The opioid epidemic is a public health and safety emergency that is killing thousands and destroying the quality of life for hundreds of thousands of Americans and those who care about them. Fentanyl and other opioids affect all age ranges, ethnicities, and communities, including our most vulnerable population, children. Producing fentanyl is increasingly cheap, costing pennies for a fatal dose, with the opioid intentionally or unintentionally mixed with common illicit street drugs and pressed into counterfeit pills. Fentanyl is odorless and tasteless, making it nearly untraceable when mixed with other drugs. Extremely small doses of fentanyl, roughly equivalent to a few grains of salt, can be fatal, while carfentanil, a large animal tranquilizer, is 100 times more potent than fentanyl and fatal at an even smaller amount.

The Biden-Harris Administration should do even more to fund opioid-related prevention, treatment, eradication, and interdiction efforts to save lives in the United States. The 2022 Executive Order to Address the Opioid Epidemic and Support Recovery awarded $1.5 billion to states and territories to expand treatment access, enhance services in rural communities, and fund law enforcement efforts. In his 2023 State of the Union address, President Biden highlighted reducing opioid overdoses as part of his bipartisan Unity Agenda, pledging to disrupt trafficking and sales of fentanyl and focus on prevention and harm reduction. Despite extensive funding, opioid-related overdoses have not significantly decreased, showing that a different strategy is needed to save lives. 

Opioid-related deaths have been estimated cost the U.S. nearly $4 trillion over the past seven years—not including the human aspect of the deaths. The cost of fatal overdoses was determined to be $550 billion in 2017. The cost of the opioid epidemic in 2020 alone was an estimated $1.5 trillion, up 37% from 2017. About two-thirds of the cost was due to the value of lives lost and opioid use disorder, with $35 billion spent on healthcare and opioid-related treatments and about $15 billion spent on criminal justice involvement. In 2017, per capita costs of opioid use disorder and opioid toxicity-related deaths were as high as $7247, with the cost per case of opioid use disorder over $221,000. With inflation in November 2023 at $1.26 compared to $1 in 2017, not including increases in healthcare costs and the significant increase in drug toxicity-related deaths, the total rate of $693 billion is likely significantly understated for fatal overdoses in 2023. Even with extensive funding, opioid-related deaths continue to rise.

With fatal opioid-related deaths being underreported, the Centers for Disease Control and Prevention (CDC) must take a primary role in real-time surveillance of opioid-related fatal and non-fatal overdoses by funding expanded toxicology testing, training first responder and medicolegal professionals, and ensuring compliance with data submission. The Department of Justice (DOJ) should support enforcement efforts to reduce drug toxicity-related morbidity and mortality, with the Department of Homeland Security (DHS) and the Department of the Treasury (TREAS) assisting with enforcement and sanctions, to prevent future overdoses. Key recommendations for reducing opioid-related morbidity and mortality include:

• Funding research to determine the efficacy of current efforts in opioid misuse reduction and prevention.
• Modernizing data systems and surveillance to provide real-time information.
• Increasing overdose awareness, prevention education, and availability of naloxone.
• Improve training of first responders and medicolegal death investigators.
• Funding rapid and thorough toxicology testing in emergency departments and coroner/medical examiner agencies.
• Enhancing prevention and enforcement efforts.

Challenge and Opportunity

Opioids are a class of drugs, including pain relievers that can be illegally prescribed and the illicit drug heroin. There are three defined waves of the opioid crisis, starting in the early 1990s as physicians increasingly prescribed opioids for pain control. The uptick in prescriptions stemmed from pharmaceutical companies promising physicians that these medications had low addiction rates and medical professionals adding pain levels being added to objective vital signs for treatment. From 1999 to 2010, prescription opioid sales quadrupled—and opioid-related deaths doubled. During this time frame when the relationship between drug abuse and misuse was linked to opioids, a significant push was made to limit physicians from prescribing opioids. This contributed to the second wave of the epidemic, when heroin abuse increased as former opioid patients sought relief. Heroin-related deaths increased 286% from 2002 to 2013, with about 80% of heroin users acknowledging that they misused prescription opioids before using heroin.  The third wave of the opioid crisis came in 2013 with an increase in illegally manufactured fentanyl, a synthetic opioid used to treat severe pain that is up to 100 times stronger than morphine, and carfentanil, which is 100 times more potent than fentanyl. 

In 2022, nearly 110,000 people in the United States died from drug toxicity, with about 75% of the deaths involving opioids. In 2021, six times as many people died from drug overdoses as in 1999, with a 16% increase from 2020 to 2021 alone. While heroin-related deaths decreased by over 30% from 2020 to 2021, opioid-related deaths increased by 15%, with synthetic opioid-involved deaths like fentanyl increasing by over 22%. Over 700,000 people have died of opioid-related drug toxicity since 1999, and since 2021 45 people have died every day from a prescription opioid overdose. Opioid-related deaths have increased tenfold since 1999, with no signs of slowing down. The District of Columbia declared a public emergency in November 2023 to draw more attention to the opioid crisis.

In 2023, we are at the precipice of the fourth wave of the crisis, as synthetic opioids like fentanyl are combined with a stimulant, commonly methamphetamine. Speedballs have been common for decades, using stimulants to counterbalance the fatigue that occurs with opiates. The fatal combination of fentanyl and a stimulant was responsible for just 0.6% of overdose deaths in 2010 but 32.3% of opioid deaths in 2021, an over fifty-fold increase in 12 years. Fentanyl, originally used in end-of-life and cancer care, is commonly manufactured in Mexico with precursor chemicals from China. Fentanyl is also commonly added to pressed pills made to look like legitimate prescription medications. In the first nine months of 2023, the Drug Enforcement Agency (DEA) seized over 62 million counterfeit pills and nearly five tons of powdered fentanyl, which equates to over 287 million fatal doses. These staggering seizure numbers do not include local law enforcement efforts, with the New York City Police Department recovering 13 kilos of fentanyl in the Bronx, enough powder to kill 6.5 million people. 

The ease of creating and trafficking fentanyl and similar opioids has led to an epidemic in the United States. Currently, fentanyl can be made for pennies and sold for as little as 40 cents in Washington State. The ease of availability has led to deaths in our most vulnerable population—children. Between June and September 2023, there were three fatal overdoses of children five years and younger in Portland, OR. In a high-profile case in New York City, investigators found a kilogram of fentanyl powder in a day care facility after a 1-year-old died and three others became critically ill. 

The Biden Administration has responding to the crisis in part by placing sanctions against and indicting executives in Chinese companies for manufacturing and distributing precursor chemicals, which are commonly sold to Mexican drug cartels to create fentanyl. The drug is then trafficked into the United States for sale and use. There are also concerns about fentanyl being used as a weapon of mass destruction, similar to the anthrax concerns in the early 2000s.

The daily concerns of opioid overdoses have plagued public health and law enforcement professionals for years. In Seattle, WA, alone, there are 15 non-fatal overdoses daily, straining the emergency medical systems. There were nearly 5,000 non-fatal overdoses in the first seven months of 2023 in King County, WA, an increase of 70% compared to 2022. In a landmark decision, in March 2023 the Food and Drug Administration (FDA) approved naloxone, a drug to reverse the effects of opioid overdoses, as an over-the-counter nasal spray in an attempt to reduce overdose deaths. Naloxone nasal spray was initially approved for prescription use only in 2015 , significantly limiting access to first responders and available to high-risk patients when prescribed opioids. In New York, physicians have been required to prescribe naloxone to patients at risk of overdose since 2022. Although naloxone is now available without a prescription, access is still limited by price, with one dose costing as much as $65, and some people requiring more than one dose to reverse the overdose. Citing budget concerns, Governor Newsom vetoed California’s proposed AB 1060, which would have limited the cost of naloxone to $10 per dose. Fentanyl testing strips that can be used to test substances for the presence of fentanyl before use show promise in preventing unwanted fentanyl-adulterated overdoses. The Expanding Nationwide Access to Test Strips Act, which was introduced to the Senate in July 2023, would decriminalize the testing strips as an inexpensive way to reduce overdose while following evidence-based harm-reduction theories.

Illicit drugs are also one of the top threats to national security. Law enforcement agencies are dealing with a triple epidemic of gun violence, the opioid crisis, and critical staffing levels. Crime prevention is tied directly to increased police staffing, with lower staffing limiting crime control tactics, such as using interagency task forces, to focus on a specific crime problem. Police are at the forefront of the opioid crisis, expected to provide an emergency response to potential overdoses and ensure public safety while disrupting and investigating drug-related crimes. Phoenix Police Department seized over 500,000 fentanyl pills in June 2023 as part of Operation Summer Shield, showing law enforcement’s central role in fighting the opioid crisis. DHS created a comprehensive interdiction plan to reduce the national and international supply of opioids, working with the private sector to decrease drugs brought into the United States and increasing task forces to focus on drug traffickers. 

Prosecutors are starting to charge drug dealers and parents of children exposed to fentanyl in their residences in fatal overdose cases. In an unprecedented action, Attorney General Merrick Garland recently charged Mexican cartel members with trafficking fentanyl and indicting Chinese companies and their executives for creating and selling precursor chemicals. In November 2023, sanctions were placed against the Sinaloa cartel and four firms from Mexico suspected of drug trafficking to the United States, removing their ability to legally access the American banking system. Despite this work, criminal justice-related efforts alone are not reducing overdoses and deaths, showing a need for a multifaceted approach to save lives. 

While these numbers of opioid overdoses are appalling, they are likely underreported. Accurate reporting of fatal overdoses varies dramatically across the country, with the lack of training of medicolegal death investigators to recognize potential drug toxicity-related deaths, coupled with the shortage of forensic pathologists and the high costs of toxicology testing, leading to inaccurate cause of death information. The data ecosystem is changing, with agencies and their valuable data remaining disjointed and unable to communicate across systems. A new model could be found in the CDC’s Data Modernization Initiative, which tracked millions of COVID-19 cases across all states and districts, including data from emergency departments and medicolegal offices. This robust initiative to modernize data transfer and accessibility could be transformative for public health. The electronic case reporting system and strong surveillance systems that are now in place can be used for other public health outbreaks, although they have not been institutionalized for the opioid epidemic.

Toxicology testing can take upwards of 8–10 weeks to receive, then weeks more for interpretation and final reporting of the cause of death. The CDC’s State Unintentional Drug Overdose Reporting System receives data from 47 states from death certificates and coroner/medical examiner reports. Even with the CDC’s extensive efforts, the data-sharing is voluntary, and submission is rarely timely enough for tracking real-time outbreaks of overdoses and newly emerging drugs. The increase of novel psychoactive substances, including the addition of the animal tranquilizer xylazineto other drugs, is commonly not included in toxicology panels, leaving early fatal drug interactions undetected and slowing notification of emerging drugs regionally. The data from medicolegal reports is extremely valuable for interdisciplinary overdose fatality review teams at the regional level that bring together healthcare, social services, criminal justice, and medicolegal personnel to review deaths and determine potential intervention points. Overdose fatality review teams can use the data to inform prevention efforts, as has been successful with infant sleeping position recommendations formed through infant mortality review teams.

Plan of Action

Reducing opioid misuse and saving lives requires a multi-stage, multi-agency approach. This includes expanding real-time opioid surveillance efforts; funding for overdose awareness, prevention, and education; and improved training of first responders and medicolegal personnel on recognizing, responding to, and reporting overdoses. Nationwide, improved toxicology testing and reporting is essential for accurate reporting of overdose-involved drugs and determining the efficacy of efforts to combat the opioid epidemic.

Recommendation 1. Fund research to determine the efficacy of current efforts in opioid misuse reduction and prevention.

DOJ should provide grant funding for researchers to outline all known current efforts of opioid misuse reduction and prevention by law enforcement, public health, community programs, and other agencies. The efforts, including the use of suboxone and methadone, should be evaluated to determine if they follow evidence-based practices, how the programs are funded, and their known effect on the community. The findings should be shared widely and without paywalls with practitioners, researchers, and government agencies to hone their future work to known successful efforts and to be used as a foundation for future evidence-based, innovative program implementation.

Recommendation 2. Modernize data systems and surveillance to provide real-time information.

City, county, regional, and state first responder agencies work across different platforms, as do social service agencies, hospitals, private physicians, clinics, and medicolegal offices. A single fatal drug toxicity-related death has associated reports from a law enforcement officer, fire department personnel, emergency medical services, an emergency department, and a medicolegal agency. Additional reports and information are sought from hospitals and clinics, prior treating clinicians, and social service agencies. Even if all of these reports can be obtained, data received and reviewed is not real-time and not accessible across all of the systems. 

Medicolegal agencies are arguably the most underprepared for data and surveillance modernization. Only 43% of medicolegal agencies had a computerized case management system in 2018, which was an increase from 31% in 2004. Outside of county or state property, only 75% of medicolegal personnel had internet access from personal devices. The lack of computerized case management systems and limited access to the internet can greatly hinder case reporting and providing timely information to public health and other reporting agencies.

With the availability and use of naloxone by private persons, the Public Naloxone Administration Dashboard from the National EMS Information System (NEMSIS) should be supported and expanded to include community member administration of naloxone. The emergency medical services data can be aligned with the anonymous upload of when, where, and basic demographics for the recipient of naloxone, which can also be made accessible to emergency departments and medicolegal death investigation agencies. While the database likely will not be used for all naloxone administrations, it can provide hot spot information and notify social services of potential areas for intervention and assistance. The database should be tied to the first responder/hospital/medicolegal database to assist in robust surveillance of the opioid epidemic.

Recommendation 3. Increase overdose awareness, prevention education, and availability of naloxone.

Awareness of the likelihood of poisoning and potential death from the use of fentanyl or counterfeit pills is key in prevention. The DEA declared August 21 National Fentanyl Prevention and Awareness Day to increase knowledge of the dangers of fentanyl, with the Senate adopting a resolution to formally recognize the day in 2023. Many states have opioid and fentanyl prevention tactics on their public health websites, and the CDC has educational campaigns designed to reach young adults, though the education needs to be specifically sought out. Funding should be made available to community organizations and city/county governments to create public awareness campaigns about fentanyl and opioid usage, including billboards, television and streaming ads, and highly visible spaces like buses and grocery carts. 

ED allows evidence-based prevention programs in school settings to assist in reducing risk factors associated with drug use and misuse. The San Diego Board of Supervisors approved a proposal to add education focused on fentanyl awareness after 12 juveniles died of fentanyl toxicity in 2021. The district attorney supported the education and sought funding to sponsor drug and alcohol training on school campuses. Schools in Arlington, VA, note the rise in overdoses but recognize that preventative education, when present, is insufficient. ED should create prevention programs at grade-appropriate levels that can be adapted for use in classrooms nationwide.

With the legalization of over-the-counter naloxone, funding is needed to provide subsidized or free access to this life-saving medication. Powerful fentanyl analogs require higher doses of naloxone to reverse the toxicity, commonly requiring multiple naloxone administrations, which may not be available to an intervening community member. The State of Washington’s Department of Public Health offers free naloxone kits by mail and at certain pharmacies and community organizations, while Santa Clara University in California has a vending machine that distributes naloxone for free. While naloxone reverses the effects of opioids for a short period, once it wears off, there is a risk of a secondary overdose from the initial ingestion of the opioid, which is why seeking medical attention after an overdose is paramount to survival. Increasing access to naloxone in highly accessible locations—and via mail for more rural locations—can save lives. Naloxone access and basic training on signs of an opioid overdose may increase recognition of opioid misuse and empower the community to provide immediate, lifesaving action. 

However, there are concerns that naloxone may end up in a shortage. With its over-the-counter access, naloxone may still be unavailable for those who need it most due to cost (approximately $20 per dose) or access to pharmacies. There is a national push for increasing naloxone distribution, though there are concerns of precursor shortages that will limit or halt production of naloxone. Governmental support of naloxone manufacturing and distribution can assist with meeting demand and ensuring sustainability in the supply chain.

Recommendation 4. Improve training of first responders and medicolegal death investigators.

Most first responders receive training on recognizing signs and symptoms of a potential overdose, and emergency medical and firefighting personnel generally receive additional training for providing medical treatment for those who are under the influence. To avoid exposure to fentanyl, potentially causing a deadly situation for the first responder, additional training is needed about what to do during exposure and how to safely provide naloxone or other medical care. DEA’s safety guide for fentanyl specifically outlines a history of inconsistent and misinformation about fentanyl exposure and treatment. Creating an evidence-based training program that can be distributed virtually and allow first responders to earn continuing education credit can decrease exposure incidents and increase care and responsiveness for those who have overdosed.

While the focus is rightfully placed on first responders as the frontline of the opioid epidemic, medicolegal death investigators also serve a vital function at the intersection of public health and criminal justice. As the professionals who respond to scenes to investigate the circumstances (including cause and manner) surrounding death, medicolegal death investigators must be able to recognize signs of drug toxicity. Training is needed to provide foundational knowledge on deciphering evidence of potential overdose-related deaths, photographing scenes and evidence to share with forensic pathologists, and memorializing the findings to provide an accurate manner of death. Causes of death, as determined by forensic pathologists, need appropriate postmortem examinations and toxicology testing for accuracy, incorporated with standardized wording for death certificates to reflect the drugs contributing to the death. Statistics on drug-related deaths collected by the CDC and public health departments nationwide rely on accurate death certificates to determine trends.

The CDC created the Collaborating Office for Medical Examiners and Coroners (COMEC) in 2022 to provide public health support for medicolegal death investigation professionals. COMEC coordinates health surveillance efforts in the medicolegal community and champions quality investigations and accurate certification of death. The CDC offers free virtual, asynchronous training for investigating and certifying drug toxicity deaths, though the program is not well known or advertised, and there is no ability to ask questions of professionals to aid in understanding the content. Funding is needed to provide no-cost, live instruction, preferably in person, to medicolegal offices, as well as continuing education hours and thorough training on investigating potential drug toxicity-related deaths and accurately certifying death certificates.

