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Climate change poses a growing threat to health care systems worldwide, exposing weaknesses in infrastructure, workforce, and governance. Climate risk-defined by the interaction of hazard, exposure, and vulnerability-is both similar to and distinct from other systemic risks that health care systems must manage. We propose a risk-based framework that integrates insights from disaster risk management and health systems thinking to identify adaptation strategies. Our approach emphasizes understanding and addressing the upstream determinants of climate risk, including the intersectoral operating environment and social and environmental vulnerabilities that amplify health impacts. This perspective links climate risk reduction to the broader agenda of health equity. Within the health sector, climate change exerts simultaneous pressure on both demand and supply, challenging systems to move from reactive crisis response toward proactive, risk-informed planning. Established tools-such as strategic investment, workforce planning, and emergency preparedness-can be leveraged to manage climate-related risks while advancing core health policy goals. Framing climate change as a systemic risk encourages the integration of climate considerations into everyday policy and planning and strengthens health care system performance.

Understanding what the US spends to treat mental health and substance use disorders (SUD) is important for understanding spending patterns and informing health policy. In this study, we determined that from 2000 through 2021, mental health and SUD nominal spending grew from $40.9 billion to $139.6 billion. Mental health and SUD accounted for 4.5 percent of all medical services spending in 2000 and 5.5 percent in 2021. Real per capita mental health and SUD spending grew at an average annual rate of 3.27 percent, which was faster than the growth rate for overall medical services (2.21 percent). Our decomposition analysis showed that mental health and SUD spending growth was driven primarily by increases in the number of people receiving treatment (representing 87.3 percent of the growth) and to a much lesser extent by increases in the cost per case (12.7 percent of the growth). However, because disease severity was unobserved, these patterns may partly reflect increased treatment of less severe cases rather than unchanged severity-adjusted treatment costs. During this period, the number of mental health and SUD cases treated grew by 253 percent. In contrast, for spending increases on all diseases, 66.3 percent of the total spending growth resulted from increases in cost per case, and 33.7 percent resulted from more people receiving treatment.

The US health care system significantly contributes to climate change while increasingly facing its adverse consequences. Despite this dual challenge, policy efforts to incentivize carbon reduction and make care delivery climate-resilient remain fragmented. In this article, we identify policy interventions and other strategies that have the potential to accelerate the transition toward low-carbon, climate-smart health care systems. Drawing on academic literature and real-world implementation examples, we present a framework of strategies, highlighting the evidence in support of mechanisms such as green reimbursement models, integration of climate change into health professional education, and sustainable procurement standards. We further examine emerging policy levers, including circular economy practices and mandated carbon accounting. Last, we highlight opportunities for federal and state policy makers, payers, and health system leaders to guide future action. Ensuring that health policies actively support climate mitigation and adaptation is a moral and environmental imperative and a strategic opportunity to improve quality, reduce costs, and advance health equity.

Pacific Island Jurisdictions are highly affected by climate change. Across the health sector, implementation of planned adaptation strategies has been uneven. It has been constrained by limited human and financial resources and organizational capacity, inadequate climate-health risk assessments, and imprecise estimates about the effectiveness of climate-related interventions. To fill these gaps, this study assessed the degree of implementation of health adaptation activities in Pacific Island Jurisdictions, using a combination of implementation science and climate change adaptation frameworks. We found that Pacific Island Jurisdictions have made advances in the implementation of health adaptation activities such as establishing coordination mechanisms, building awareness, and conducting assessments. However, less progress has been made in operationalizing targeted policies, programs, and interventions, including monitoring, evaluation, and learning. Our findings offer the potential to increase resilience if applied by practitioners (for example, public health professionals) and decision makers to inform and seek support for additional health adaptation investments.

Latino communities in California experience disproportionate climate-related health risks, including extreme heat and air pollution. Despite the state's leadership in climate and environmental justice policy, existing data systems often do not integrate climate exposures, health outcomes, or neighborhood-level vulnerability in ways that meaningfully inform policy action. This Analysis draws on insights from the Latino Climate and Health Dashboard, a publicly available, neighborhood-level data tool that documents disparities between Latino and non-Latino White neighborhoods across California. The dashboard was developed with advisory board guidance, using the EPIS (exploration, preparation, implementation, sustainment) framework to structure data development and engagement. After the dashboard's release, we convened community policy dialogues ("policy pláticas") in which community organization leaders, practitioners, advocates, and legislative staff interpreted the findings and identified five policy priorities: coordinated climate and air quality governance, sustained community monitoring and early warning systems, equitable cooling and infrastructure investments, stronger connections between climate policy and health outcomes, and climate-resilient access to health care and worker protections. A participatory data tool can support equity-oriented climate-health policy making and inform efforts to translate data into policy action.

