The heat is rising, and not everyone can afford to cool down

By Will Atwater

As extreme heat becomes more common, people on government-paid health plans are more likely than people with private insurance to land in the emergency department with heat‑related illnesses, according to a recent study. 

The analysis, which drew on claims from more than 44 million insured patients across the country, found that heat waves drove up emergency room visits and costs across all insurance types, with especially sharp increases for patients on publicly paid programs like Medicaid and Medicare.

Forecasters and climate scientists say those days with dangerous heat are becoming more frequent and intense as the climate warms, with U.S. cities now seeing many more extreme‑heat events and much longer heat‑wave seasons than in past decades. That warming trend was highlighted in 2024, which became the warmest year on record. 

But rising temperatures do not affect all communities equally — and the reasons why are rooted in decades of policy decisions, not geography alone.

A U.S. government assessment published in 2023 found that the legacy of discriminatory housing and land-use policy has left Black communities and other communities of color “disproportionately exposed to environmental risks and with fewer resources to address them when compared to majority White communities.”

The study, published in the journal Health Affairs, found that just one additional day with a heat index of 100°F or hotter in a week was associated with increased emergency department use and cost for almost all coverage populations and age groups. 

But they also found that heat disproportionately affects low-income communities, which already have a lot of other health burdens. 

Contributing factors

That pattern of heat stress is familiar to Mark McNeill, a primary care physician in Asheville. 

Many of McNeill’s publicly insured patients are lower-income adults between 18 and 64 who, he said, “are frequently in historically African American neighborhoods.” 

About 30 percent of his patients are covered by Medicare, 15 percent by Medicaid and roughly 55 percent by private insurance. 

Medicaid is state- and federally-funded health insurance for low- and no-income adults and people with disabilities. Medicare is health insurance for adults 65 and older, as well as some people with certain disabilities, paid for by the federal government. About half of U.S. Medicare patients are in so-called Advantage plans, administered by private insurers but paid for by federal dollars.

McNeill said the social determinants of health — the conditions of daily life, including housing, employment and neighborhood environment — help explain why his publicly insured patients have more problems with heat and end up relying more on emergency care.

These residents often live in low‑income housing that has not been well maintained, often in neighborhoods with few trees and green spaces and lots of asphalt and concrete. These are conditions that create urban heat islands, where temperatures can run several degrees higher than in greener areas. 

“When you have a heat wave, it’s going to get hotter there [and] that’s where a lot of adults on Medicaid are living,” McNeill said.

He noted that many of these residents either lack air conditioning or can’t afford to use it. They often work outside and have underlying health conditions that are exacerbated by hot weather. 

“This is a sicker population than the [privately] insured adults between 18 and 64,” McNeill said. “Even in people below the age of 64, you’re going to see more cardiovascular disease, more asthma, more COPD, more mental illness — and all of those diseases are very vulnerable to heat.”

The health issues McNeill describes are compounded by an added financial burden. 

Addressing the heat burden

The authors of the Health Affairs study looked at insurance claims data for people on private insurance, Medicare, Medicare Advantage and Medicaid. 

They calculated additional claims costs for all of the populations for emergency department, outpatient and inpatient care associated with days 80°F or hotter, compared with more temperate days, for each insurance type and age group.

The authors found that extreme heat costs Medicare Advantage members an average of $34.21 per member annually in additional healthcare spending. In contrast, days of extreme heat translated into only $15.95 in extra spending on average for privately insured adults in the same age group, according to the study. 

For adults on Medicaid, the average increase in health spending tallied $25.77 — a cost that represents a proportionally larger share of their annual spending than it does for their privately insured counterparts.

The study’s authors argue that extreme heat should be treated as “a recurring driver of demand, rather than an external random shock,” and recommend that health systems and policymakers invest in preparedness and preventive outreach — an approach that some North Carolina governments and agencies have already begun to adopt.

In recent years Durham, Raleigh, Wilmington, Charlotte and Asheville, among others, have worked to increase the tree cover to offset some of the heat that builds up in urban population centers. Street trees provide shade and help lower the ambient temperature in neighborhoods and parks.

All of those cities have received the Tree City designation from the Arbor Day Foundation for their efforts. 

Other cooling strategies being employed in urban areas include reducing asphalt surfaces where possible — replacing them with grass, mulch or permeable pavement that absorbs less heat and reduces stormwater runoff. Where asphalt cannot be removed, shade structures are being installed on school playgrounds and in community gathering spaces. Light-colored or “cool” rooftops and green roofs with plants are also being used on larger buildings to absorb less heat and, in the case of green roofs, reduce stormwater runoff.

But that might not be enough for some low-income residents who don’t have air conditioning.

Those programs address immediate heat exposure, but reducing the energy costs that keep low-income residents from running air conditioning takes a longer-term investment.

Tackling energy burden

The 2022 Inflation Reduction Act, signed into law by former President Joe Biden, allocated money disbursed by the U.S. Department of Energy to help low-income homeowners make their homes more energy efficient, with the goal of reducing energy costs. Energy Saver North Carolina launched on Jan. 16, 2025, and is administered through the North Carolina Department of Environmental Quality.

These programs prioritize the households most in need. Low-income residents — those with household incomes below 80 percent of the Area Median Income in a given municipality — are eligible for the full Energy Saver rebate amounts, while moderate-income households, those earning between 80 and 150 percent of the Area Median Income, may qualify for partial rebates. 

Renters are also eligible with permission from their landlord. NCDEQ said the program “started in high energy burden communities” before expanding to all 100 counties statewide, where it is expected to run until 2031 or until funds are depleted.

Michelle Carter, clean energy campaigns director for the North Carolina League of Conservation Voters, said the connection between household appliances and health is often the most effective entry point when talking with residents about the program.

During an outreach event in western North Carolina, Carter spoke with an older woman whose husband depended on supplemental oxygen and cooked regularly on a gas stove. The woman was interested in Energy Saver NC but was reluctant to switch to electric appliances after Hurricane Helene had left her wary of losing power. 

Carter explained that gas stove emissions can worsen respiratory conditions — something the woman had not known. 

“She literally wrote in her little notebook, ‘gas stoves are unhealthy,’” Carter said. 

The woman signed up for the program.

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