Cumulatively, the roughly 2,000 medicolegal death investigation agencies nationwide investigated more than 600,000 deaths in 2018, running on an average budget of $470,000 per agency. Of these agencies, less than 45% had a computerized case management system, which can significantly delay data sharing with public health and allied agencies and reduce reporting accuracy, and only 75% had access to the internet outside of their personally owned devices. Funding is needed to modernize and extend the infrastructure for medicolegal agencies to allow basic functions such as computerized case management systems and internet access, similar to grant funding from the National Network of Public Health Institutes.

Recommendation 5. Fund rapid and thorough toxicology testing in emergency departments and coroner/medical examiner agencies.

Rapid, accurate toxicology testing in an emergency department setting can be the difference between life and death treatment for a patient. Urine toxicology testing is fast, economical, and can be done at the bedside, though it cannot quantify the amount of drug and is not inclusive for emerging drugs. Funding for enhanced accurate toxicology testing in hospitals with emergency departments, including for novel psychoactive substances and opioid analogs, is necessary to provide critical information to attending physicians in a timely manner to allow reversal agents or other vital medical care to be performed.

With the limited resources medicolegal death investigation agencies have nationally and the average cost of $3000 per autopsy performed, administrators need to triage which deaths receive toxicology testing and how in-depth the testing will be. Advanced panels, including ever-changing novel psychoactive substances, are costly and can result in inaccurate cause of death reporting if not performed routinely. Funding should be provided to medicolegal death investigating agencies to subsidize toxicology testing costs to provide the most accurate drugs involved in the death. Accurate cause of death reporting will allow for timely public health surveillance to determine trends and surges of specific drugs. Precise cause of death information and detailed death investigations can significantly contribute to regional multidisciplinary overdose fatality review task forces that can identify potential intervention points to strengthen services and create evidence to build future life-saving action plans.

Recommendation 6. Enhance prevention and enforcement efforts.

DOJ should fund municipal and state law enforcement grants to use evidence-based practices to prevent and enforce drug-related crimes. Grant applications should include a review of the National Institute of Justice’s CrimeSolutions.gov practices in determining potential effectiveness or using foundational knowledge to build innovative, region-specific efforts. The funding should be through competitive grants, requiring an analysis of local trends and efforts and a detailed evaluation and research dissemination plan. Competitive grant funding should also be available for community groups and programs focusing on prevention and access to naloxone.

An often overlooked area of prevention is for justice-involved individuals who enter jail or prison with substance use disorders. Approximately 65% of prisoners in the United States have a substance abuse order, and an additional 20% of prisoners were under the influence of drugs or alcohol when they committed their crime. About 15% of the incarcerated population was formally diagnosed with an opioid use disorder. Medications are available to assist with opioid use disorder treatments that can reduce relapses and post-incarceration toxicity-related deaths, though less than 15% of correctional systems offer medication-assisted opioid use treatments. Extensive case management coupled with trained professionals to prescribe medication-assisted treatment can help reduce opioid-related relapses and overdoses when justice-involved individuals are released to their communities, with the potential to reduce recidivism if treatment is maintained.

DEA should lead local and state law enforcement training on recognizing drug trends, creating regional taskforces for data-sharing and enforcement focus, and organizing drug takeback days. Removing unused prescription medications from homes can reduce overdoses and remove access to unauthorized users, including children and adolescents. Funding to increase collection sites, assist in the expensive process of properly destroying drugs, and advertising takeback days and locations can reduce the amount of available prescription medications that can result in an overdose. 

DHS, TREAS, and DOS should expand their current efforts in international trafficking investigations, create additional sanctions against businesses and individuals illegally selling precursor chemicals, and collaborate with countries to universally reduce drug production.

Budget Proposal

A budget of $800 million is proposed to evaluate the current efficacy of drug prevention and enforcement efforts, fund prevention and enforcement efforts, improve training for first responders and medicolegal death investigators, increase rapid and accurate toxicology testing in emergency and medicolegal settings, and enhance collaboration between law enforcement agencies. The foundational research on the efficacy of current enforcement, preventative efforts, and surveillance should receive $25 million, with findings transparently available and shared with practitioners, lawmakers, and community members to hone current practices.

DOJ should receive $375 million to fund grants; collaborative enforcement efforts between local, state, and federal agencies; preventative strategies and programs; training for first responders; and safe drug disposal programs.

CDC should receive $250 million to fund the training of medicolegal death investigators to recognize and appropriately document potential drug toxicity-related deaths, modernize data and reporting systems to assist with accurate surveillance, and provide improved toxicology testing options to emergency departments and medicolegal offices to assist with appropriate diagnoses. Funding should also be used to enhance current data collection efforts with the Overdose to Action program³⁴ by encouraging timely submissions, simplifying the submission process, and helping create or support overdose fatality review teams to determine potential intervention points.

ED should receive $75 million to develop curricula for K-12 and colleges to raise awareness of the dangers of opioids and prevent usage. The curriculum should be made publicly available for access by parents, community groups, and other organizations to increase its usage and reach as many people as possible.

BOP should receive $25 million to provide opioid use disorder medication-assisted treatments by trained clinicians and extensive case management to assist in reducing post-incarceration relapse and drug toxicity-related deaths. The policies, procedures, and steps to create medication-assisted programming should be shared with state corrections departments and county jails to build into their programming to expand use in carceral settings and assist in reducing drug toxicity-related deaths at all incarceration levels.

DOS, DHS, and TREAS should jointly receive $50 million to strengthen their current international investigations and collaborations to stop drug trafficking, the manufacture and sales of precursors, and combating organized crime’s association with the illegal drug markets.

Conclusion

Opioid-related overdoses and deaths continue to needlessly and negatively affect society, with parents burying children, sometimes infants, in an unnatural order. With the low cost of fentanyl production and the high return on investment, fentanyl is commonly added to illicit drugs and counterfeit, real-looking prescription pills. Opioid addiction and fatal overdoses affect all genders, races, ethnicities, and socioeconomic statuses, with no end to this deadly path in sight. Combining public health surveillance with enforcement actions, preventative education, and innovative programming is the most promising framework for saving lives nationally.

Firearm-related violence is tearing apart the social fabric in the United States. Communities continue to be negatively impacted by the increasing rates of firearm violence, with guns being the leading cause of death for children and young adults (1-19 years of age). Gun-related violence killed over 48,000 people in 2022, a 21% increase from 2019. With more than 130 people dying from firearm-related injuries every day, the Centers for Disease Control and Prevention (CDC) have deemed firearm violence a serious public health issue. While it is challenging to place a dollar amount on the loss of life, injuries, and immediate costs of violence, gun-related violence costs an estimated $557 billion annually, double the U.S. Department of Education Budget for FY 23-24. With the dual epidemic of gun violence and the opioid crisis, coupled with decreased staffing since the COVID-19 pandemic, law enforcement agencies are rapidly running out of resources to battle gun violence to reduce deaths, injuries, and other victimization. A multifaceted approach to preventing gun violence must unite law enforcement, public health, forensic science, community organizations, and education to save lives and reduce continued violence-related trauma.

The Biden-Harris Administration should fund actionable, evidence-based programs for law enforcement, crime laboratories, community organizations, disaster response, and robust data surveillance systems. The Department of Justice (DOJ) would be ideal to provide resources from a law enforcement and forensic science perspective, aided by the CDC, the Department of Commerce (DOC), and the Federal Emergency Management Agency (FEMA) to assist with data collection and analysis, developing standards, and supporting communities impacted by violence. Key recommendations for the prevention of firearm-related violence include:

• Fund law enforcement, crime laboratories, community organizations, and data surveillance.
• Create firearm-related gun violence hubs to support law enforcement efforts.
• Preventative education for youth and adults.
• Provide support to communities recovering from gun violence.

Challenge and Opportunity

Firearm violence continues to significantly affect our communities. Every 11 minutes, someone dies from firearm-related injuries. Underrepresented minority men, especially teens and young adults, account for most firearm deaths. From 2000 to 2020, African Americans were nearly 12 times more likely to be killed in a firearm-related homicide than white Americans. The racial and gender inequities of firearm violence bleed into the community, where disadvantaged and at-risk youth are exposed to high violent crime rates through direct and indirect exposure. Firearm-related violence is associated with many factors, including concentrated disadvantage from areas with high median incomes and significant levels of poverty, racial segregation, poor current and historical police-community relationships, and institutional racism. The media also perpetuates stereotypes of young African American males as assailants but less commonly as victims, putting less importance on the lives of African Americans in the news cycle. Determining the many factors causing gun violence can help prevent further injuries, improve community safety, and transition at-risk youth to at-promise.

In the first eleven months of 2023, there were 619 mass shootings with four or more people shot in the United States, nearly double the number of mass shootings in all of 2017. These mass shootings include school shootings, with 46 shootings in 2022 and 27 in the first nine months of 2023. The shootings resulted in four deaths and 18 injuries, with over 25,600 students on the school campus when the shootings occurred. These do not include shootings on college or university campuses, including two in 2023 at Michigan State University, the University of North Carolina Chapel Hill, and Morgan State University, which resulted in four deaths and 10 injuries. The Morgan State University shooting suspect had a previous felony gun charge that was transitioned to a misdemeanor during a plea bargain, allowing him to purchase guns after his conviction.

The newly established White House Office of Gun Violence Prevention (OGVP) will be monitored by Vice President Harris and aligned with the March 2023 Executive Order to increase firearm purchase background checks and increase red flag laws to remove firearms from perceived dangerous persons. Executive Order 14092 also focuses on firearms reported lost or stolen during the transportation of weapons from the manufacturer to federally licensed firearm dealers, with over 6000 guns lost or stolen during the shipping process in 2022 alone. A renewed focus on the Bipartisan Safer Communities Act of 2022 requires the Secretaries of Health and Human Services, Homeland Security, and Education to provide reports to the President about actions taken to implement the Act and how public awareness and resources were made available to maximize the effects of the Act. Particular attention should be placed on privately made firearms (PMFs), also known as ghost guns, which saw a 1,038% rise in recoveries from 2017 to 2021 and can be easily obtained and constructed without restriction or tracking in most states. Only 13 states have laws restricting PMFs, with the restrictions ranging from requiring serial numbers to background checks for component purchases and not allowing 3D print instructions to be shared (Figure 1). With firearms being deeply rooted in American culture, including being memorialized in the Second Amendment of the Constitution, legal challenges will continue as gun technology changes, new equipment develops to enhance current weapons, and weaponry continues to be available through illicit means, curtailing laws and restrictions.

While laws provide a basis for criminality, law enforcement action is needed to recognize and investigate gun-related crimes, and district attorneys must commit to prosecuting crimes. Significant staffing issues continue to plague law enforcement, limiting the ability to reduce violent crime, act proactively, and work with the community to build healthy relationships. Forensic evidence collection and processing are vital to investigation and prosecution, requiring personnel, training, standards, and technology that is not universally accessible to criminal justice agencies. Law enforcement participation in task forces and collaboration with federal, state, and local partners, including prosecutors, can reduce gun violence but requires significant resources and personnel that are not currently available in all jurisdictions. Law enforcement agencies publicly stating they will not enforce gun laws and emergency orders work against the necessary joint vision and actions needed to reduce violence. 

Examining the efficacy of past firearm-related crime interventions and community efforts while seeking innovative solutions can help build robust and successful gun violence prevention efforts across the nation. No single program or intervention will work for all jurisdictions, so data-driven implementation and research efforts will be required for each community to adequately combat firearm-related crime. Community-based intervention programs vary from local nonprofit organizations and religious groups to national think tanks working with the common goal of reducing violence and improving community well-being. As the causes of gun violence vary by community and region, having non-law-enforcement entities and social workers employed in collaboration with criminal justice agencies may improve well-being and safety while reducing violence. Treating gun violence as a public health issue is an important allied approach to enforcement since public health focuses on research-based avenues to reduce morbidity and mortality. A public health lens can assist in examining societal structural and social factors while reducing the political aspect that can affect gun violence tactics. Public-health-related gun violence research was severely limited by the Dickey Amendment in 1996, which restricted federal funds to advance gun control or gun violence research. With the 2018 omnibus spending bill passed to support firearm-related research, there has not been a significant change to funding, continuing to limit funding for the CDC to research the causes of gun violence.

Plan of Action

Addressing the many aspects of gun violence, including preventative education, requires a multifaceted approach. Collaboration between federal, state, and local government agencies and community organizations is necessary to determine and address gun violence and preventative efforts. The additional details of federal agency involvement and their governmental roles are below.

Recommendation 1. Fund law enforcement, crime laboratories, community organizations, and data surveillance. 

The DOJ should fund action-oriented efforts for states and local law enforcement agencies to focus on reducing firearm-related violence. Creating regional task forces can assist in data-sharing and firearm-specific crime reduction tactics with additional resources and personnel. Funding should also be available to update report management systems to assist with evidence tracking, trends to modified weapons, and types of magazines used, especially the involvement of extended magazines.

Funding of accredited crime laboratories can help expand the use of the National Integrated Ballistics Information Network (NIBIN), which allows cartridge cases found at crime scenes to be matched to guns and other crimes. Training additional ballistics specialists and increasing NIBIN submissions can link more crimes and increase enforcement efforts. NIST should develop and broadcast standards for ballistic evidence collection and processing to assist law enforcement and forensic scientists in improving evidence recovery and analysis as technology and techniques improve. With firearm evidence backlogs persisting, funds for personnel, equipment, and processing costs to assist with the timely submission of firearm-related crime evidence are necessary to improve evidence collection and processing efforts. 

The DOJ should also fund community violence intervention programs spearheaded by local nonprofit and street outreach organizations. With continued distrust of police, especially in the most violent of areas, community-based intervention programs can focus on crime prevention through environmental design, working with at-risk/at-promise youth, and mediating conflicts that do not escalate to require law enforcement intervention.

All DOJ funding should require successful evidence-based practices, such as those outlined in the National Institute of Justice’s CrimeSolutions.gov, and data collection and evaluation to determine effectiveness. Funding should be competitive grants, studying trends, root causes, and community efforts to reduce gun violence. Researchers should convene at a national firearm-related crime prevention symposium to discuss findings, determine regional and national trends, and outline recommendations to prevent firearm violence.

The CDC should fund real-time data collection efforts to support the National Crime Victimization Survey by hiring more epidemiologists and data entry specialists, expanding current research efforts on firearm violence and injury prevention, and public health-related grants focused on reducing firearm morbidity and mortality. Research and reports, especially resources for action, should be expanded to include firearm-related injuries and deaths and assist with providing comprehensive planning and policy work to communities to combat gun violence. Data modernization efforts are needed to encourage auto-reporting of gun-related incidents from law enforcement, emergency medical services, and hospitals to increase accuracy and real-time reporting and surveillance.

Recommendation 2. Create firearms-related gun violence hubs to support law enforcement efforts. 

Gun violence hubs are regional resources involving multiple levels of criminal justice agencies to share data, assets, and strategies. A hub in central Ohio involves local and state law enforcement, a narcotics intelligence center, Attorney General investigators, and the ATF, which has been vital to linking crimes and aiding in gun crime prosecution. While some large law enforcement agencies, such as Los Angeles and New York City Police Departments, have the resources to run gun crime-related intelligence centers with in-house investigative and forensic personnel with modern technology, most agencies do not have similar capital. Federally funded state-wide or regional hubs in larger states can provide the necessary personnel, funding, and intelligence to battle gun violence while incorporating community intervention programs to ensure alignment with efforts. Vigorous research on efforts and robust data sets are needed to accurately guide future interventions and actions, instead of anecdotal evidence relating to policy implementation that can currently shape programming. The research results should also be made available open-source and presented at local, state, and national levels to share information about implementation and findings.

Increasing communication and pooling resources can help break down traditional silos in local, state, and federal law enforcement. Incorporating community groups into gun violence prevention efforts can bring information and programming closer to the people who need assistance without directly incorporating law enforcement with community efforts. Community violence intervention programs, targeting the most at-risk of victimization and breaking cycles of retaliatory violence, can work in concert with law enforcement efforts, sharing data and resources. Community programs can also assist in using a public health and racial equity lens to determine the root causes of violence and advocate for victims in underserved communities.

Recommendation 3. Develop preventative education for youth and adults.

The Department of Education should create gun violence prevention education and integrate it into all levels of education. The educational program should focus on gun safety when guns are encountered at home; handling pressure to participate in violent activities, including gang membership; situational awareness and safety in mass shooting situations; and anger management. The educational efforts for students can be extended to adults through social media marketing with television and streaming service advertisements. The DOJ should enhance educational requirements when purchasing weapons and ammunition. The DOJ should also complete widespread information sharing about red flag laws for reporting someone who exhibits risks of violence to help save lives while protecting the rights of the person reported.

Advertising to youth was shown to promote tobacco usage, and marketing was also shown to influence gender and ethnic communities to use tobacco. The CDC can evaluate how gun manufacturers market firearms to minors to determine how the marketing can affect health trajectory. 

Recommendation 4. Provide support to help communities recover from gun violence.

Over 4,500 children and teenagers were killed by gunfire in 2022, making gun violence the leading cause of death for this age group. From 2013 to 2022, there was an 87% increase in gun deaths of children and teenagers, with Black youth 20 times more likely to be killed by firearm violence than white youth. The racial disparity in firearm-related deaths can be tied to generational inequities in our health, housing, justice, and educational systems coupled with police mistrust and hurdles to access victim services. Community violence, especially when children and teenagers are shot and survive, has a significantly negative impact on mental health and substance abuse. In the year after a child or adolescent suffered a gunshot injury, research found a nearly 120% increase in pain disorders, an almost 70% increase in psychiatric disorders, and a nearly 145% increase in substance abuse disorders. Parents of survivors have an approximately 30% increase in psychiatric disorders with a reduction of mother and sibling routine healthcare appointments. The mental health and disorder effects on children and adolescents were similar to adult gun violence survivors, who also had significantly increased healthcare costs post-injury. Gun violence effects ripple far from the victims and families and also affect community mental health and healthcare costs.