In 2020, Massachusetts Medicaid launched the Flexible Services Program (FSP) to fund housing and nutrition assistance services for beneficiaries in accountable care organizations. To evaluate the program's impact on health outcomes for beneficiaries with behavioral health conditions, we compared changes in total health care costs, hospitalizations, emergency department (ED) visits, primary care visits, and hospital readmissions among 6,575 FSP participants enrolled during the period 2020-23 with those of a comparison group of people who were eligible for but did not receive FSP services. We also conducted the analysis with a secondary comparison group of 6,419 similar beneficiaries enrolled in Medicaid managed care organizations that did not offer FSP services. Relative to the primary comparison group, per person health care costs for FSP participants were $2,117 lower six months after beginning the program and $3,260 lower at twelve months. ED visits were 5 percent lower and readmissions were 36 percent lower at twelve months among FSP participants compared with the primary comparison group. Analyses using the secondary comparison group found similar reductions in costs at six months after FSP initiation, larger cost reductions at twelve months, and similar twelve-month declines in readmissions. These findings support the continuation of housing assistance programs for Medicaid beneficiaries with behavioral health conditions.

Climate-sensitive hazards-heat, wildfire smoke, floods, and hurricanes-increase morbidity and mortality and disrupt routine care, yet US policy centers on disaster declarations rather than day-to-day hazards. We outline a practical framework to integrate climate adaptation into health insurance coverage, using public indicators such as heat alerts and air quality indices to trigger regional activations that last for the duration of the hazard window. Actions follow two pathways: reduce exposure during short high-risk periods by providing supports such as cooling access and indoor air filtration, and when routine channels fail, preserve care by expanding access during hazard windows using exceptions such as early refills and temporary network flexibilities. Near-term implementation channels include Medicaid Section 1115 demonstrations and "in lieu of services" provisions (which allow a state to substitute cost-effective services outside of its federally approved state Medicaid plan); Medicare Advantage supplemental benefits and Special Needs Plans; existing emergency authorities; and commercial plan flexibilities, following comparable domestic and international precedents. As climate risks grow, embedding adaptation in health insurance systems may be among the most practical and scalable strategies to protect population health.

Extreme heat events have been demonstrated to increase emergency department (ED) visits, hospitalizations, and mortality, but evidence of their impacts on the associated costs and on outpatient use is more limited. We used 2016-23 health insurance claims from a large, national insurer and national temperature and humidity data to conduct a regression analysis on the relationship between extreme heat exposure and ED, inpatient, and outpatient use and cost in the commercial insurance, Medicaid, and Medicare Advantage (MA) populations. One additional day with a heat index of 100°F or hotter within a week was associated with increased ED use and cost across nearly all coverage populations and age groups. Extreme heat was associated with significant increases in inpatient use for children with commercial coverage (1.4 percent), members ages 18-64 with Medicaid coverage (0.47 percent), and MA members (0.5 percent) but was not associated with statistically significant increases in inpatient cost for any population group. It was not associated with increases in outpatient use or cost in any population group. MA members had the highest annual cost due to extreme heat. These findings provide evidence to inform population health management strategies, seasonal preparedness planning, and policy interventions to mitigate heat-related morbidity and health care costs.

The Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) program is a Medicare Alternative Payment Model that launched in January 2023, based on the Global and Professional Direct Contracting Model that preceded it. The transition from that program to ACO REACH was unique in the Medicare portfolio in its focus on health equity and emphasis on capitated payments. We found that in the first year of ACO REACH, 132 participating ACOs cared for more than two million Medicare beneficiaries. Nearly nine in ten ACOs met quality cutoffs for Continuous Improvement/Sustained Exceptional Performance bonuses. The average Medicare spending benchmark was approximately $16,000 per beneficiary, and nearly three-quarters of participants had spending that was lower than their benchmark. ACOs with more experience and those with a higher proportion of medically complex beneficiaries (and thus higher benchmarks) had greater savings than newer ACOs and those with lower benchmarks.

In recent years, community health centers (CHCs) have struggled to meet the needs of underserved communities because of limited resources and growing demand. Medicaid and Medicare use prospective payment systems (PPSs) to reimburse CHCs at enhanced rates to safeguard their financial stability by providing consistent and predictable payments. However, whether and how these rates vary across centers is unknown. In this study, we conducted the first known analysis of Medicaid and Medicare PPS rates across CHCs by compiling a novel data set from forty-two states and Washington, D.C. We found that Medicaid PPS rates were 23 percent higher, on average, than Medicare PPS rates in 2023. Concerningly, centers that served more patients who identified as non-Hispanic Black, were uninsured, or had more chronic conditions received lower PPS rates. Overall, we observed that payment rates were generally insufficient to offset the average per visit cost of care delivered in CHCs. Standardized policies concerning how public insurance payers reimburse CHCs are needed to promote equity and sustainability in the health care safety net.

