged in the Second Quarter of 2023,“ November 14, 2023; The White House, “Record Marketplace Coverage in 2024: A Banner Year for Coverage,” January 24, 2024; Kaiser Family Foundation, “The Uninsured and the ACA: A Primer – Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act,” January 25, 2019. ↩︎
5. “Key Facts on Health Coverage of Immigrants,” KFF, September 17, 2023. ↩︎
6. M. Buettgens and U. Ramchandani, “Coverage Gains if 10 States Were to Expand Medicaid Eligibility,” Robert Wood Johnson Foundation, October 23, 2023; Laura Harker and Breanna Sharer, “Medicaid Expansion: Frequently Asked Questions,” Center for Budget and Policy Priorities, updated June 14, 2024. ↩︎
7. Association of American Medical Colleges, “New AAMC Report Shows Continuing Projected Physician Shortage,” March 21, 2024; Health Resources and Services Administration, U.S. Department of Health and Human Services, “Health Workforce Shortage Areas,” accessed October 1, 2024; “State Health Facts: Primary Care Health Professional Shortage Areas (HPSAs),” KFF, as of April 1, 2024; American Medical Association, “AMA president sounds alarm on national physician shortage,” October 25, 2023. See also Health Resources and Services Administration, U.S. Department of Health and Human Services, “State of the Primary Care Workforce, 2023,” November 2023 and Rural Health Information Hub, “Health Professional Shortage Areas: Primary Care, by County, July 2024,” accessed October 1, 2024. ↩︎
8. Shalina Chatlani, “Need to go to the hospital? Texas and Florida want to know your immigration status,” October 3, 2024. ↩︎
9. Karyn Schwartz, Eric Lopez, Matthew Rae, and Tricia Neumann, “What We Know About Provider Consolidation,” KFF, September 2, 2020; Amy Phillips, “What the research says about the impacts of hospital consolidation across the United States,” Washington Center for Equitable Growth, December 6, 2023; Kara Contrary, Saumya Chatrath, David J. Jones, Genna Cohen, Daniel Miller, and Eugune Rich, “Consolidation And Mergers Among Health Systems In 2021: New Data From The AHRQ Compendium,” Health Affairs, June 20, 2023; Zachary Levinson, Jamie Godwin, Scott Hulver, and Tricia Neuman, “Ten Things to Know About Consolidation in Health Care Provider Markets,” KFF, April 19, 2024. ↩︎
10. Ola Abdelhadi, Brend D. Fulton, Laura Alexander, and Richard M. Scheffler, “Private Equity–Acquired Physician Practices And Market Penetration Increased Substantially, 2012–21,” Health Affairs, March 2024; Kevin Grumbach, Deborah J. Cohen, and Yalda Jabbarpour, “The Failing Experiment Of Primary Care As A For-Profit Enterprise,” Health Affairs, September 5, 2024. ↩︎
11.  Center for Healthcare Quality and Payment Reform, “Rural Hospitals at Risk of Closing,” July 2024; American Hospital Association, “Rural Hospital Closures Threaten Access: Solutions to Preserve Care in Local Communities,” September 2022. See also The Cecil G. Sheps Center for Health Services Research, University of North Carolina, “192 Rural Hospital Closures and Conversions since January 2005,” accessed October 1, 2024. ↩︎
12. Jazmin Orozco Rodriguez, “Operating in the Red: Half of Rural Hospitals Lose Money, as Many Cut Services,” KFF Health News, March 7, 2024; Zachary Levinson, Jamie Godwin, Scott Hulver, and Tricia Neuman, “Ten Things to Know About Consolidation in Health Care Provider Markets,” KFF, April 19, 2024; Rural Health Information Hub, “Rural Emergency Hospitals (REHs),” accessed October 4, 2024. ↩︎
13. S. 1655, “Medicare for All Act,” 118th Congress, 2023-2024; H.R. 2764/S.1229, “Green New Deal for Health Act,” 118th Congress, 2023-2024; Devi Shastri, “Community health centers serve 1 in 11 Americans. They’re a safety net under stress,” Associated Press, January 29, 2024; Jennifer Lubell, “Powerful Senate committee takes up physician shortage,” American Medical Association, August 7, 2024. ↩︎
14.  193rd General Court of the Commonwealth of Massachusetts, “Senate Passes Health Care Reform Boosting Safeguards Against For-Profit Entities,” July 18, 2024; Sam Hughes and Natasha Murphy, “Empowering State Attorneys General To Fight Health Care Consolidation,” February 16, 2023; JD Supra, “Governor Newsom Vetoes AB 3129, Addressing Private Equity in California Health Care Transactions,” October 1, 2024; Senator Ed Markey, “Senator Markey, Rep. Jayapal Introduce Health Over Wealth Act, Setting Guardrails for Private Equity in Health Care,” July 25, 2024; Federal Trade Commission, “Federal Trade Commission, the Department of Justice and the Department of Health and Human Services Launch Cross-Government Inquiry on Impact of Corporate Greed in Health Care,” March 5, 2024. ↩︎