FEMA offers financial, medical, and mental health resources during and after disasters while working to improve preparedness, response, and recovery efforts from hazards. Traditionally, FEMA response has been to declare disasters, primarily natural disasters, governed by legal authorities of disaster response. New Mexico Governor Michelle Lujan Grisham declared a public health emergency in September 2023 relating to gun violence, though the emergency did not enact a federal response or recovery from FEMA. New York Governor Andrew Cuomo formally declared a disaster due to gun violence in July 2021 via executive order, which was extended in April 2023. FEMA helped ensure Medicare was extended through the disaster time frame, though no other federal resources were provided. Amendments to disaster acts should include mass shootings with eight or more injuries/deaths, which would be considered mass casualty incidents in many jurisdictions. Funding through FEMA can provide medical and other basic needs resources, enhance safety efforts, strengthen social infrastructure, and promote resilience. FEMA has funded similar programs around building resilient infrastructure relating to hazard mitigation with disasters and natural hazards, promoting partnerships, and building capacity for innovation. FEMA’s Office of Emerging Threats could be used to handle gun violence disaster requests, make connections between data and risk, and bring another layer of operational planning and response to communities from a recovery aspect. FEMA’s Preparedness grants can also be extended to include gun violence, another funding opportunity for local governments and communities.

Budget Proposal

A budget of $500 million over five years is proposed to evaluate the efficacy of current interventions; fund criminal justice, public health, and community intervention organizations; and create preventative gun violence-related education. The foundational research on the current interventions should receive $20 million, requiring transparent findings and a research conference available to practitioners, lawmakers, and community members to share data and assist with determining future research and grant-funding directions.

DOJ should receive $320 million to fund grants, collaborative efforts, community violence intervention programs, gun violence hubs, enhancement of evidence recovery and processing, and development of criminal justice-related standards to improve investigations and prosecution rates. Competitive grants should be offered in addition to guaranteed funding for states willing to create regional task forces and gun violence hubs. All funding should require an evaluation component with results available publicly without paywalls on the Office of Gun Violence Prevention website.

ED should receive $50 million to develop curricula to prevent gun violence and fully integrate it into the grade-specific curriculum for K-12 and require education in colleges. The educational materials created, especially at the college level, will be made public for use in community training programs, ads to reduce gun violence, and other applicable settings.

FEMA should receive $100 million to respond to communities affected by gun violence to provide a disaster response. The Federal Trade Commission should receive $5 million to investigate the marketing of firearms to youth and military-style weaponry. An evaluation of the entire proposal should be funded for $5 million after five to eight years of expected evaluative work. The final report will be made public, in addition to annual progress reports, and available transparently on government websites. 

Conclusion

Gun violence negatively affects the lives of Americans daily, with no end in sight. Firearm intervention efforts and enforcement tend to lack collaboration, data-driven insights, focus on root causes, and sustainable funding. The widespread exposure to gun violence and societal inequities in communities are generally not addressed, though they can lead to significant health and well-being impacts and a continued cycle of violence. Reducing gun violence requires a comprehensive approach through a public health lens involving community input and intervention while creating awareness of effective legal and policy strategies. 

A shared framework between all federal, state, and local agencies is necessary to align priorities, resources, and efforts to mobilize evidence-based initiatives, collect data, and prevent gun violence. Congregating researchers, practitioners, community members, and lawmakers at a firearm-related violence symposium to share efforts, research findings, and outline future paths will be vital to violence prevention nationally. Mobilizing disaster-response-level support to communities affected by gun violence and providing preventative education can provide resources to heal and help break the cycle of violence while providing opportunities for social mobility.

Medicolegal death investigations produce vital information on fatal illnesses and injuries in the United States, yet the system is fractured and underfunded. Less than half of deaths are reported and investigated by medicolegal death investigation agencies. In addition to providing cause and manner of death determinations, the investigations are instrumental in identifying public health trends, including early identification of the opioid epidemic and fatal fentanyl overdoses. Data from death investigations is used by over 40 federal agency programs in creating policies and regulations. Medicolegal death investigations agencies are generally underresourced, with insufficient infrastructure for data-sharing and computerized record management. These critical shortfalls are combined with a dire shortage of board-certified forensic pathologists to complete postmortem examinations and a lack of mass fatality preparedness, which can directly affect community health and well-being.

The last time medicolegal death investigation policies were reviewed by the Executive Branch was during the Obama Administration. In 2016, the National Science and Technology Council (NSTC) Committee on Science’s Medicolegal Death Investigation Working Group noted the essential role medicolegal death investigation agencies play in establishing a scientific cause and manner of death while serving public health and reporting emerging health threats. The working group outlined the importance of accrediting medicolegal death investigation offices and certifying medicolegal death investigators. In the seven years since the report, there has only been an increase of 23.7% in certified death investigators, with more jurisdictions requiring certification to maintain employment. The NSTC’s Fast-Track Action Committee found the need to improve infrastructure and support for medicolegal death investigation agencies to reinforce the integrity of public health and criminal justice systems.

Key recommendations for improving public health by advancing the medicolegal profession include:

• Creating national foundational medicolegal death investigation training standards.
• Funding data infrastructure modernization and enhanced surveillance efforts.
• Researching the current efficacy of mass fatality response policies and efforts to create standardized procedures.
• Increasing certification and accreditation to enhance professionalism, knowledge, and skills.
• Supporting forensic pathologist pathways and debt reduction.

Challenge and Opportunity

Medicolegal death investigation is at the intersection of medicine, public health, and the criminal justice system, yet it does not have a formal place in any system nationally. Public health trends, including early detection of outbreaks and emerging health threats, are found during autopsies and reported on death certificates. The data from death certificates is used in public health surveillance at a local, regional, state, and national level to determine trends and the impact of interventions, shape policy, and help recognize health disparities. The information from the death certificates is obtained through death scene investigations, evidence collection, medical record reviews, postmortem examinations, and toxicology testing, coupled with interviews of witnesses, family, and friends of the decedent. Data obtained during medicolegal death investigations not only provides an accurate cause and manner of death but also helps the living by showing the health of our communities and tracking death trends and health threats.

The coroner system in the United States stems from the English system dating to the 12th century. A physician-headed medical examiner system was created in Massachusetts in the late 1800s, leading to versions of our current systems. State statutes and local jurisdictional charters create the structure of medicolegal death investigation offices. There is no standardized medicolegal death investigation system across the United States. Coroners are typically elected officials who run for the political role through normal voting processes. Coroners can also be appointed based on the jurisdiction and are regularly non-medical professionals. In contrast, medical examiner’s offices generally have a physician leading the office, except in Wisconsin, where the appointed medical examiner can be a non-physician. The jurisdiction of a coroner or medical examiner’s office is most commonly a county, though 16 states have a centralized state medical examiner system. There are 14 states with a county or district-based coroner system, 14 states with a mixture of coroner and medical examiner offices, and six states with county or district medical examiner systems. Texas has Justice of the Peace positions where the elected role hears misdemeanor, traffic, and civil disputes in addition to holding medicolegal duties without a requirement for any legal or medical experience or education. California is unique with four different medicolegal investigation agency types, including a Sheriff-Coroner, Coroner, Medical Examiner, and Coroner-Medical Examiner. The Sheriff-Coroner’s position, which is in 48 of California’s 58 counties, is the most contentious due to concerns about the independence of investigations when the medicolegal agency head also serves as the sheriff. A 2022 attempt to separate sheriff and coroner positions was unsuccessful. Medicolegal death investigation agencies range from having one part-time elected official responsible for the entire jurisdiction to having over 100 employees, with most agencies across the nation having few full-time employees and significantly limited resources.

The varied names and jurisdictions for medicolegal death investigation offices do not change the foundation of the duties: investigating unexpected and unnatural deaths. Typically, the medicolegal death investigation agency receives a call from a law enforcement agency, medical first responder, hospital, care facility, or other medical professional to report a death. Basic demographic information, the known circumstances behind the death, medical history, and other vital information are obtained to determine jurisdiction. Based on agency practices and state law, the medicolegal death investigator may respond to the death scene to assume jurisdiction and custody of the decedent. For natural deaths where a physician will certify the death to natural causes, the medicolegal death investigator may be able to release the decedent to a funeral home or mortuary of the family’s choice. When a medicolegal death scene investigation is required, the investigation includes photography, collecting evidence, identifying the decedent, locating and notifying kin, writing an investigative report, and providing information to the forensic pathologist, who will determine the cause of death. Death certificates are commonly generated by the medicolegal office, with the manner of death determined by the chief medicolegal officer. Medicolegal death investigation offices are also tasked with identifying decedents, which may require advanced scientific testing. Less than 50% of medicolegal agencies collect DNA samples from unidentified decedents, which is essential in present-day scientific identification and adds information to national databases. Not collecting DNA can significantly delay the identification of decedents and notification to friends and family of missing and unidentified people.

Medicolegal death investigation offices also participate in specialized fatality review teams, which include multidisciplinary stakeholders from social services, public health, law enforcement, emergency medical services, and other areas to find systemic gaps in treatment and identify potential missed intervention points. Fatality review teams can be regional and can include overdose fatality review, infant and child death fatality review, domestic violence fatality review, and elder abuse fatality review. Meeting findings are summarized into actionable items to prevent future deaths. The medicolegal investigative and autopsy reports and the reviewed medical and social history provide the requisite information to allow the multidisciplinary teams to make prevention determinations. 

Medicolegal death investigation agencies report to local, state, and national organizations to assist with surveillance and injury prevention. Many states require medicolegal death investigators to report workplace injuries and deaths to the regional Occupational Safety and Health Administration branch, with death certificates reporting contagious diseases and drug toxicity-related deaths to local health departments. The United States Consumer Product Safety Commission relies on medical examiners and coroners to report consumer product-related deaths so they can further investigate products, create appropriate warning labels, and potentially prevent injuries and deaths. For deaths relating to medical misadventure, medicolegal death investigation agencies must also report deaths to the state medical board, dental board, nursing board, or county-level emergency medical services board. There are two national reporting systems, both overseen by the Centers for Disease Control and Prevention (CDC), for violent deaths and overdoses. The National Violent Death Reporting System records violent death data from medicolegal and law enforcement reports to link over 600 data points to create a context behind the death and develop violence prevention strategies. The State Unintentional Drug Overdose Reporting System oversees 49 states and Washington, DC, to obtain inclusive overdose fatality data. The data includes information on the known circumstances behind the death and identification of the substances involved to gain nearly real-time information about emerging drug threats and determine the effect of prevention efforts. Coroner and medical examiner agencies may also be required to enter unidentified persons into missing and unidentified person systems and the National Missing and Unidentified Persons System to assist with future identification efforts. Data review and entry are complicated, with limited resources, a lack of case management systems, and time constraints with part-time employee offices.

The data and information obtained from medicolegal death investigations have many uses that can assist in local, state, and national prevention efforts. The challenges for the reporting systems are that they are voluntary, and many agencies do not have the resources to provide hundreds of data sources to multiple systems. Having data organized and in a searchable database is key for access and data-sharing, though less than 50% of medicolegal offices with a population of less than 250,000 people have a computerized case management system. Only 87% of agencies with a population of over 250,000 people have a case management system, with 40% of coroner offices not having internet access outside of their personal devices. Computerized case management systems help reduce errors and lost paperwork while increasing efficiency and resource allocation. Less than 70% of coroner offices have access to fingerprint databases, compared to 91% of medical examiner agencies, and 82% of agencies have access to bloodborne pathogen training. The average budget of a medicolegal office is $470,000, with each decedent autopsy and investigation costing approximately $3000. With about 2,040 medicolegal death investigation offices nationally and almost 11,000 full-time equivalent employees, there is an average of just five full-time employees per office. A large portion of the budget is commonly spent on personnel, leaving little funding for improving infrastructure and training.

There is no standardized oversight or required training of medicolegal death investigation personnel. Only 16 states require training for medicolegal death investigations. For example, California requires 80 hours of training for medicolegal death investigators, the highest of all state requirements. In contrast, New York requires training for the coroner and deputy coroners but does not outline the required number of hours or duration. The American Board of Medicolegal Death Investigators (ABMDI) is a national certifying board that the Forensic Specialties Accreditation Board accredits. ABMDI tests medicolegal death investigators on foundational and advanced knowledge, awarding registry and board certifications. ABMDI certification requires continuing education to maintain certification, though most medicolegal agencies do not require certification for employment. The lack of standardized training of medicolegal death investigation personnel can lead to gaps in knowledge and recognizing evidence, dramatically reducing the accuracy of death certificates and reporting. Limited budgets, personnel, and resources contribute to a lack of investigative awareness that can lead to incorrect causes and manners of death. Inaccuracies on death certificates can have a profoundly negative effect on families and the community and contribute to public mistrust.

Training is not the only constraint in accurate and timely medicolegal death investigations. There is an extreme shortage of board-certified forensic pathologists, who are the physicians conducting postmortem examinations and determining the cause of death. In 2020, there were approximately 500 practicing forensic pathologists, but the workload required 1,280 forensic pathologists. The gap is now likely even greater, with workloads having increased with the rise of the opioid epidemic, fentanyl deaths, gun violence, and COVID-19. The 2018 coroner/medical examiner census noted 890 forensic pathologists employed by medicolegal agencies, though forensic pathologists commonly work in neighboring counties or other states as a locum tenens, a temporary, per-diem physician. The shared nature of some forensic pathologists inflates the number of physicians who appear to be working, shrouding the significantly lower number of practicing physicians. In medical examiner officers, such as in Los Angeles and New York City, the department head is a forensic pathologist assigned solely to administrative work, limiting the number of available forensic pathologists to complete postmortem examinations. Some jurisdictions resort to using non-board-certified forensic pathologists for postmortem examinations, which can result in inaccurate causes and manners of death. The lack of available forensic pathologists also allows for non-qualified people to falsify credentials and autopsy reports, even in high-profile cases, defrauding grieving people and the government alike. A 2015 report on increasing the number of board-certified forensic pathologists mentioned that physicians should work in a nationally accredited office. Agency accreditation is important to ensure proper working conditions and a high standard for policies and procedures to create an environment for the best possible medicolegal death investigations. Yet the last coroner/medical examiner census showed that only 17% of medicolegal death investigation offices were accredited. Some agencies will never be able to reach accreditation, as there is a limit of 325 autopsies per year, and workload shortages restrict the number of available forensic pathologists to complete autopsies.

The medicolegal profession is highlighted in the media in high-profile deaths and mass fatality situations. A significant amount of time and effort by medicolegal administrators should be devoted to mass fatality planning to provide an efficient, effective response, coordinate with allied agencies, and safely recover and identify decedents. There is no specific number for what constitutes a mass fatality incident, as mass fatality is when the number of deaths exceeds agency resources. In some jurisdictions, a mass fatality may be three decedents from one incident, while others may request allied resources when 50 decedents are from an incident, such as in the October 1, 2017 mass shooting in Las Vegas, NV. All states have an Office of Emergency Response or similarly named emergency response commission, where medicolegal death investigation agencies should be integrated into mutual aid and planning committees. There are significant limitations with the response to and accurate handling of medicolegal death investigations without a case management system and internet access, impacting smaller and underresourced jurisdictions.  The federal-level Disaster Mortuary Operational Response Team (DMORT), run by the National Disaster Medical System, deploys to mass fatality scenes to assist with recovery, examination, identification, and collecting ante- and postmortem decedent data. DMORT responds with qualified personnel, including forensic pathologists and investigators, to set up a mobile autopsy suite and bring decedent storage facilities. With the high cost of deployment, DMORT only responds to large-scale mass fatality scenes and needs to be requested by a state Office of Emergency of Response when other mutual aid responses have been exhausted. A vast majority of medicolegal agencies lack the resources to handle a mass fatality. Less than 30% of agencies had specialized response training, and nearly half of agencies reported that they were only moderately prepared for a mass fatality.

The challenges of advancing mass fatality planning and improving medicolegal infrastructure are restricted by agency budgets and limited grant funding. Due to the specialty of the field and because it crosses the medicine, public health, and the criminal justice systems, there are few federal grant opportunities. The Bureau of Justice Assistance’s Strengthening the Medical Examiner-Coroner System Program helps with accreditation, including purchasing supplies and upgrades to meet standards and assisting with funding for forensic pathology fellowships. There were 14 awards in 2023 totaling over $2 million, with funding ranging from $53,878 to $300,000. Most of the awards were to larger agencies, including Los Angeles and New York City, where there are resources for grant writing and administration. The competitive Paul Coverdell Forensic Science Improvement Grant Program is offered to forensic science and medicolegal agencies with forensic science laboratories. In 2023, more than $4.6 million was awarded to 15 agencies, with only one grant awarded to a medicolegal death investigation agency. The National Network of Public Health Institutes funded $200,000 to 10 medicolegal death investigation agencies in 2023 to improve data collection from medicolegal agencies for surveillance of overdose-related mortality reporting. Nationwide, there are more than 2,000 medicolegal death investigation agencies, but in 2023 just 25 received federal or national-level grant funding.

Plan of Action

A multi-stage, multi-agency approach is needed to improve medicolegal death investigations in the United States to provide accurate mortality data to shape prevention and policy efforts. In addition to increasing minimum medicolegal death investigation operating budgets, funding is needed to improve training, attract physicians to forensic pathology, and advance infrastructure upgrades for timely and accurate mortality data reporting. National standards for medicolegal death investigation should be established and integrated into state systems for reliable, reproducible, and scientifically valid investigative results and analysis.