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Medical trainees in Florida during Hurricane Irma learned firsthand how to fend for themselves during and after a storm.

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Extreme heat is a complex public health problem driven by interactions at the individual, community, health system, and policy levels. Participatory systems science engages interested parties to examine the interconnected factors driving heat-related illness and to develop locally tailored adaptation strategies. This article describes how local government agencies and community members from an area with high heat exposure in King County, Washington, engaged in the participatory systems science approach of group model building to co-develop extreme heat solutions during 2024-25. Recommended solutions included community education on heat risk; health system policies that increase access to health care; policy-informed infrastructure changes that expand access to green space; and lifesaving direct support, including distribution of cool kits to unhoused people and energy assistance programs. The insights generated can inform heat adaptation efforts across jurisdictions. The methods described offer a scalable approach to co-designing policies and interventions that can inform national and global climate resilience strategies to reduce health risks from climate-related events.

Cold-related illnesses (CRIs) are preventable yet often deadly. Using twenty-five years of data from the National Inpatient Sample (1998-2022), we assessed nationwide trends in CRI hospitalizations and concomitant alcohol use, substance use, and mental health disorders and housing insecurity. We identified 345,314 (weighted) CRI hospitalizations and found that age- and sex-adjusted rates tripled from 42.0 to 122.5 per 100,000 hospitalizations. CRI inpatients were more likely than others to die during hospitalization, live in high-poverty ZIP codes, be publicly insured or uninsured, and have behavioral health conditions and housing instability. These findings highlight the rising and unequal toll of CRIs in the context of social instability and increasingly severe cold events associated with climate change. Expanded access to behavioral health treatments, increased subsidies for home heating, investments in affordable and supportive housing and shelter capacity, and public health measures to increase resilience to extreme weather events could reduce CRI morbidity and mortality.

The health effects of extreme heat have gained attention rapidly, as rising global temperatures cause more frequent and severe heat waves. More attention is needed, however, to the myriad pathways by which the financial and physical tolls of extreme heat are ultimately borne by the most disadvantaged members of society. These tolls include direct impacts on health and indirect impacts on income as costs incurred by industry, government, and other entities are passed on to individuals as increased prices or decreased earnings. Strained household finances in turn affect individuals' ability to pursue a healthy lifestyle and seek medical care. Existing research says little about transmission of these effects between individuals and organizations, however. We explore current evidence, identify gaps in this research, and recommend priorities for future work to promote more comprehensive understanding of the direct and indirect impacts of rising temperatures on health and financial well-being.

Farmers and ranchers are on the front lines of climate change, facing escalating production pressures, economic uncertainty, and profound psychological impacts. Drawing on first-person experience and research in agricultural communities, this Commentary uses narrative to illuminate how climate grief-grief experienced in response to actual or anticipated loss resulting from climate change-affects farmers and ranchers and shapes their capacity for climate adaptation. In addition to this experiential framing, the authors include an illustrative example of a team-developed intervention designed to support farmers' and ranchers' mental health; this example is offered not as original research but as a practice-based case to stimulate the broader policy conversation. Taken together, these perspectives underscore the need to integrate mental health support into agricultural climate resilience efforts. Although programs such as the Department of Agriculture's Farm and Ranch Stress Assistance Network represent important progress, current initiatives remain fragmented and underresourced. Research on mental health interventions related to climate change in general is sparse. Increasing investment and coherent policy are essential to ensuring that climate adaptation strategies address the full spectrum of challenges that farmers and ranchers face-physical, economic, and psychological.

Understanding the evolving composition of cost sharing and its interaction with shifts in inpatient and outpatient care delivery is essential for anticipating financial pressures on both patients and health care providers. This study leveraged eleven years of commercial insurance claims from the Health Care Cost Institute to investigate changes in the distribution of magnitudes of cost sharing owed and the share of allowed amounts anticipated as cost-sharing collections by hospitals. We found that despite declining or stable utilization rates during the period 2012-22, mean per enrollee spending and patient cost-sharing burdens grew substantially in more recent years. Cost sharing has notably shifted in composition toward both high-cost and zero-cost encounters, consistent with the adoption of high-deductible health plans on the one hand and out-of-pocket maximums and preventive or other services covered in full on the other. These trends may disproportionately affect rural hospitals, which face a higher share of patient-responsible revenue and likely greater challenges in collection.