In recent years, climate change has evolved from a once abstract threat into an urgent health reality. Floods cripple hospitals, record-high temperatures strain vulnerable populations, and pollution contributes to the development of chronic diseases. No sector feels this danger more acutely than health care itself.
That’s all according to a recent report from the Commonwealth Fund titled State Scorecard on Climate, Health and Health Care, which ranks U.S. states on environmental risk, health system emissions, and resilience to climate stressors. The paper offers new insights into how health policy, infrastructure and climate strategy must converge.
In a conversation with Ozarks at Large’s Jack Travis, Northeastern University researchers Matthew Eckelman, professor and associate chair for faculty in civil and environmental engineering, and Melanie Marino, Ph.D. candidate, join Lovisa Gustafsson, vice president at the Commonwealth Fund. They discussed the report and what its findings mean for Arkansans.
Eckelman: This is a report that we’ve done in cooperation with the Commonwealth Fund. This is looking at several indicators that are evaluating environmental risks and environmental impacts associated with health care and to the health care system. So we were trying to evaluate the health implications of the changes that we see in the environment. Changes in environmental quality like heat and air quality, changes in state policy that affect that environmental quality and that have some kind of influence on public health or residents in different states, and also what the health care system is doing about it. How are they responding? How are they getting ready? How are they caring for their own communities? And how are they thinking about the future?
Travis: Yeah. Let’s dive into that for just a second. Could you talk about how the environment and public health are kind of inextricably linked?
Eckelman: So environmental drivers are really important when you look at overall implications for human health. Air pollution in particular is one of the most important influences on public health here in the United States and even more so in many other countries, and one of the leading reasons why we care about environmental quality if you look at the damages to human health. So the hospital visits and lost productivity add up to hundreds of billions of dollars a year just in the United States. So these have major economic implications for states and for countries, of course, and on a personal level can lead to real tragedy for individuals. And it’s something where states and the federal government as well have a real influence to protect human health through improving environmental quality and just trying to reduce the pollution that’s out there in the environment.
Gustafsson: I think for us as a health care research organization, we haven’t always focused on climate. We focus on the other obvious things that impact health—whether you have health insurance, whether you can afford the care you need, if there are doctors available in your community. But what we’ve just seen over time is that the environment and climate are having a bigger and bigger impact on people’s health care and just requires us as health researchers to be thinking about these implications. Matt walked through a number of the ways that it’s impacting people’s lives already, and there’s more. We see people dying in floods, and we see people’s care being disrupted when a health system is taken offline, and so they can’t get the care that they need both in that moment but also for weeks afterward as the community is recovering from some of these events. We see supply chains being disrupted and people not being able to get the medicines and other supplies that they need. So it really is just creeping up in a whole lot of different ways, and it is impacting public health, the availability of health care and directly people’s health on a day-to-day basis.
Travis: Yeah, yeah. Let’s talk a little bit about this study. Specifically, I was hoping you could tell me about the indicators that y’all looked at and what they mean and how y’all use them to rank these different states.
Marino: The indicators that we selected—we first kind of identified some key climate threats to health and health care systems and key sustainability challenges for health care systems. And then from that, we selected indicators based on publicly available data, and we wanted to select indicators that had data that are scientifically valid and verifiable. And we also selected indicators where policy action can be taken to improve upon these indicators, so states can actually do something about them. And so we also selected indicators in kind of three facets for the scorecard—looking at the impact of the environment on human health and health care systems, looking at how the health care systems impact the environment and human health, and also more on the state policy side and how state policies make a difference and the policy levers states have to impact human health.
Travis: Could you go through—and there were eight indicators, right?
Marino: Yes. So our indicators are air quality index, extreme heat or health risk from extreme heat, health care facility risk from natural hazards, health care facility flood risk or the percentage of beds in flood zones, state energy efficiency policy, state electricity emissions and their health impacts, so health impacts from electricity generation, and per-capita health care sector greenhouse gas emissions, and then lastly, health care worker commuting emissions.
Travis: Let’s talk about the findings. What were your major findings? And specifically, was there anything that y’all uncovered that surprised you, that you weren’t expecting to see?
Eckelman: It was full of surprises. Some of these metrics were new, so they hadn’t been calculated before, and so we didn’t really have necessarily an idea of what was coming. But what we saw when you look at the whole report and across the whole of the U.S., there’s a mixed bag. There’s no state that’s at the top for every indicator, and there’s no state that’s at the bottom for every indicator. Every state has something that’s going well. Every state has some risks that they are contending with or will need to contend with.
In the state of Arkansas, there were some surprises for us. The one that stood out to me was around worker commuting. And we thought states out West—for example, Montana—less dense population, huge areas, long distances. But in fact, Arkansas and many of the other Southeast states topped the country list in terms of the distance people would travel—workers to get to health care facilities—and the emissions associated with that travel. So this tells you something about the way the health care system is organized spatially and just the way that cities and towns are spread out in the Southeast. And the clinics might be spaced in a way that requires more travel.