Recommendation 1. Create national foundational training standards.

Building from the National Institute of Justice’s 2011 Death Investigation: A Guide for the Scene Investigator Technical Update and fundamental tasks of medicolegal death investigation from the American Board of Medicolegal Death Investigators, the NIST should convene a multidisciplinary group of subject matter experts to develop foundational training standards guided by NIST’s Organized Scientific Area Committees for Forensic Science best practices and standards. The DOL should be involved in reviewing and structuring training standards and programming from a labor and workforce perspective. Subject matter experts should determine a continuing education structure to allow for continuous training for contemporary topics in the field, similar to requirements for maintaining medical licensure. Although NIST is not an enforcing agency, the created standards should be made widely available to state legislation and the medicolegal community. States that adopt the standards should have access to additional NIJ funding to improve medicolegal offices. Similar to NIJ funding requiring credentials for discretionary funding for law enforcement agencies for use-of-force policies and the prohibition of chokeholds, the discretionary funding can be limited to agencies that have adopted the NIST standards.   

Funding for training should be available through grants and legislation for funding from burial permits. Since 1991, California has designated $1 from each burial permit to fund medicolegal death investigation training. Creating similar legislation for every state can allow for sustainable funding for continued training, alleviating the need for continued federal funding.

Foundational training standards will create a minimum and standardized training nationally to improve medicolegal death investigations and utilize best practices to best serve communities. The training will also allow medicolegal death investigation agencies to provide more accurate and timely data for public health surveillance and participate in multidisciplinary task forces, which can potentially reduce future deaths. Requirements for foundational and continued training can be shared widely by COMEC, with virtual training programs created by COMEC and available for continuing education credit. COMEC currently hosts virtual training for sudden unexpected infant death investigation, the investigation and certification of drug toxicity-related deaths, and death investigation after natural disasters and radiation emergencies. Existing training and structure can be used to create and distribute foundational training and continuing education at a national level without reinventing a new nationally available website and training structure.

Recommendation 2. Fund data infrastructure modernization and enhanced surveillance efforts.

The health of communities lies in early recognition and timely reporting of causes of death. With less than 50% of medicolegal death investigation agencies having a computerized case management system and under 40% of coroner offices having business-related internet access, the field cannot progress without a significant investment in infrastructure. The lack of computerized case management will continue to severely limit timely data-sharing with local, state, and federal public health agencies, restricting near real-time analysis of death trends and disease tracking. Public health surveillance of mortality data assists in recognition, intervention, and preventive efforts, which cannot be accurately completed without timely and complete data from medicolegal death investigation agencies.

With the current state of the opioid epidemic and fentanyl drug toxicity-related deaths, rapid and accurate toxicology testing is needed for public health surveillance. Advanced toxicology panels, including the ever-growing novel psychoactive substances, are expensive, and agencies need to make difficult budgetary decisions around personnel and toxicology testing. Funding is needed to subsidize advanced, rapid toxicology testing to provide the most accurate types of drugs involved with the death. Additional funding, awarded through a cooperative agreement by the CDC, should be allocated to advanced panel toxicology testing and the purchase of rapid toxicology screening machines that can be housed in the medicolegal office. Rapid toxicology screening machines do not quantify all drug levels, which commonly requires secondary toxicology testing through an accredited laboratory. But the screening does allow for nearly immediate identification of fatal drug trends, allowing for early notification to public health officials. The NIJ should specifically request research and development of a rapid toxicology testing process with an accuracy level that does not require secondary testing in their research grant for forensic science for criminal justice purposes to provide additional options for medicolegal agencies. The precise cause of death, involved drugs, and thorough investigations significantly contribute to multidisciplinary overdose fatality review teams. The fatality review teams can use the information to identify timely intervention strategies and strengthen services to reduce future drug toxicity-related deaths in near real-time.

Recommendation 3. Research the current efficacy of mass fatality response policies and efforts to create standardized procedures.

In the focus on current caseload and office needs, mass fatality preparedness and training tend to be overlooked. This deprioritization is dangerous for medicolegal death investigation personnel responding to scenes and is concerning for the community with underprepared and underresourced investigators working to navigate a mass fatality incident. The declaration of a federal state of emergency does not always provide funding for medicolegal death investigation agencies for fatality management operations, and the nature of the mass fatality may limit mutual aid response to assist jurisdictions, such as in the case of earthquakes, biological acts of terrorism, and other large-scale natural disasters. Research is needed to determine best practices in mass fatality planning and resourcing for all jurisdictional sizes, including determining the current state of planning and available resources. DOJ should fund the research through BJA or BJS via a grant process to find the most qualified and knowledgeable researchers. Findings should be shared widely via open-source academic journals, at national and regional medicolegal conferences, and via webinars to ensure the information is readily available. The findings should also be published in a guide on the DOJ website to assist agencies in creating personalized mass fatality plans and practical exercises.

Recommendation 4. Increase certification and accreditation to enhance professionalism, knowledge, and skills.

The National Commission on Forensic Science supported recommendations for the accreditation of medicolegal death investigation offices and the certification of medicolegal death investigators in 2015. Despite these recommendations, only 17% of medicolegal death investigation offices were accredited in 2018. In November 2023, there were 2,049 actively certified diplomates with the American Board of Medicolegal Death Investigators, from an approximate 11,000 full-time equivalent positions,  totaling approximately 19% of full-time equivalent medicolegal death investigators. Increasing the number of accredited offices and certified medicolegal death investigators can provide consistency in practice, improve data quality, enhance facilities, incorporate evidence-based best practices, and elevate surveillance efforts. 

Recommendation 5. Support forensic pathologist pathways and debt reduction.

There is no end in sight to the critical shortage of forensic pathologists, who are neutral scientists specializing in determining the cause of death while providing valuable data for public health surveillance. A federal grant is available to provide a stipend for forensic pathology fellows in training, including limited loan repayment and travel for fellowship recruitment. Funding is limited and requires medicolegal death investigation agencies to be knowledgeable about the grants and be awarded funding. A more grassroots approach to creating more forensic pathologists should begin earlier, both in medical school and in offering scholarships for current medicolegal investigative personnel to attend medical school to become forensic pathologists. The field should be highlighted during the early years of medical school, requiring a rotation through a local medicolegal death investigation office, and increasing residency and fellowship pay to encourage physicians to enter the field and become board-certified. Similar to other loan repayment programs, loan forgiveness for forensic pathologists should be reduced to five years in public practice as a board-certified forensic pathologist. Funding should be provided to medical schools, residency, and fellowship programs and not dependent on a limited competitive federal grant funding process.

Budget Proposal

A budget of $90 million is proposed to create national medicolegal death investigation training standards, fund data infrastructure modernization and enhance surveillance efforts, research the current efficacy of mass fatality response, increase medicolegal certification and accreditation, and support forensic pathologist career pathways. NIST should receive $2.5 million to hire and support subject matter experts to create the national foundational medicolegal death investigation training standards. The DOL should be awarded $500,000 to support standards development with a focus on the workforce and labor. Circulating the standards through a standards-developing agency, such as the American Academy of Forensic Science’s Academy Standards Board, should occur at no cost.

The CDC should be provided with $32 million to create and manage low-barrier infrastructure improvement grants focusing on smaller and medium medicolegal jurisdictions to ensure agencies have computerized case management systems and basic internet connection at a minimum. Medicolegal death investigation data elements for reporting and information exchange have been outlined by the Medicolegal Death Investigation Subcommittee of NIST’s Organization of Scientific Area Committees, providing a baseline of data needs for a computerized case management system. At least $1 million of the funding should focus on low-barrier scholarship-type funding for individual medicolegal death investigator certification, with the certifying agency accredited by the Forensic Specialties Accreditation Board for monitoring professional board certification. At least $5 million should be available for low-barrier grants to assist medicolegal agencies in achieving accreditation through one of the two medicolegal death investigation agency accreditation boards. Annual reporting on the number of agencies and individuals funded for infrastructure improvements, accreditation, and certification should be transparently listed on the CDC funding website.

The DOJ should receive $4 million for nationwide research on the efficacy of mass fatality response policies and the creation of standardized procedures. Portions of the funding should be dedicated to open-source publishing to allow broad access to the research findings, with a guide on best practices and standards made available on a federal government website to help agencies create and hone their policies. The information should also be presented at national, state, and regional medicolegal and forensic science conferences with at least one recorded webinar to provide data and support to the most agencies possible. 

Similar to providing grants for physicians and healthcare professionals to work in health professional shortage areas, medically underserved areas, or primary care shortage areas, funding should be provided to state Departments of Health Care Access and Information or similarly positioned state-level departments. Each state and the District of Columbia should receive $1 million for scholarships, loan forgiveness, and fellowship reimbursement for physicians on track to become board-certified forensic pathologists. State funding should also be used to introduce forensic pathology as a subspecialty during medical school rotations to provide exposure to the career.  

Conclusion

The current state of medicolegal death investigations in the United States is plagued with significant variations in practices, budgets, and training across jurisdictions. The heterogeneity creates disparities in the quality of investigations, data reporting, participation in fatality review teams, and overall professionalism in the field. The continued shortage of board-certified forensic pathologists to complete postmortem examinations and the lack of standardized training exacerbates the challenges. Increased federal funding to support medicolegal death investigation efforts can lead to more accurate and timely data reporting, improved public health surveillance, better-informed policy creation, and enhanced capabilities to respond to mass fatality incidents. Ultimately, these measures will contribute to the well-being of communities and assist public health prevention efforts.

Federal climate initiatives, like the ‘Climate Corps’ and the National Climate Resilience Framework, overlook the integration of technology-focused green jobs, missing opportunities for equity and innovation in technology, artificial intelligence (AI), and machine learning (ML). Our objective is to advocate for the integration of technology-focused green jobs within these initiatives to foster equity. Leveraging funding opportunities from recent legislation, notably the Infrastructure Investment and Jobs Act (IIJA) and the Environmental Protection Agency’s (EPA) environmental education fund, we aim to craft novel job descriptions, tailored training programs, and foster strategic public-private partnerships.

Methods and Approach

Our approach was based on comprehensive research and extensive stakeholder engagement, including discussions with key federal agencies and industry experts, identifying challenges and opportunities for integrating technology-focused green jobs. We engaged with officials and experts from various organizations, including the Department of Energy, EPA, USDA, FEMA, New America, the Benton Institute, National Urban League, Kajeet, the Blue Green Alliance, and the Alliance for Rural Innovation.We conducted data research and analysis, reviewed government frameworks and CRS reports, as well as surveyed programs and reports from diverse sources.

Challenge and Opportunity

The integration of technology-focused green jobs within existing federal climate initiatives presents both challenges and opportunities. One primary challenge lies in the predominant focus on traditional green jobs within current initiatives, which may inadvertently overlook the potential for equitable opportunities in technology, artificial intelligence (AI), and machine learning (ML). This narrow emphasis risks excluding individuals with expertise in emerging technologies from participating in climate-related efforts, hindering innovation and limiting the scope of solutions. Moreover, the lack of adequate integration of technology within climate strategies creates a gap in inclusive and forward-looking approaches, potentially impeding the effectiveness of initiatives aimed at addressing climate change. Addressing these challenges requires a paradigm shift in how federal climate initiatives are structured and implemented, necessitating a deliberate effort to incorporate technology-driven solutions alongside traditional green job programs.

However, amidst these challenges lie significant opportunities to foster equity and innovation in the climate sector. By advocating for the integration of technology-focused green jobs within federal initiatives, there is an opportunity to broaden the talent pool and harness the potential of emerging technologies to tackle pressing environmental issues. Leveraging funding opportunities from recent legislation, such as the Infrastructure Investment and Jobs Act (IIJA) and the Environmental Protection Agency’s (EPA) environmental education fund, presents a unique opportunity to invest in novel job descriptions, tailored training programs, and strategic public-private partnerships. Furthermore, initiatives aimed at reconciling concerns about equity in job creation and transitions, particularly in designing roles that require advanced degrees and ensuring consistent labor protections, provide avenues for fostering a more inclusive and equitable workforce in the green technology sector. By seizing these opportunities, federal climate initiatives can not only advance technological innovation but also promote diversity, equity, and inclusion in the emerging green economy.

Plan of Action

Moving the integration of these policy frameworks internally and with an aspiration to reflect market and community needs will require a multi-faceted approach. In response to the identified challenges and opportunities, the following policy recommendations are proposed:

Recommendation 1. Restructuring Federal Climate Initiatives to Embrace Technology-Focused Green Jobs

In light of the evolving landscape of climate challenges and technological advancements, there is a pressing need to review existing federal climate initiatives, such as the ‘Climate Corps’ and the National Climate Resilience Framework, to actively integrate technology-focused green jobs. Doing so creates an opportunity for integrated implementation guidance. This recommendation aims to ensure equitable opportunities in technology, artificial intelligence (AI), and machine learning (ML) within the climate sector while addressing the intersection between climate and technology. By undertaking this restructuring, federal climate initiatives can better align with the demands of the modern workforce and foster innovation in climate solutions. For example, the two aforementioned initiatives and the Executive Order on Artificial Intelligence all infer or clearly mention the following: green or climate jobs, equity, job training programs and tech and climate literacy. There is room to create programs to research and generate solutions around the ecological impacts of AI development within the auspices of the Climate Resilience Framework, and consider creating roles to implement those solutions as part of the Climate Corps (see Appendix II). 

The rationale behind this recommendation lies in the recognition of the imperative to adapt federal climate initiatives to embrace emerging technologies and promote diversity and inclusion in green job opportunities. As the climate crisis intensifies and technological advancements accelerate, there is a growing need for skilled professionals who can leverage technology to address environmental challenges effectively. However, existing initiatives predominantly prioritize traditional green jobs, potentially overlooking the untapped potential of technology-driven solutions. Therefore, restructuring federal climate initiatives to actively integrate technology-focused green jobs is essential to harnessing the full spectrum of talent and expertise needed to confront the complexities of climate change.

1. Developing a Green Tech Job Initiative. This initiative should focus on creating and promoting jobs in the tech, AI, and ML sectors that contribute to climate solutions. This could include roles in developing clean energy technologies, climate modeling, and data analysis for climate research and policy development. Burgeoning industries such as regenerative finance offer opportunities to combine AI and climate resilience goals. 
2. Ensuring Equitable Opportunities. Policies should be put in place to ensure these job opportunities are accessible to all, regardless of background or location. One example would be to leverage the Justice40 initiative, and use those allocations to underserved communities to create targeted training and education programs in tech-driven environmental solutions for underrepresented groups. Additionally, public-private partnerships could be strategically designed to support community-based projects that utilize technology to address local environmental issues.
3. Addressing the Intersection of Climate and Technology. The intersection of climate and technology should be a key focus of federal climate policy. This could involve promoting the use of technology in climate mitigation and adaptation strategies, as well as considering the environmental impact of the tech industry itself. (Strengthening community colleges, accredited online programs and other low-cost alternatives to traditional education and job training)

Recommendation 2. Leveraging Funding for Technology-Driven Solutions in Federal Climate Initiatives

In order to harness the funding avenues provided by recent legislation such as the Infrastructure Investment and Jobs Act (IIJA) and the Environmental Protection Agency’s (EPA) environmental education fund, strategic policy measures must be implemented to facilitate the development of comprehensive job descriptions, tailored training plans, and robust public-private partnerships aimed at advancing technology-driven solutions within federal climate initiatives. This recommendation underscores the importance of utilizing available resources to cultivate a skilled workforce, foster innovation, and enhance collaboration between government, industry, and academia in addressing climate challenges through technology.

The rationale behind this recommendation is rooted in the recognition of the transformative potential of technology-driven solutions in mitigating climate change and building resilience. With significant funding streams allocated to climate-related initiatives, there is a unique opportunity to invest in the development of job descriptions that reflect the evolving demands of the green technology sector, as well as training programs that equip individuals with the necessary skills to excel in these roles. Moreover, fostering robust public-private partnerships can facilitate knowledge sharing, resource pooling, and joint innovation efforts, thereby maximizing the impact of federal climate initiatives. By strategically leveraging available funding, federal agencies can catalyze the adoption of technology-driven solutions and drive progress towards a more sustainable and resilient future.

1. Comprehensive Job Descriptions. Develop comprehensive job descriptions for technology-focused green jobs within federal climate initiatives. These descriptions should clearly outline the roles and responsibilities, required skills and qualifications, and potential career paths. This could be overseen by the Department of Labor (DOL) in collaboration with the Department of Energy (DOE) and the EPA.
2. Tailored Training Plans. Establish tailored training plans to equip individuals with the necessary skills for these jobs. This could involve partnerships with educational institutions and industry bodies to develop curriculum and training programs. The National Science Foundation (NSF) could play a key role in this, given its mandate to promote science and engineering education.
3. Public-Private Partnerships. Foster robust public-private partnerships to advance technology-driven solutions within federal climate initiatives. This could involve collaborations between government agencies, tech companies, research institutions, and non-profit organizations. The Department of Commerce, through its National Institute of Standards and Technology (NIST), could facilitate these partnerships, given its role in fostering innovation and industrial competitiveness.

Recommendation 3. Updating Bureau of Labor Statistics Job Categories for Green and Tech Jobs

To address the outdated Bureau of Labor Statistics (BLS) job categories, particularly in relation to the green and innovation economies, federal agencies and stakeholders must collaborate to support an update of these categories and classifications. This recommendation emphasizes the importance of modernizing job classifications to accurately reflect the evolving nature of the workforce, especially in sectors related to green technology and innovation.

The rationale behind this recommendation is rooted in the recognition of the significant impact that outdated job categories can have on program and policy design, particularly in areas related to green and technology-driven jobs. Currently the green jobs categorization work has been interrupted by sequestration.¹ The tech job updates are on differing schedules. By updating BLS job categories to align with current market trends and emerging technologies, federal agencies can ensure that workforce development efforts are targeted and effective. Moreover, fostering collaboration between public and private sector stakeholders, alongside inter-agency work, can provide the necessary support for BLS to undertake this update process. Through coordinated efforts, agencies can contribute valuable insights and expertise to inform the revision of job categories, ultimately facilitating more informed decision-making and resource allocation in the domains of green and tech jobs.

1. Inter-Agency Collaboration. Establish an inter-agency task force, including representatives from the BLS, Department of Energy (DOE), Environmental Protection Agency (EPA), and Department of Labor (DOL), to review and update the current job categories and classifications. This task force would be responsible for ensuring that the classifications accurately reflect the evolving nature of jobs in the green and innovation economies.
2. Public-Private Partnerships. Engage in public-private partnerships with industry leaders, academic institutions, and non-profit organizations. These partnerships can provide valuable insights into the changing job landscape and help inform the update of job categories and classifications.
3. Stakeholder Engagement. Conduct regular consultations with stakeholders, including employers, workers, and unions in the green and innovation economies. Their input can ensure that the updated classifications accurately represent the realities of the job market.
4. Regular Updates. Implement a policy for regular reviews and updates of job categories and classifications, particularly in renewing and syncing the green and tech jobs.The Office of Budget and Management can offer guidance about regular reviews and feedback based on government-wide standards. Initiating such a policy may require additional personnel in the short-term, but long-term this will increase agency efficiency. It will also ensure that the classifications remain relevant as the green and innovation economies continue to evolve (see FAQ section and Appendix I).

Conclusion

The integration of technology-focused green jobs within federal climate initiatives is imperative for fostering equity and innovation in addressing climate challenges. By restructuring existing programs and leveraging funding opportunities, the federal government can create inclusive pathways for individuals to contribute to climate solutions while advancing in technology-driven fields. Collaboration between government agencies, private sector partners, educational institutions, and community stakeholders is essential for developing comprehensive job descriptions, tailored training programs, and strategic public-private partnerships. Moreover, updating outdated job categories and classifications through inter-agency collaboration and stakeholder engagement will ensure that policy design accurately reflects the evolving green and innovation economies. Through these concerted efforts, the federal government can drive sustainable economic growth, promote workforce development, and address climate change in an equitable and inclusive manner.

Appendix

The recommendations outlined in this memo represent the culmination of extensive research and collaborative efforts with stakeholders. As of March 2024, while the final project and products are still undergoing refinement through stakeholder collaboration, the values, solutions, and potential implementation strategies detailed here are the outcomes of a thorough research process.

Our research methodology was comprehensive, employing diverse approaches such as stakeholder interviews, data analysis, examination of government frameworks, review of Congressional Research Service (CRS) reports, and surveying of existing programs and reports.

Stakeholder interviews were instrumental in gathering insights and perspectives from officials and experts across various sectors, including the Department of Energy, FEMA, New America, the Benton Institute, National Urban League, Kajeet, and the Alliance for Rural Innovation. Ongoing efforts are also in place to engage with additional key stakeholders such as the EPA, USDA, select Congressional offices, labor representatives, and community-based organizations and alliances.

Furthermore, our research included a thorough analysis of Bureau of Labor Statistics (BLS) data to understand industry projections and job classification limitations. We employed text mining techniques to identify common themes and cross-topic programming or guidance within government frameworks. Additionally, we reviewed CRS reports to gain insights into public policy writings on related topics and examined existing programs and reports from various sources, including think tanks, international non-governmental organizations (INGOs), non-governmental organizations (NGOs), and journalism.
The detailed findings of our research, including analyzed data, report summaries, and interview portfolio, are provided as appendices to this report, offering further depth and context to the recommendations outlined in the main text.

I. BLS Data Analysis: Employment Trends in Tech-Related Industries (2022-2032)

This section provides a detailed analysis of employment statistics extracted from CSV data across various industries, emphasizing green, AI, and tech jobs. The analysis outlines notable growth and potential advancement areas within technology-related sectors.

The robust growth in employment figures across key sectors such as computer and electronic product manufacturing, software publishing, and computer systems design underscores the promising outlook for tech-related job sectors. Similarly, the notable expansion within the information sector, while not explicitly AI-focused due to industry constraints, signals an escalating demand for skill sets closely aligned with technological advancements.

Moreover, the significant growth observed in support activities for agriculture and forestry hints at progressive strides in integrating green technologies within these domains. This holistic analysis not only sheds light on evolving employment trends but also provides valuable insights into market dynamics. Understanding these trends can aid in identifying potential opportunities for workforce development initiatives and strategic investments, ensuring alignment with emerging industry needs and fostering sustainable growth in the broader economic landscape.

Further Analysis

• Search Industry. Projections indicate a robust growth of 5.4% by 2032, signaling a promising trajectory for this sector.
• Self-Employed Workers. There’s a concerning projected decline in employment by 8.6%, indicating potential challenges for individuals in this category, necessitating exploration into the underlying causes.
• Agriculture, Forestry, Fishing, and Hunting. With an anticipated increase of 5.4% in employment, this sector demonstrates resilience and potential opportunities for growth, possibly driven by technological advancements or shifts in consumer demand.
• Utilities. A notable expected decline of 7.4% suggests a need for strategic interventions to address factors contributing to this trend, such as changing energy policies or shifts in market dynamics.
• Construction. While a moderate drop of 4.0% is projected, deeper analysis is warranted to understand whether this decline is indicative of cyclical fluctuations or more systemic challenges facing the industry.
• Manufacturing. Despite an overall slight decrease of 1.9%, it’s essential to dissect this trend further to discern which sub sectors are driving this decline and whether there are opportunities for innovation or retooling to reverse this trajectory.
• Wholesale Trade. A potential decline of 2.6% underscores the need for adaptation within this sector to address evolving market demands and competitive pressures.
• Retail Trade. With a significant expected drop of 10.0%, there’s a pressing need for retailers to explore strategies for reinvention, such as embracing e-commerce, enhancing customer experiences, or diversifying product offerings.

This nuanced analysis illuminates the varied trajectories across different industries, highlighting both areas of growth and challenges. It underscores the importance of proactive strategic planning and adaptation to navigate the evolving employment landscape effectively.

Regarding job classifications, while the Bureau of Labor Statistics (BLS) provides valuable insights, it may not fully capture emerging roles in next-gen fields like AI, Web 3.0, Web 4.0, or climate tech. Exploring analogous roles or interdisciplinary skill sets within existing classifications can offer a starting point for understanding employment trends in these innovative domains. Additionally, leveraging alternative sources of data, such as industry reports or specialized surveys, can complement BLS data to provide a more comprehensive picture of evolving employment dynamics.

Based on the information from the Bureau of Labor Statistics (BLS) and the search results, here’s what I found:

Market Demand for Tech Jobs. The BLS projects that overall employment in computer and information technology occupations is expected to grow much faster than the average for all occupations from 2022 to 20321. This suggests that these jobs are being filled according to market demand but not quickly enough for market demand.

Green and Tech Jobs. The BLS produces data on jobs related to the production of green goods and services, jobs related to the use of green technologies and practices, and green careers23. Many of the jobs listed on the provided BLS links fall under tech jobs, especially those related to AI, Web 3.0, and Web 4.0. However, specific data on jobs related to regenerative finance or climate tech was not found in the search results.

Education Requirements. Most of the jobs listed on the provided BLS links typically require a Bachelor’s degree for entry14. Some occupations may require a Master’s degree or higher. However, the exact education requirement can vary depending on the specific role and employer expectations.

These industries demonstrate growth potential from 2022 to the projected 2032 data, underscoring the increasing demand for tech-related job sectors, especially in computer and electronic product manufacturing, software publishing, and computer systems design. The information sector also shows significant growth, potentially reflecting the rise in AI and technology advancements.

Appendix I.A. BLS Data and Standard Occupation Codes (Climate Corps Specific)

These job classifications encompass a range of roles pertinent to green initiatives, infrastructure technology, and AI/ML development, reflecting the evolving landscape of employment opportunities.

Intersection of Green Jobs

Here’s a summary based on the jobs that explicitly refer to green jobs and the Federal Job Codes requiring different levels of education:

Green Jobs:

• 47-2230 Solar Photovoltaic Installers
  • Description: Assemble, install, or maintain solar photovoltaic (PV) systems on roofs or other structures in compliance with site assessment and schematics. May include measuring, cutting, assembling, and bolting structural framing and solar modules. May perform minor electrical work such as current checks.
  • Illustrative examples: Photovoltaic (PV) Installation Technician, Solar PV Installer

Federal Job Codes/Roles Requiring Different Levels of Education:

Bachelor’s Degree

• 11-2020 Marketing Managers
• 15-1250 Web and Digital Interface Designers
• 15-1255 Software Developers, Applications
• 15-1256 Software Developers, Systems Software
• 15-1299 Computer Occupations, All Other
• 17-3020 Electrical and Electronics Engineering Technicians
• 17-3023 Electrical and Electronics Engineering Technologists
• 17-3031 Surveying and Mapping Technicians
• 17-4010 Architectural and Civil Drafters
• 17-4020 Surveyors
• 17-4030 Cartographers and Photogrammetrists
• 17-4040 Hazardous Materials Removal Workers

Associate’s Degree

• 17-3020 Electrical and Electronics Engineering Technicians
• 17-3023 Electrical and Electronics Engineering Technologists
• 17-3031 Surveying and Mapping Technicians
• 17-4010 Architectural and Civil Drafters

High School Diploma

• 17-4050 Highway Maintenance Workers
• 17-4060 Rail-Track Laying and Maintenance Equipment Operators

Please note that while this list includes occupations that explicitly require a bachelor’s degree, associate’s degree, or high school diploma and showed up in an NLP search, it may have missed jobs that require certifications only. Additionally, other green job titles such as environmental engineers, conservationists, social scientists, and environmental scientists may require advanced degrees.

II. Analysis of EOs, Frameworks, TAs and Initiatives

This appendix analyzes executive orders, frameworks, technical assistance guides, and initiatives related to green and climate jobs, equity, job training programs, and tech and climate literacy. It presents findings from documents such as the American Climate Corps initiative, National Climate Resilience Framework, and Executive Order on AI, focusing on their implications for job creation and skills development in the green and tech sectors.

*Note about technologies use, this was text mined (SAS NLP, later bespoke app from team member) and Read (explain creating of text mining browser add on in methods overview/disclosure) using key terms “green”, “climate”, “equity”, “training”, “technology” and “literacy.”

Analysis of Executive Orders, Frameworks, Technical Assistance Guides, and Initiatives

This appendix delves into executive orders, frameworks, technical assistance guides, and initiatives pertaining to green and climate jobs, equity, job training programs, and tech and climate literacy. It scrutinizes documents such as the American Climate Corps initiative, National Climate Resilience Framework, and Executive Order on AI, dissecting their implications for job creation and skills development in the green and tech sectors.

Climate Corps:

• Green or Climate Jobs. The American Climate Corps initiative aims to equip young individuals with high-demand skills for employment in the clean energy economy, emphasizing areas like conservation, community resilience, clean energy deployment, and environmental justice.
• Equity. With a focus on marginalized communities, including energy communities, the initiative underscores equity and environmental justice.
• Job Training Programs. In its inaugural year, the initiative provides skills-based training to over 20,000 individuals and offers comprehensive information about federal technical assistance programs supporting community endeavors.
• Tech and Climate Literacy. While not explicitly stated, the emphasis on training in clean energy and climate resilience could indirectly enhance tech and climate literacy within both the federal workforce and the broader U.S. populace.

National Climate Resilience Framework:

• Green or Climate Jobs. The framework hints at initiatives such as restoring natural infrastructure and improving forestry practices, suggesting potential job opportunities in green or climate-related sectors.
• Equity. Ensuring inclusivity, the framework demonstrates a commitment to preventing any community from being overlooked, thereby reflecting an equity-oriented approach in climate resilience strategies.
• Job Training Programs. Although not overtly addressed, the comprehensive government approach mobilized by the framework may entail job training programs.
• Tech and Climate Literacy. While not explicitly discussed, the community-driven solutions and investments in clean energy and climate action endorsed by the framework could contribute to increased tech and climate literacy.

Executive Order on AI:

• Green or Climate Jobs. While not expressly mentioned, the acknowledgment of AI’s potential to tackle urgent challenges implies its relevance to environmental and climate-related issues.
• Equity. Emphasizing inclusive AI development, the order stresses diverse stakeholder involvement, suggesting a commitment to equity considerations.
• Job Training Programs. Though not explicitly outlined, the necessity for robust evaluations of AI systems implies a potential demand for training programs to ensure workforce preparedness.
• Tech and Climate Literacy. While not directly addressed, the emphasis on ethical AI development implies a requisite level of literacy within the federal workforce. Additionally, efforts to establish effective labeling mechanisms for AI-generated content could contribute to tech literacy across the general population.

Please note that this analysis is based on provided excerpts, and the full documents may contain additional relevant insights.

Technical Assistance Guidance: Creating Green or Climate Jobs

The Bipartisan Infrastructure Law (BIL) and the Inflation Reduction Act (IRA) are poised to create green or climate jobs, strengthen equity, and bolster job training programs, signaling a concerted effort towards enhancing tech and climate literacy across the workforce and the general U.S. population.

Creating Green or Climate Jobs

Both the Bipartisan Infrastructure Law (BIL) and the Inflation Reduction Act (IRA) are anticipated to generate green or climate jobs. The BIL aims to enhance the nation’s resilience to extreme weather and climate change, concurrently mitigating greenhouse gas emissions. Similarly, the IRA is forecasted to yield over 9 million quality jobs in the forthcoming decade.

Considering Equity

Both the BIL and the IRA prioritize equity in their provisions. The BIL endeavors to bridge historically disadvantaged and underserved communities to job opportunities and economic empowerment. Similarly, the IRA addresses energy equity through its climate provisions and investment tax credits in renewable energy.

Strengthening Job Training Programs

Both legislations incorporate provisions for enhancing job training programs. The BIL allocates over $800 million in dedicated investments towards workforce development, while the IRA mandates workforce development and apprenticeship requirements.

Increasing Tech and Climate Literacy within the Federal Workforce

Although explicit information on boosting tech and climate literacy within the federal workforce is lacking, both the BIL and the IRA include provisions for workforce development and training. These initiatives could potentially encompass tech and climate literacy training.

Increasing Tech and Climate Literacy in the General U.S. Population

The substantial investments in clean energy and climate mitigation under the BIL and the IRA may indirectly contribute to enhancing tech and climate literacy across the general U.S. populace. However, there is no specific information regarding programs aimed at directly augmenting tech and climate literacy in the general population.

III. Report Summaries

Insights from various reports shed light on the demand for tech and green jobs, digital skills, and challenges in the broadband workforce. Drawing from reputable sources such as Bank of America, BCG, the Federal Reserve of Atlanta, and others, these summaries emphasize the necessity for targeted educational and policy interventions.

• Bank of America NPower. Provides tech training programs for high school graduates lacking necessary skills and connections for tech careers. Offers a blend of classes and practical experience partnering with programs like Year Up, NPower, and Road to Hire.
• BCG Future of Jobs in AI. Highlights discrepancies between labor supply and demand in various sectors, particularly in tech-related occupations. Foresees significant worker deficits in computer-related fields due to automation’s pervasive impact.
• Federal Reserve of Atlanta Digital Skills Report. Reveals that 92% of jobs require digital skills, yet the supply of skilled workers is insufficient. Urges policymakers and educators to collaborate to bridge the digital skills gap through accessible training and education.
• National Skills Coalition Report. Discusses the digital skill divide and advocates for policies supporting skill development. Recommends investing in training programs and ensuring access to education tailored to the digital economy’s demands.
• Benton Broadband Workforce Report. Examines challenges in broadband rollout and underscores the need for training programs and education to meet digital economy demands.
• Forbes Demand Outpacing Supply For Green Jobs Skills. Highlights the mismatch between demand and supply for green skills, urging investment in training programs and education for success in the green economy.
• Global Green Skills Report (LinkedIn). Provides insights into the importance of green skills in transitioning to a low-carbon economy. Emphasizes the necessity of policies supporting green skills development.
• IMF. How the green transition will impact U.S. Jobs: Explores the impact of the green transition on U.S. jobs, predicting both job creation in renewable energy and losses in the fossil fuel sector. Recommends investment in training programs for success in the green economy.

These reports collectively underscore the growing demand for digital and green skills in the U.S. workforce, accompanied by a shortage of skilled workers. Collaboration between policymakers and educators is essential to provide adequate training and education for success in the digital and green economies.

IV. Digital Discrimination Reports

This section delves into findings from reports on digital discrimination, broadband access, and AI literacy, sourced from reputable institutions such as The Markup, Consumer Reports, Pew, and the World Economic Forum. These reports illuminate the inequities present in digital access and knowledge and emphasize the necessity for equitable policies to foster widespread participation in the digital economy.

• The Markup. Highlights how internet service providers often charge different prices for the same service based on geographic location, arguing for government regulation to ensure affordable internet access for all.
• Consumer Reports. Discusses the inadequate state of broadband access in the U.S., emphasizing the necessity of affordable, high-speed internet for full participation in the digital economy. Recommends policy interventions to invest in broadband infrastructure and ensure equitable access for all Americans.
• Pew Report on Americans’ Knowledge Level on AI. Examines Americans’ understanding of AI, cybersecurity, and big tech, revealing significant gaps in knowledge that could impact future work prospects. Recommends investment in education and training programs to equip workers with necessary digital skills for success in the digital economy.
• World Economic Forum Future of Jobs Report. Forecasts technology adoption as a key driver of business transformation, with over 85% of organizations anticipating increased adoption of new technologies and broader digital access. Emphasizes the need for Environmental, Social, and Governance (ESG) standards and discusses significant job creation and destruction effects driven by environmental, technological, and economic trends.