But with each of the indicators, they represent a complex problem, and an indicator is a measure that we’re using as a proxy for that problem—disconnection of people from their health care centers. And what we can see with this indicator is that in the event of flooding or in the event of some kind of event that prevents people from getting to the hospital, that also applies to the health care workers. They have to travel longer distances, and in times of need, this can perhaps increase the risk to patients.
Travis: You kind of touched on it there, but what recommendations, if you could have the ear of a lawmaker or policymaker in Arkansas—or really anywhere—what recommendations would you have for them?
Gustafsson: I was going to say, I mean, in the report at the end, there are a number of different policy recommendations. And I think one of the things we really wanted to think about was the different levels of action. So there are things that the federal government can do, there are things that states can do, and there are even things that communities and health systems themselves can do. And so we really wanted to think about all those potential actors and all the potential things that they could think about and how to do this.
One thing for states to think about is their energy policies—energy efficiency, clean energy. We see a number of states that lead in this area. States like California and Massachusetts do a really great job there. We also see states thinking innovatively about new things they could do. So if you look at Arizona, where they suffer from really a lot of extreme heat, they have a new chief heat officer who is charged with making the state ready for all the extreme heat that they have.
And states can also have a role in helping health systems themselves understand their vulnerabilities and prepare for those vulnerabilities to make sure that the health system is protected. Matt and I had more suggestions in terms of additional things, but I think those are just a few of them. But I think it’s really important to think about all the different levels in which there are policymakers as well as institutions who can help to prepare and improve on these measures.
Travis: And then what about lower on that hierarchy—citizens at large? Why should we read this report, consider its results, and what can we do?
Gustafsson: I think it’s important just to know what your risks are. Matt mentioned this before—that some of these things are just inherent in your geography—but it’s important to be aware of them so that when these events happen, you’re prepared and you can protect yourself. If you know that your local hospital is in a flood-prone area, you might want to think about a backup provider to go to or know how you’re going to get there during a flood when roads might be hard to pass and things like that. So there are some things that people can do.
But I do think it’s really important for policymakers—whether it’s local officials, state officials and others—to really be thinking about this to make sure that the infrastructure is in place for their residents.
Eckelman: To pick up on what Lovisa was saying, one thing we were trying to achieve with this report is the idea that different types of policies from really different areas of state government will have important health implications. In the public health community, we call this a “health in all policies” approach, and we tried to choose indicators that were pretty diverse.
If you look at the report, you might wonder, how are these things connected? And what ties them together is the implications for public health. So for people in state legislative roles or people who have some influence over the policy process, usually, unless you’re the governor, you have your own area. The health department works on health policies, and the transportation department works on transportation policies.
But hopefully this report helps emphasize this idea that no matter what kind of policy area you’re working on, having a lens thinking about implications for health, trying to quantify the health benefits of the policies that you have—often the health benefits are huge. They might be much larger than the direct economic benefits that you might get through fuel savings, for example. So that undercurrent was a major motivation for us.
Travis: Y’all got data through 2024, am I correct?
Marino: I believe our most recent source—the Heat and Health Index—is from 2024, but it spanned from 2020 to 2024.
Travis: So how are y’all—you know, environmental policy is changing rapidly, and there’s a lot of, I mean, companies in Arkansas are backsliding on their green energy promises. How are y’all considering that, and did that play a part in the study? Would you recommend looking at it from maybe a different perspective or a slightly changed perspective as all of these changes on the federal level are slowly starting to seep down into the state and municipal level?
Eckelman: Our hope and our plan was always to carry this report forward, look at it over time and see how indicators evolve, because of the really rapid changes that have happened this year. None of that is captured in the indicators that we see, but next year we certainly will. And not just that—it’s not only the policies that are changing. The environment is changing, climate is changing, and so some of the risks, some of the actual damages from storms, some of the human toll of high-heat events—those will change over time.
Even though the scorecard is designed so you can see how states compare to one another, it’s almost more important to see how states do against their own benchmarking. States have really different settings, different histories, different cultural communities. It’s not necessarily fair to just take the indicators on the face of them and say, well, this state’s doing better than that state. They might be more vulnerable or less active for lots of different reasons. So we hope to see these changes over time.
So, Jack, if we can talk with you again next year, we’ll see how it all plays out.
Travis: Absolutely. I would love to speak again next year.
Gustafsson: This is actually a question for Matt, but my one thought was around data availability—our ability to do this in the future, given that some federal data sources have been going away.
Eckelman: Part of what we recommend in the report is that the federal government maintain its commitment to policies—environmental policies or resilience policies—but those policies that are very clearly protective of public health and that have had huge public health benefits over the years. In terms of data, some of the sources that we got information from have undergone changes, and it could be that it may be difficult to get all of those data again for future versions of the report.
One thing we’ve seen is that other entities have started to archive data sets to make sure that they’re still available to the public and to science. So that’s heartening to see, and we may be able to use those data sets in the future.
That was Ozarks at Large’s Jack Travis speaking with Northeastern University’s Matthew Eckelman and Melanie Marino, and Lovisa Gustafsson with the Commonwealth Fund about the report State Scorecard on Climate, Health and Health Care.
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