These reports collectively underscore the urgent need for policies supporting digital skill development and ensuring affordable, high-speed internet access across the U.S. Policymakers are urged to collaborate in providing necessary training and education opportunities to empower workers for success in the digital economy.

V. CRS Report Summaries

This section provides a synopsis of Congressional Research Service (CRS) reports addressing skills gaps, broadband considerations, job training programs, and economic assistance for transitioning communities. These reports offer insights into legislative and policy contexts for bridging digital divides and supporting transitions to green economies, with a focus on workforce development and economic assistance.

• Skills Gaps. A Review of Underlying Concepts and Evidence: Explores the complex nature of skills gaps and their impact, attributing them to various factors such as technological advancements and demographic shifts. Recommends investment in training programs to equip workers for success in digital and green economies.
• Bridging the Digital Divide. Broadband Workforce Considerations for the 118th Congress: Discusses the inadequate access to affordable, high-speed internet in the U.S. and recommends policy interventions to invest in broadband infrastructure and ensure universal access.
• The Infrastructure Investment and Jobs Act (P.L. 117-58). Summary of the Broadband Provisions in Division F: Summarizes broadband provisions in the Infrastructure Investment and Jobs Act, emphasizing its role in narrowing the digital divide through infrastructure investment and expanded internet access.
• Federal Youth Employment and Job Training Programs. Highlights the importance of federal youth employment and job training programs in preparing young individuals for success in digital and green economies. Recommends increased investment in these programs to support skill development.
• Federal Economic Assistance For Coal Communities. Explores federal economic assistance for coal communities, emphasizing the need to transition workforce skills from coal-related jobs to other industries. Recommends investment in training programs and removal of barriers to labor mobility.
• Economic Development Administration Announces Phase 1 of New Tech Hubs Program. Discusses the Economic Development Administration’s Tech Hubs Program aimed at fostering regional technology ecosystems for economic growth. Recommends policymakers invest in such programs to bolster digital and green economies.

Overall, these reports underscore the necessity for policies supporting the development of digital and green skills, as well as ensuring equitable access to high-speed internet across the U.S. Policymakers are urged to collaborate in providing necessary training and education opportunities to empower workers for success in evolving economic landscapes.

Heat risks are borne out of a combination of contextual factors (e.g., physical geography, planning efforts, political priorities, etc.) and the creation of vulnerability through exposure to the heat hazard (e.g., exposure, sensitivity, adaptive capacity, etc.). These heat-specific, contextual risks provide insight for formulating tailored strategies and technical guidance for devising heat-mitigation interventions that align with regional needs and climatic conditions.

Thus, heat action planning systematically and scientifically organizes short-, medium-, and long-term heat interventions within a spectrum of context-specific, socially, and fiscally responsive options. Integrating existing planning tools and risk assessment frameworks, similar to the broader-scale natural hazard mitigation planning process, offers a timely and effective approach to developing regionally tailored heat action plans. 

For heat action planning to succeed nationwide, multiple agencies and offices within the federal government need to 1) support state, local, tribal, and territorial (SLTT) governments with timely information and tools that identify specific guidelines, thresholds, objectives, and financial support for advancing interventions for extreme heat adaptation and 2) include extreme heat within their planning processes. Since all state and local public agencies are already involved in a wide variety of planning processes—many of which are requirements to receive federal investments—the focus on heat offers opportunities to integrate several currently disparate efforts into a comprehensive activity aimed at safeguarding the public’s health and infrastructure.

Challenge and Opportunity

Few U.S. municipal governments are actively engaged in a systematic process that prepares local communities for extreme heat. For example, as of 2023, only seven U.S. states had a section dedicated to extreme heat in their Hazard Mitigation Plans (HMPs), as required by the Federal Emergency Management Agency (FEMA). Even when included within HMPs, the medium and long-term planning implications are consistently lacking. Planning for extreme heat’s current and future risk is not a requirement of many federally-mandated planning processes for SLTTs, limiting nationwide uptake. 

Despite decades of scientific assessments on risks to human health and infrastructure, there currently needs to be more precedent for developing comprehensive plans that address heat, nor the integration of risks with effective interventions. Many state, local, tribal, and territorial governments (SLTTs) are not planning for extreme heat and its future risk to populations. The appointment of Chief Heat Officers and other regional coordination efforts are currently limited, and the primary mechanism for heat response relies on emergency management. This short-term solution needs to be revised to prepare a region for ongoing and acute temperature increases. SLTTs and the federal government are just starting to invest billions of dollars in material services and non-material interventions, including tree plantings, air conditioning and heat pumps, white paints, cooling centers, new staff roles (i.e., Chief Heat Officers), and communication programs. 

Planning for Future Risks of Extreme Heat 

Further, as the federal government is just starting to assess its portfolio of assets and programs for heat resilience, it will need to consider future risks of extreme heat beyond immediate health and infrastructure risks to establish a fiscal agenda for risk mitigation. For one, extreme heat events are a catalyst for other destructive disasters, like wildfires and drought. Higher temperatures increase evapotranspiration rates, drying out grasses and trees and turning fallen branches into firewood. Compounding this are the shrinking snowpacks in western states, which make forests more flammable by reducing the water available for vegetation. All of these factors caused by excess heat — along with a history of unsustainable forest management practices and land use decisions — are contributing to more destructive wildfires. From 2017 to 2024, these wildfires came with an estimated $97+ billion in costs. 

Additionally, more surface evaporation (1) increases SLTT reliance on limited groundwater sources and (2) leads to less groundwater seepage and aquifer replenishment. Warmer temperatures also mean plants and animals need more water, further driving up consumption of this limited resource. All of these factors compound the growing risk of drought facing American communities. In 2023, over 80% of the United States Department of Agriculture’s (USDA) emergency disaster designations were for drought or excessive heat, and the costliest 2023 disaster was a combined drought/heat wave at $14.5 billion. The interactions and compounding risk of natural hazards are often unaccounted for in HMPs and other plans that consider hazard events in isolation. 

Federal Support for Risk Mapping and Planning

Existing federal initiatives to assist SLTTs in planning for extreme heat have focused on documenting extreme heat’s disparate impacts in cities and regions but do not strategically progress heat action planning. For example, the National Integrated Heat Health Information System (NIHHIS) is an interagency entity operated by the National Oceanic and Atmospheric Administration (NOAA) that manages www.heat.gov, and provides several opportunities for SLTTs to socialize and familiarize heat-related interventions. Since 2017, NOAA, in collaboration with NIHHIS, has supported the Heat Watch Campaigns, wherein SLTTs and community groups use temperature sensors to collect hyperlocal heat measurements. These sensors measure and collect temperatures every second, and the resulting maps describe differences in intra-regional heat, known popularly as “urban heat islands” (UHIs), which often vary by upwards of 20°F. These Heat Watch campaigns communicate heat as a local challenge and engage residents in socializing the potential impacts, while also advancing several initiatives and policies that aim to reduce the harmful effects of extreme temperatures. While almost all Heat Watch participating organizations have taken some immediate and often one-off actions, these campaigns have not advanced heat action planning through a systematic process. SLTTs have faced barriers to identifying promising adaptation strategies and resourcing necessary infrastructure improvements without dedicated, reliable follow-on investments. And, because most campaigns are conducted in urban areas, the Heat Watch campaigns currently do not capture the rural and ecosystem effects of heat. More systemic actions that integrate chronological and science-based applications of interventions that include the public, along with scientific assessments and contextual factors, are necessary for SLTTs to adapt.

Moreover, the federal government, which employs +3 million people, procures +$700 billion in goods and services annually, and delivers +$700 billion in financial assistance to states, locals, and private entities, must plan more effectively for extreme heat’s impacts on basic operations, services, infrastructure, and program delivery. As an example, the U.S. Department of Defense (DoD) has completed several assessments on heat (and continues to), and other agencies need to follow suit to ensure infrastructure and programs are resilient to future temperatures. The heat risks posed to basic operations can further strain vulnerable supply chains and put employees who are on the frontline of enabling and operating these Federal programs at risk of illness and death.

Plan of Action

The heat action planning process requires five steps that help identify areas and populations that face disproportionate exposure to regionally-specific hottest temperatures and move towards interventions for mitigating extreme heat for SLTTs and the federal government:

Recommendation 1. Define “extreme heat” risk by local geography.

Extreme heat in Phoenix, AZ differs from extreme heat in Portland, OR; a week of 90°F in the Pacific Northwest can cause as many heat-related illnesses as a 110°F day in the South East.  A regional approach to characterizing the relevant risks is an essential first step. Developing heat hazard maps that describe the potential implications of extreme ambient temperatures on the public’s health, infrastructure, and critical services is essential to prepare SLTTs and the federal government. Existing “heat vulnerability indexes and maps” support the articulation of heat hazards, though they remain primarily passive interfaces that do not directly contribute to broader planning or policy processes. In addition, response to hazards requires local understanding and communication of existing risk, which is done by the National Weather Service (NWS) and FEMA through the Integrated Public Alert & Warning System. 

To define current and future “extreme heat” risk by local geography: 

1. FEMA, NOAA, USDA, Centers for Disease Control and Prevention (CDC), and the National Aeronautics and Space Administration (NASA) can collaborate on assessments of regionally-specific risk in the present and future, codifying cooling assets (potentially through ground-based assessments of summertime air temperatures, atmospheric dynamics, land use and land cover assessments), expected population acclimatization and existing health risks, and assessments of future climate conditions, such as ClimRR. Finally, USDA could assess agricultural growing zones for heat risk and better predict impacts on food and nutrition services supply chains.
2. HUD, EPA, and NOAA can work to identify localized exposure to extreme heat by expanding opportunities for monitoring indoor and outdoor air temperature in and around potentially vulnerable land uses (e.g., multifamily residential, older single-family residential, manufactured homes, and trailer parks), seeking additional funding from Congress where needed to develop and place these sensors.
3. FEMA can include metrics in its National Risk Index that characterize the building stock (i.e., by adherence to certain building codes), expected thermal comfort levels (even with cooling devices) under current and future climate conditions, and thermal resilience during power brownouts and blackouts. Additional focus on heat inequities will also help to advance approaches that center the public’s long-term health and safety.

Recommendation 2. Establish standards and codes for extreme heat resilience and risk mitigation.

Several federal agencies are directly involved in the development of standards (National Institute of Standards and Technology (NIST), Housing and Urban Development (HUD), Department of Energy (DOE), Department of Transportation (DOT), Environmental Protection Agency (EPA), FEMA, Department of Education (Ed)); however, we have no current designation for heat risk, certification of promising solutions, and identification of best practices for heat action planning. Once standards and guidelines exist, funding can accelerate the application of suitable technologies, analysis, and local engagement for developing heat action plans for SLTTs and federal government operations. Further, it is critical that adaptation solutions do not come at the risk of climate mitigation, for example, relying solely on air conditioning to keep people cool, which then leads to increased greenhouse gas emissions. Other strategies like urban forestry, building codes, and reflective materials in suitable locations will also need to be directly applied. 

To establish standards and codes for extreme heat resilience and risk mitigation: 

1. NIST, EPA, and U.S. Forest Service (USFS) can create “technology test beds” for heat resilience best practices, effectiveness evaluation, and associated benefits-costs analysis. 
2. DOE can work with stakeholders to create “cool” building standards and metrics with human health and safety in mind, and integrate them into building codes like ASHREI 189.1 and 90 series that can then be adopted by SLTTs. Where possible, DOE should explore evaluations of co-benefits of heat resilience with decarbonization and energy efficiency and work with state energy offices to implement these evaluations. Finally, DOE can also consider grid impacts during increasing periods of demand and conduct predictive analyses needed to prevent overload and prepare SLTT energy suppliers.
3. FEMA can integrate extreme heat considerations and thermal resilience within its National Strategy to Improve Building Codes.
4. HUD can update the Manufactured Home Construction and Safety Standards to require homes to perform a certain level of cooling under high heat conditions.
5. HUD and Ed can consider what safe thresholds for occupancy look like for residential settings and schools and provide guidance to SLTTs.
6. The Office of Management and Budget (OMB) and USFS can consider future risks to nature-based solutions (i.e., extreme heat) within different climate regions as a part of government-wide efforts to scale nature-based solutions.
7. DOT can consider requirements for infrastructure projects in SLTTs to mitigate UHI effects.

Recommendation 3. Operationalize interventions and coordinate amongst agencies that require SLTT planning processes.

While knowledge about heat exposure requires further assessment, integrating thresholds and programming to reduce preventable exposure to heat is necessary within planning processes, financial assistance delivery, and program and regulatory implementation. For example, an important next step will be establishing a heat tolerance threshold for occupations with higher heat exposure to ensure workers do not exceed core body temperatures. Currently, several wearable sensor technologies offer a direct means for firms to monitor the health of their outdoor workers. Such information can help develop material and non-material interventions that reduce the likelihood of heat stress and risk and ensure compliance with federal mandates and regulations. As another example, EPA, Health and Human Services (HHS), HUD, FEMA, Internal Revenue Service (IRS), and others can use new standards to implement federal funds or tax incentives. 

To better operationalize interventions and coordinate amongst agencies that require SLTT planning processes,

1. FEMA can incentivize Hazard Mitigation Planning for SLTTs that accounts for and emphasizes extreme heat risk as well as compounding disaster risk as a part of its National Mitigation Planning Program.
2. The Executive Office of the President (EOP) can consider its role in coordinating nationwide climate-risk planning, through auditing plans required by CDC, Administration for Strategic Planning and Response (ASPR), Federal Energy Regulatory Commission (FERC), Department of Transportation (DOT), FEMA, and other agencies for their readiness for future climate conditions (i.e. extreme heat). Where heat risk is not currently required in a federally-mandated plan, federal agencies should consider incentives to drive the adoption and uptake of heat action planning by SLTTs. 
3. OMB can identify potential regulatory pathways to build extreme heat resilience within SLTTs and federal government operations, considering technology standards, behavioral guidelines and expectations, and performance standards.
   1. Technology standards: Required presence of a cooling and/or thermal-regulating technology
   2. Behavioral guidelines and expectations: Required actions to avert overexposure
   3. Performance standards: Requirements that heat exposure cannot cross a certain threshold.

Recommendation 4. Support fiscal planning and funding prioritization.

Local jurisdictions must plan for many hazards and risks, and because heat funding is scarce and hard to get, it falls to the bottom of the list of priorities. Establishing a clear and accessible set of resources to understand the resources available to support heat adaptation and resilience can help to advance effective solutions. Further, SLTTs will get more funding to prevent past hazards, versus prepare for future ones like extreme heat. Current funding through FEMA and DOE is helping to shore up heat risk assessments and interventions in select locations, yet they remain inadequate for the scale of the challenge facing SLTTs. By prioritizing future climate risk in fiscal planning and funding, extreme heat resilience will become a larger priority because it can integrate into several programmatic and policy priorities, such as transportation, housing, and emergency response. The insurance and healthcare industries, operated by the Centers for Medicare and Medicaid (CMS) and Veterans Health Administration (VHA) can also play a larger role in shepherding heat resilience forward, by advancing beneficiaries that are adapting to extreme heat, and reducing emergency room visits due to heat illness.  

To support fiscal planning and funding prioritization,

1. OMB can work with federal agencies to perform a budget review of actual allocations to extreme heat activities, including financial assistance to SLTTs, as well as extreme heat’s existing risks to federal assets, critical infrastructure, programs, and workforce. OMB can collaborate with the General Services Administration (GSA) on federal workforce and contractor workforce safety protections and VHA, Department of Justice (DOJ), U.S. Army Corps of Engineers (USACE), DOT, Cybersecurity and Infrastructure Security Agency (CISA), DOE, and other relevant agencies on operations of critical infrastructure during current and future heat events.
2. OMB, in collaboration with EPA, FEMA, DOE, and NIST, can produce a report that identifies gaps in funding to advance heat mitigation and preparedness efforts.
3. HUD, FEMA, EPA, and others can recommend recipients of federal financial assistance adhere to building and energy codes that ensure thermal comfort and resilience.
4. Treasury can investigate potential insurance options for covering the losses from extreme heat, including security from utility cost spikes, real-estate assessment and scoring for future heat risk, “worker wage” coverage for days where it is unsafe to work, protections for household resources lost during an extended blackout or power outage, and coverage for healthcare expenses caused by or exacerbated by heat waves that CMS could incentivize.
5. The Securities and Exchange Commission (SEC) can price climate risk when deciding on interest payments for municipal bonds for SLTTs and give beneficial rates to SLTTs that have done a full analysis of their risks and made steps towards resilience.

Recommendation 5. Build evaluative capacity of extreme heat resilience interventions.

There is a need for designated bodies that evaluate and monitor the effectiveness of specific heat mitigation interventions to make systematic improvements. Universities, research non-profits, and many private organizations have deep expertise in evaluating and assessing heat-relevant programs and projects. Such programs will need to be developed through universities and through private-public partnerships that support SLTTs in ensuring that specific actions are effective and transferable. 

To build out the evaluative capacity of extreme heat resilience interventions,

1. GSA can demonstrate low-power, passive and resilient cooling strategies in its buildings as a part of “Net Zero” initiatives and document promising strategies by climate region. DOE can also conduct more demonstration projects to build strategies that ensure indoor survivability in everyday and extreme conditions.
2. EPA and NOAA can administer research and evaluation grants to assess, identify, and promote heat mitigation actions that are effective in reducing heat risks across diverse geographies as well as design effective heat action planning strategies for SLTTs. This could look like further expansion and institutionalization of the NIHHIS Centers of Excellence program.

Conclusion

In all scientific estimates, 2024 will be the next hottest year on human record, and each year thereafter is likely to be even hotter. Under even existing climate conditions, thousands of Americans are already unnecessarily dying every year, and critical infrastructures like grids are being pushed to their limits. With temperature trends point to ever-hotter summers, effective and strategic heat adaptation planning within SLTTs and across the federal government is a national security priority. Through the broad uptake and implementation of the Heat Action Planning framework by key agencies and offices (EOP, OMB, Treasury, SEC, NOAA, USDA, CDC, NASA, HUD, DHS, FEMA, NIST, EPA, USFS, DOE, DOJ, DOT, ASPR, GSA, USACE, VHA, SEC, and others), the federal government will enable a more heat-prepared nation.

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.

In 2000, Fortune magazine observed, “Water promises to be to the 21st century what oil was to the 20th century: the precious commodity that determines the wealth of nations.” Like petroleum, freshwater resources vary across the globe. Unlike petroleum, no living creature survives long without it. Recent global episodes of extreme heat intensify water shortages caused by extended drought and overpumping. Creating actionable solutions to the challenges of a warming planet requires cooperation across all water consumers.

The Biden-Harris administration should work with stakeholders to (1) develop a comprehensive U.S. water policy to preserve equitable access to clean water in the face of a changing climate, extreme heat, and aridification; (2) identify and invest in agricultural improvements to address extreme heat-related challenges via U.S. Department of Agriculture (USDA) and Farm Bill funding; and (3) invest in water replenishment infrastructure and activities to maintain critical surface and subsurface reservoirs. America’s legacy water rules, developed under completely different demographic and environmental conditions than today, no longer meet the nation’s current and emerging needs. A well-conceived holistic policy will optimize water supply for agriculture, tribes, cities, recreation, and ecosystem health even as the planet warms.

Challenge and Opportunity

In 2023, the National Oceanic and Atmospheric Administration (NOAA) recorded the hottest global average temperature since records began 173 years prior. In the same year, the U.S. experienced a record 28 billion-dollar disasters. The earth system responds to increasing heat in a variety of ways, most of them involving swings in weather and water cycles. Warming air holds more moisture, increasing the possibility of severe storm events. Extreme heat also depletes soil moisture and increases evapotranspiration. Finally, warmer average temperatures across the U.S. induce northward shifts in plant hardiness zones, reshaping state economies in the process.

As a result, agriculture currently experiences billions of dollars in losses each year (Fig. 1). Drought, made worse by high heat conditions, accounts for a significant amount of the losses. In 2023, 80% of emergency disaster designations declared by USDA were for drought or excessive heat.

Agriculture consumes up to 80% of the freshwater used annually. Farmers rely on surface water and groundwater during dry conditions, as climate change systematically strains water resources. Rising heat can increase overall demand for water for irrigating crops, exacerbating water shortages. Plants need more water; evapotranspiration rates increase to keep internal temperatures in check. Warming is also shrinking the snowpack that feeds rivers, driving a “snow loss cliff” that will impact future supply. Compounding all of this, Americans have overused depleted reservoirs across the country, leading to a system in crisis.

America’s freshwater resources fall under a tangle of state, local, and watershed agreements cobbled together over the past 100 years. In general, rules fall into two main categories: riparian rights and prior appropriation. In the water-replete eastern U.S., states favor riparian rights. Under this doctrine, property owners generally maintain local use of the water running through the property or in the aquifer below it, except in the case of malicious overuse. Most riparian states currently fall under the Absolute Dominion (or the English) Rule, the Correlative Rights Doctrine, or the Reasonable Use Rule, and many use term-limited permitting to regulate water rights (Table 1). In the arid western region, states prefer the Doctrine of Prior Appropriation. Under this scheme, termed “first in time, first in right,” property owners with older claims have priority over all newer claimants. Unlike riparian rights, prior appropriation claims may be separated from the land and sold or leased elsewhere. Part of the rationale for this is that prior appropriation claims refer to shares of water that must be transported to the land via canals or pipes, rather than water that exists natively on the property, as found in the riparian case. Some states use a mix of the two approaches, and some maintain separate groundwater and surface water rules (Fig. 2).

Original “use it or lose it” rules required claimants to take their entire water allotment as a hedge against speculation by absentee owners. While persistent drought and overuse reduced water availability over time, “use it or lose it” rules continue to penalize reduction in usage rates, making efficiency counterproductive. For example, Colorado’s “use it or lose it”’ rule remains on the books, despite repeated efforts to revise it. In a sign of progress, in 2021, Arizona passed a bipartisan law to change their “use it or lose it” rule to guarantee continued water rights if users choose to conserve water.

Water scarcity extends well beyond the arid western states. In the Midwest, higher temperatures and drought exacerbate overpumping that continues to deplete the vast Ogallala Reservoir that underlies the Great Plains (Fig. 3). Driven in part by rising temperatures, the effective 100th meridian that separates the arid West from the humid East appears to have shifted east by about 140 miles since 1980, indicating creeping aridification across the Midwest. The drought-impacted Mississippi River level dropped for the past two consecutive years, impeding river transport and causing saltwater intrusion into Louisiana groundwater, contaminating formerly potable water in many wells.

Figure 3. Changes to the water level of the Ogallala Aquifer that underlies most of the Great Plains states show depletion in most regions

via Climate.gov

Recognition of water’s increased importance, especially in a future of more extreme heat and its cascading impacts, drives new markets for the trade of physical water. The impetus for some markets arises from the variance in water availability and cost between different industries and communities. Ideally, benefits accrue to both sellers and buyers by offering a valuable revenue stream for meeting a resource need. Markets differ between groundwater and surface water. For groundwater markets, agreements allow one user to trade some portion of allocated pumping rights to another local user, although impacts to neighbors and ecosystems that share the aquifer must be considered. Successful groundwater trades rely on accurate assessments of subsurface water levels over time. For surface water trades, a portion of the prior appropriation water can be sold or leased to another user regardless of proximity, or banked for future use. Legislation passed in 2022 enables Colorado River Indian Tribes to lease or trade newly settled water rights, or to bank them for future use in surface or subsurface reservoirs without facing a “use it or lose it” penalty.

There are less obvious water considerations. Import from and export to foreign nations of heavily irrigated crops or water-intensive commodities equates to virtual water trade. The most common virtual water export involves foreign sale of American farmer-grown crops. Other means include sales or leases of domestic land to foreign entities that grow water-intensive crops on U.S. soil, often on arid land, for export. Virtual water trades occur within the U.S. as well, through exchange of goods and services.

Developing a framework for cooperation across end users, complementary to previous frameworks recommended for the Ogallala Aquifer, creates a mechanism to address urgent water issues. Establishing the federal government’s role to convene and collaborate with stakeholders helps all parties participate within a common structure toward solving a mutual problem. To promote sustained productivity and water resources in the face of extreme heat and aridification, a holistic federal water policy should focus on:

• Simplifying and streamlining water rights 
• Creating a framework for water trades
• Increasing water use efficiency
• Developing data-driven predictive tools
• Initiating and supporting new agricultural approaches 
• Developing strategic water recharge

The Biden-Harris administration should develop a plan that creates incentives for all stakeholders to participate in water management policy development in the face of rising heat and climate change. Specifically, discussions must consider real reservoir volumes (surface and subsurface), current and future temperatures, annual rain and snow measurements, evapotranspiration calculations, and estimates of current and future water needs and trades across all end users. History supports federal assistance in thorny resource management areas. One close analog, that of fisheries management, shows the power of compromise to conserve future resources despite fierce competition. 

Plan of Action

Recommendation 1. The White House Council on Environmental Quality should convene a working group of experts from across federal and state agencies to develop a National Water Policy to future-proof water resources for a hotter nation.

Progress toward increased scientific understanding of the large-scale hydrologic cycle offers new opportunities for managing resources in the face of change. Management efforts started at local scales and expanded to regional scales. Country-wide management requires a more holistic view. The U.S. water budget is moving to a more unstable regime. Climate change and extreme heat add complexity by shifting weather and water cycles in real-time. Improving the system balance requires convening stakeholders and experts to formulate a high-level policy framework that:

• Creates mechanisms for cooperation across all stakeholders
• Coordinates with stakeholders to restructure water rights at the basin scale, including high-demand industries like agriculture
• Accounts for changes in total, and basin- and aquifer-scale, water volumes at the necessary spatial and temporal resolution as a basis for decision-making, including estimations of future water capacity
• Develops a mechanism to assess and manage, when necessary, physical and virtual water trades, considering climate risk to supply and demand
• Identifies opportunities for investment based on observations and best-in-class models
• Includes a framework for adaptive policy modification as climate changes, heat’s impacts are better understood, and new water trends occur
• Monitors and evaluates emerging markets to “buy” water to “bank” it for sale at a higher price during drought years and/or high heat events
• Identifies one lead government agency to coordinate water policy, nominally the Department of the Interior (DOI)
• Coordinates with Congress to identify a lead committee in each chamber to oversee water policy

As such, the White House Council on Environmental Quality should convene a working group of experts from across federal and state agencies to create a comprehensive National Water Policy. Relevant government agencies include the DOI; the U.S. Geological Survey (USGS); the Bureau of Indian Affairs; the U.S. Army Corps of Engineers (USACE); Federal Emergency Management Agency (FEMA); Department of Commerce; NOAA; and the USDA. The envisioned National Water Policy complements the U.S. Government Global Water Strategy.

Figure 4. Map of principal aquifers of the U.S.

via USGS

Data products to support the creation of a robust National Water Policy already exist (Fig. 4). USGS, FEMA, the National Weather Service, USDA’s Natural Resources Conservation Service, and NOAA’s National Climate Data Center, Office of Water Prediction, and National Water Center all contribute data critical to development of both high-level and regional-scale assessments and data layers crucial for short- and mid-term planning. Creating term reassessments as more data accrue and models improve supports effective decision-making as climate change and extreme heat continue to alter the hydrologic cycle. An overall water policy must remain dynamic due to changing trends and new data.

National, regional, and local aspects of the water budget and related models and visualizations help federal and state decision makers develop a strategic plan for modernizing water rights for both river water, basins, and groundwater and to identify risks to supplies (e.g., decreasing snowpack due to higher heat) and opportunities for recharge. Stakeholders and water managers with shared knowledge of well-documented data are best positioned to determine minimum reservoir volumes in the primary storage basins, including aquifers, in alignment with the objectives of the National Strategy to Develop Statistics for Environmental and Economic Decisions. By creating a strategy that uses actual average values to maintain reservoir volumes, some of the potential shocks created by drought years and high heat could be cushioned, and related financial losses could be avoided or mitigated. Ultimately, stakeholders and managers must share a common understanding of the water budget when seeking to resolve water rights disputes, to review and revise water rights, and to inform trades.

Basin and local data promote development of a strategic framework for water trades. As trades and markets continue to grow, states and municipalities must account for water rights, both the lease and sale of rights, to buffer large fluctuations in water prices and availability. Emerging markets to “buy” water to “bank” it for sale at a higher price during drought years and/or high heat events should also be monitored and evaluated by relevant agencies like Commerce. States’ and investors’ maintenance of transparency around market activities, including investor purchases of land with water rights, promotes fair trade and ensures stakeholder confidence in the process. 

Finally, to communicate clearly with the public, funds should be provided through the DOI budget to NOAA and USGS data scientists to create decision-support tools that build on the work already underway through mature databases (e.g., at drought.gov and water.weather.gov). New water visualization tools to show the nowcast and forecast of the national water status would help the public understand policy decisions, akin to depictions used by weather forecasters. Variables should include heat index, humidity, expected evapotranspiration, precipitation, surface volumes, and groundwater levels, along with information on water use restrictions and recharge mechanisms at the local level. Making this product media-friendly aids public education and bolsters policy adoption and acceptance.

Recommendation 2. USDA should invest in infrastructure, research, and development.

Agriculture, as the largest water consumer, faces scarcity in the coming years even as populations continue to grow. Increasing demands on a dwindling resource and growing need for more water lead to conflict and acrimony. To ease tensions and maintain the goods and services needed to fuel the U.S. economy in the future, investment in both immediately practicable future-proofed, heat-resilient water solutions and over-the-horizon research and development must commence. To prepare, USDA will need to:

• Continue to fund the installation of liners or pipes for irrigation and conveyance canals, in alignment with efforts under the Bipartisan Infrastructure Law (BIL). Farmers historically irrigated their fields by flooding them via outdated earthen canals. Extensive evaporation and ground seepage losses delay water delivery to fields and creates unintended ecological side effects.
• Promote the installation of water-efficient irrigation methods on farms that previously used field flooding or other inefficient practices. Policy may include co-funding improvements, buying back “conserved water” and offering low-interest loans. The combination of improved canals with efficient irrigation technologies maintains agricultural production while reducing water loss.
• Test the efficacy of installing solar panels over or adjacent to open lined aqueducts or conveyance canals to both produce energy by taking advantage of evaporative cooling of the panel undersides and reduce some heat-driven evaporation of water from the canal by blocking sunlight. The dual benefit especially increases in the face of extreme heat where panels ordinarily become much less efficient as temperatures rise. An additional advantage includes running electrical infrastructure out to farms where farmers could use energy or connect their own panels if they wished to sell energy back to the grid.
• Add agrivoltaics (or other emerging energy/agricultural land use options) to the Agricultural Conservation Easement Program (ACEP). Research indicates that co-benefits include locally increased moisture for plants protected by panels while evapotranspiration cools the panels. This adaptation creates a reliable source of local energy while keeping agricultural land productive.
• Support transition to USDA-recommended varieties of climate-resilient Western native grasses for forage and soil stabilization of marginal land. Converting some highly irrigated farmland to desert livestock forage maintains agricultural land while reducing water usage, in line with the goals of the ACEP program.
• Support market development for desert agricultural crops adapted to the native conditions under the new Regional Agricultural Promotion Program (RAPP). Include food science and animal feed research to increase adoption. Examples include cactus opuntia fruit for natural sweetening, cactus paddles for food and fodder, drought-tolerant grasses and grains, mesquite grass forage, and mesquite bush seed pod flour. These developments build on careful research and accounts of Indigenous people and early settler practices and diets.
• Support development and deployment of technology that remotely detects water-stressed, heat-stressed plants to enable smart irrigation and cooling under USDA’s Agriculture and Food Research Initiative (AFRI).
• Develop crops with greater resilience to extreme heat, intermittent flooding, and intermittent drought via funding through Agriculture Advanced Research and Development Authority (AgARDA) and AFRI. Examples include genetically modifying or hybridizing plants for:
  • greater heat-tolerance and resilience to heat-stress, 
  • adaptation to inundation-related oxygen deficiency, and
  • resilience to increased heat driving evapotranspiration during droughts.

To support these efforts and broader climate resilience needs of farmers, Congress can:

• Reauthorize and fully fund the AgARDA at the requested $50 million annual budget to begin its mission. AgARDA was originally established under the 2018 Farm Bill (Section 7132 of the Agricultural Improvement Act of 2018(Public Law 115-334)). The agency received $1 million in each of the years 2022 and 2023, for a total of 0.8% of the total amount authorized. Addressing the challenges facing this century’s agriculture requires high-risk, high-reward thinking. No mechanism within the USDA sponsors such programs. Historically, the $250 million total recommended budget represented less than 0.06% of the total value ($428 billion) of the 2018 Farm Bill over its five-year span.

Recommendation 3. Federal, state, and local governments must invest in replenishing water reserves.

To balance water shortage, federal, state and local governments must invest in recharging aquifers and reservoirs while also reducing losses due to flooding. Opportunities for flood basin recharge arise during wet years, especially accounting for the shift from longer, frequent, lighter rainstorms to shorter, less frequent durations of very heavy rainfall. Federal agencies currently have opportunities to leverage Inflation Reduction Act (IRA) and BIL money for replenishment, including the following:

• FEMA, DOI and USDA can encourage grantees to use, and USACE can implement, proven nature-based, physical barriers to slow down surface flow in the event of heavy precipitation and flooding. Restoring river oxbows with associated wetlands, creating tree falls and wetland horizontal levees, reintroducing beavers, and employing other nature-based solutions can improve recharge and reduce downstream flood damage by slowing release of water. These measures should be instigated with a view to improving the hydrologic cycle of streams in the drainage basin, especially those that have been heavily engineered in the past. Co-benefits of these greening interventions include reducing surface temperature, thereby benefiting humans, livestock, and crops.

Congress can further support these actions by:

• Implementing annual-enrollment, permanent floodplain easements in the 2023 US Farm Bill. As outlined in the American Rivers report, the Emergency Watershed Protection (EWP) program “received 2,210 applications, but less than 10 percent of total applications and 16 percent of flood prone acres have been enrolled.” At present, the EWP program solely provides funds following a disaster rather than as a long-term strategic investment. Adopting floodplain easements as policy would maintain soil fertility, offer flood protection for downstream properties, and help to recharge aquifers for subsequent use and safeguard against future extreme heat and drought.
• Creating mechanisms whereby farmers who flood their fields during wet years accrue credits toward water allocations in dry years. Where appropriate, farms should be funded to develop appropriately located swales and catchments to collect rainwater and irrigation runoff.
• Funding expansion of the USACE Managed Aquifer Recharge (MAR) program authorized under the 2016 Water Resources Development Act. Projects have commenced in 17 states so far. In this approach, USACE pumps surface water into aquifers for:
  • Drought resilience 
  • Flood mitigation 
  • Aquatic ecosystem restoration and constructed wetlands 
  • Reducing saltwater intrusion 
  • Multi-use urban environmental restoration projects
• Funding the purchase of properties repeatedly affected by flooding to convert them into natural flood buffer areas and to support aquifer recharge zones in line with FEMA’s Public Assistance Program. Expanding this program beyond disaster response would remove vulnerable structures proactively, based on historic flood records and documented flood risk (Fig. 5). The purchase approach is distinct from the easement program that allows farmers to retain ownership of the property.

Figure 5. Map of insured flood claims

via Washington Post, with credit to Federal Emergency Management Agency, Natural Resources Defense Council

Conclusion

Water policy varies regionally, by basin, and by state. Because aquifers cross regions and water supplies vary over interstate and international boundaries, the federal government is the best arbiter for managing a dynamic, precious resource. By treating the hydrologic cycle as a dynamic system, data-driven water policy benefits all stakeholders and serves as a basis for future federal investment.

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.

Extreme heat – and similar people-centered disasters like heavy wildfire smoke – kills thousands of Americans annually, more than any other weather disaster. However, U.S. disaster policy is more equipped for events that damage infrastructure than those that mainly cause deaths. Policy actions can save lives and money by better integrating people-centered disasters.

Challenge and Opportunity

At the federal level, emergency management is coordinated through the Federal Emergency Management Agency (FEMA), with many other agencies as partners, including Centers for Disease Control (CDC), Department of Housing and Urban Development (HUD), and Small Business Administration (SBA). Central to the FEMA process is the requirement under the Stafford Act that the President declare a major disaster, which has never happened for extreme heat. This seems to be caused by a lack of tools to determine when a heat wave event escalates into a heat wave disaster, as well as a lack of a clear vision of federal responsibilities around a heat wave disaster.

Gap 1. When is a heat event a heat disaster?

A core tenet of emergency management is that events escalate into disasters when the impacts exceed available resources. Impact measurement is increasingly quantitative across FEMA programs, including quantitative metrics used in awarding Fire Management Assistance Grant (FMAG), Public Assistance (PA), and Individual Assistance (IA) and in the Benefit Cost Analysis (BCA) for hazard mitigation grants.

However, existing calculations are unable to incorporate the health impacts that are a main impact of heat waves. When health impacts are included in a calculation, it is only in limited cases; for example, the BCA allows mental healthcare savings, but only for residential mitigation projects that reduce post-disaster displacement.

Gap 2. What is the federal government’s role in a heat disaster?

Separate from the declaration of a major disaster is the federal government’s role during that disaster. Existing programs within FEMA and its partner agencies are designed for historic disasters rather than those of the modern and future eras. For example, the National Risk Index (NRI), used to understand the national distribution of risks and vulnerability, bases its risk assessment on events between 1996 and 2019. As part of considering future disasters, disaster policy should consider intensified extreme events and compound hazards (e.g., wildfire during a heat wave) that are more likely in the future. 

A key part of including extreme heat and other people-centered disasters will be to shift toward future-oriented resilience and adaptation. FEMA has already been making this shift, including a reorganization to highlight resilience. The below plan of action will further help FEMA with its mission to help people before, during, and after disasters.

Plan of Action

To address these gaps and better incorporate extreme heat and people-centered disasters into U.S. emergency management, Congress and federal agencies should take several interrelated actions.

Recommendation 1. Defining disaster

To clarify that extreme heat and other people-centered disasters can be disasters, Congress should:

(1) Add heat, wildfire smoke, and compound events (e.g., wildfire during a heat wave) to the list of disasters in Section 102(2) of the Stafford Act. Though the list is intended to be illustrative rather than exhaustive, as demonstrated by the declaration of COVID-19 as a disaster despite not being on the list, explicit inclusion of these other disasters on the list clarifies that intent. This action is widely supported and example legislation includes the Extreme Heat Emergency Act of 2023. 

(2) FEMA should standardize procedures for determining when disparate events are actually a single compound event. For example, many individual tornadoes in Kentucky in 2021 were determined to be the results of a single weather pattern, so the event was declared as a disaster, but wildfires that started due to a single heat dome in 2022 were determined to be individual events and therefore unable to receive a disaster declaration. Compound hazards are expected to be more common in the future, so it is critical to work toward standardized definitions.

(3) Add a new definition of “damage” to Section 102 of the Stafford Act that includes human impacts such as death, illness, economic impacts, and loss of critical function (i.e., delivery of healthcare, school operations, etc.). Including this definition in the statute facilitates the inclusion of these categories of impact.

To quantify the impacts of heat waves, thereby facilitating disaster decisions, FEMA should adopt strategies already used by the federal government. In particular, FEMA should:

(4) Work with HHS to expand the capabilities of the National Syndromic Surveillance Program (NSSP) to evaluate in real time various societal impacts like the medical-care usage and work or school days lost. Recent studies indicate that lost work productivity is a major impact of extreme heat that is currently unaccounted—a gap of potentially billions of dollars. The NSSP Community of Practice can help expand tools across multiple jurisdictions too. Expanding syndromic surveillance expands our ability to measure the impacts of heat, building on the tools available through the CDC Heat and Health Tracker.

(5) Work with CDC to expand their use of excess-death and flu-burden methods, which can provide official estimates of the health impacts of extreme heat. These methods are already in use for heat, but should be regularly applied at the federal level, and would complement the data available from health records via NSSP because it calculates missing data.

(6) Work with EPA to expand BenMAP software to include official estimates of health impacts attributable to extreme heat. The current software provides official estimates of health impacts attributable to air pollution and is used widely in policy. Research is needed to develop health-impact functions for extreme heat, which could be solicited in a research call such as through NIH’s Climate and Health initiative, conducted by CDC epidemiologists, added to the Learning Agenda for FEMA or a partner agency, or tasked to a national lab. Additional software development is also needed to cover real-time and forecast impacts in addition to the historic impacts it currently covers. The proposed tool complements Recommendations #4-5 because it includes forecast data.

(7) Quantify heat illness and death impacts. Real-time data is available in the CDC Heat and Health Tracker. These impacts can be converted to dollars for comparison to property damage using the Value of a Statistical Life (VSL), which FEMA already does in the NRI ($11.6 million per death and $1.16 million per injury in 2022). VSL should be expanded across FEMA programs, in particular the decision for major disaster declarations. VSL could be immediately applied to current data from NSSP, to expanded NSSP and excess-death data (Recommendations #4-5), and is already incorporated into BenMAP so would be available in the expanded BenMAP (Recommendation #6).

(8) Quantify the impact of extreme heat on critical infrastructure, including agriculture. Improved quantification methods could be achieved by expanding the valuation methods for infrastructure damage already in the NRI and could be integrated with the National Integrated Heat Health Information System (NIHHIS). The damage and degradation of infrastructure is often underestimated and should be accurately quantified. For example,

• (a) The Federal Highway Administration (FHWA) has reported on extreme heat and documented heat impacts on asset management, where the Department of Transportation (DOT) in multiple states, including Arizona’s DOT, and the National Cooperative Highway Research Program have developed evaluation methods for quantifying impacts, and
• (b) Impacts to critical infrastructure have been quantified across sectors and should include representative agencies such as transportation (e.g., FHWA, DOT), transit (e.g., Federal Transit Authority (FTA)), energy (e.g., Department of Energy (DOE), EPA, water/sanitation (e.g., U.S. Army Corps of Engineers (USACE), Bureau of Reclamation (BOR)), telecommunications (e.g., Department of Homeland Security, Federal Communications Commission), social (e.g., HUD, HHS, Department of Education (ED)), and environmental infrastructures (e.g., EPA, USACE, National Parks Service (NPS)). 

Together, these proposed data tools would provide FEMA with a comprehensive understanding of the impacts of extreme heat on human health in the past, present, and near future, putting heat on the same playing field as other disasters. 

Real-time impacts are particularly important for FEMA to investigate requests for a major disaster declaration. Forecast impacts are important for the ability to preposition resources, as currently done for hurricanes. The goal for forecasting should be 72 hours. To achieve this goal from current models (e.g., air quality forecasts are generally just one day in advance):

(9) Congress should fund additional sensors for extreme weather disasters, to be installed by the appropriate agencies. More detailed ideas can be found in other FAS memos for extreme heat and wildfire smoke and in recommendation 44 of the recent Wildland Fire Commission report.

(10) Congress should invest in research on integrated wildfire-meteorological models through research centers of excellence funded by national agencies or national labs. Federal agencies can also post specific questions as part of their learning agendas. Models should specifically record the contribution of wildfire smoke from each landscape parcel to overall air pollution in order to document the contribution of impacts. This recommendation aligns with the Fire Environment Center proposed in the Wildland Fire Commission report.

Recommendation 2. Determining federal response to heat disasters

To incorporate extreme heat and people-centered disasters across emergency management, FEMA and its peer agencies can expand existing programs into new versions that incorporate such disasters. We split these programs here by the phase of emergency management.

Preparedness

(11) Using Flood Maps as a model, FEMA should create maps for extreme heat and other people-centered disasters. Like flood maps, these new maps should highlight the infrastructure at risk of failure or the loss of access to critical infrastructure (e.g., FEMA Community Lifelines) during a disaster. Failure here is defined as the inability of infrastructure to provide its critical function(s); infrastructure that ceases to be usable for its purpose when an extreme weather event occurs (i.e., bitumen softening on airport tarmacs, train line buckling, or schools canceled because classrooms were too hot or too smokey). This includes impacts to evacuation routes and critical infrastructure that would severely impact the functioning of society. Creating such a map requires a major interagency effort integrating detailed information on buildings, heat forecasts, energy grid capacity, and local heat island maps, which likely requires major interagency collaboration. NIHHIS has most of the interagency collaborators needed for such effort, but should also include the Department of Education. Such an effort likely will need direct funding from Congress in order to have the level of effort needed.

(12) FEMA and its partners should publish catastrophic location-specific scenarios to align preparedness planning. Examples include the ARkStorm for atmospheric rivers, HayWired for earthquake, and Cascadia Rising for tsunami. Such scenarios are useful because they help raise public awareness and increase and align practitioner preparedness. A key part of a heat scenario should be infrastructure failure and its cascading impacts; for example, grid failure and the resulting impact on healthcare is expected to have devastating effects.

(13) FEMA should incorporate future projections of disasters into the NRI. The NRI currently only uses historic data on losses (typically 1996 to 2019). An example framework is the $100 million Prepare California program, which combined historic and projected risks in allocating preparedness funds. An example of the type of data needed for extreme heat includes the changes in extreme events that are part of the New York State Climate Impacts Assessment.

(14) FEMA should expand its Community Lifelines to incorporate extreme heat and cascading impacts for critical infrastructure as a result of extreme heat, which must remain operable during and after a disaster to avoid significant loss of human life and property. 

(15) The strategic national stockpile (SNS) should be expanded to focus on tools that are most useful in extreme weather disasters. A key consideration will be fluids, including intravenous (IV) fluids, which the current medical-focused SNS excludes due to weight. In fact, the SNS relies on the presence of IV fluids at the impacted location, so if there is a shortage due to extreme heat, additional medicines might not be deliverable. To include fluids, a new model will be necessary because of the logistics of great weight.

(16) OSHA should develop occupational safety guidelines to protect workers and students from hazardous exposures, expanding on its outdoor and indoor heat-related hazards directive. Establishing these thresholds, such as max indoor air temperatures similar to California’s Occupational Safety and Health Standards Board, can help define the threshold of when a weather event escalates into a disaster. No federal regulations exist for air quality, so California’s example could be used as a template. The need already exists: an average of 2,700 heat-related injuries and 38 heat-related fatalities were reported annually to OSHA between 2011 and 2019.

(17) FEMA and its partners should expand support for community-led multi-hazard resilience hubs, including learning from those focused on extreme heat. FEMA already has its Hubs for Equitable Resilience and Engagement, and EPA has major funding available to support resilience hubs. This equitable model of disaster resilience that centers on the needs of the specific community should be supported.

Response

(18) FEMA should introduce smaller disaster-assistance grants for extreme weather disasters: HMAG, CMAG, and SMAG (Heat, Cold, and Smoke Management Assistance Grants, respectively). They should be modeled on FMAG grants, which are rapidly awarded when firefighting costs exceed available resources but do not necessarily escalate to the level of a major disaster declaration. For extreme weather disasters, the model would be similar, but the eligible activities might focus on climate-controlled shelters, outreach teams to reach especially vulnerable populations, or a surge in medical personnel and equipment. Just like firefighting equipment and staff needed to fight wildfires, this equipment and staff are needed to reduce the impacts of the disaster. FMAG is supported by the Disaster Relief Fund, so if the H/C/SMAG programs also tap that, it will require additional appropriations. Shelters are already supported by the Public Assistance (PA) program, but PA requires a major disaster declaration, so the introduction of lower-threshold funds would increase access.

(19) HHS could activate Disaster Medical Assistance Teams to mitigate any surge in medical needs. These teams are intended to provide a surge in medical support during a disaster and are deployed in other disasters. See our other memos on this topic.

(20) FEMA could deploy Incident Management Assistance Teams and supporting gear for additional logistics. They can also deploy backup energy resources such as generators to prevent energy failure at critical infrastructure.

Recovery and Mitigation

(21) Programs addressing gray or green infrastructure should consider the impact upgrades will have on heat mitigation. For example, EPA and DOE programs funding upgrades to school gray infrastructure should explicitly consider whether proposed upgrades will meet the heat mitigation needs based on climate projections. Projects funding schoolyard redesign should explicitly consider heat when planning blacktop, playground, and greenspace placement to avoid accidentally creating hot spots where children play. CAL FIRE’s grant to provide $47 million for schools to convert asphalt to green space is a state-level example.

(22) Expand the eligible actions of FEMA’s Hazard Mitigation Assistance (HMA) to include installation/upgrade of heating, ventilation, and cooling (HVAC) systems and a more expansive program to support nature-based solutions (NBS) like green space installation. Existing guidance allows HVAC mitigation for other hazards and incentivizes NBS for other hazards.

(23) Increase alignment across federal programs, identifying programs where goals align. For example, FEMA just announced that solar panels would be eligible for the 75% federal cost share as part of mitigation programs; other climate and weatherization improvements should also be eligible under HMA funds.

(24) FEMA should modify its Benefit Cost Analysis (BCA) process to fairly evaluate mitigation of health and life-safety hazards, to better account for mitigation of multiple hazards, and to address equity considerations introduced in Office of Management and Budget’s recent BCA proposal. Some research is likely needed (e.g., the cost-effectiveness of various nature-based solutions like green space is not yet well-defined enough to use in a BCA); this research could be performed by national labs, put into FEMA’s Learning Agenda, or tasked to a partner agency like DOE.

(25) Expand the definition of medical devices to include items that protect against extreme weather. For example, the Center for Medicare and Medicaid Services could define air-conditioning units and innovative personal cooling devices as eligible for prescription under Medicare/Medicaid.

To support the above recommendations, Congress should:

(26) Ensure FEMA is sufficiently and consistently funded to conduct resilience and adaptation activities. Congress augments the Disaster Relief Fund in response to disasters, but they report that the fund will be billions of dollars in deficit by September 2024. It has furthermore been reported that FEMA has delayed payments due to uncertainty of funding through Congressional budget negotiations. In order to support the above programs, it is essential that Congress fund FEMA at a level needed to act. To support FEMA’s shift to a focus on resilience, the increase in funding should be through annual appropriations rather than the Disaster Relief Fund, which is augmented on an ad hoc basis.

(27) Convene a congressional commission like the recent Wildland Fire Commission to analyze the federal capabilities around extreme weather disasters and/or extreme heat. This commission would help source additional ideas and identify political pathways toward creating these solutions, and is merited by the magnitude of the disaster.

Conclusion

People across the U.S. are being increasingly exposed to extreme heat and other people-centered disasters. The suggested policies and programs are needed to upgrade national emergency management for the modern and future era, thereby saving lives and reducing disaster costs to the public.

The response to the 9/11 terrorist attacks included building from scratch a bioterrorism-monitoring system that remains a model for public health systems worldwide. Today we face a similarly galvanizing moment: weather-related hazards cause multiple times the 9/11 death toll each year, with extreme heat often termed the “top weather killer,” at 1,670 official deaths a year and 10,000 attributed via excess deaths analysis. Extreme cold and dense wildfire smoke each cause comparable numbers of deaths. By rapidly upgrading and expanding the health-tracking systems of the Centers for Disease Control (CDC), Veterans Health Administration (VHA), and Centers for Medicare and Medicaid (CMS) to improve real-time surveillance of health impacts of climate change, the U.S. can similarly meet the current moment to promote climate-conscientious care that save lives.

Challenge and Opportunity

The official death toll of extreme heat since 1979 stands at over 11,000, but the methods used to develop this count are known to underestimate the true impacts of heat waves. The undercounting of deaths related to extreme heat and other people-centered disasters — like extreme cold and smoke waves — hinders the political and public drive to address the problem and adds difficulty to declaring heat waves as disasters despite the massive loss of life. Similarly, the lack of integration of critical environmental data like “wet bulb” temperature alongside these health impacts in electronic data systems hinders the provision of medical care.

National Accounting

The national reaction to the 9/11 terrorist attacks provides a roadmap forward: improved data and tracking is fundamental to a nation’s evidence-based threat response. Operated by federal, state, and local public health professionals who comprise the CDC’s National Syndromic Surveillance Program (NSSP), surveillance systems were developed across the nation to meet new challenges in disease detection and situational awareness. Since 2020, the CDC’s Data Modernization Initiative (DMI) has provided a framework for this transformation, with the stated goal of improving the nation’s ability to predict, understand, and share data on new health threats in real time. While the DMI has focused on the pioneering role of new technologies for health protection, this effort also offers a once-in-a-generation opportunity for the public health and medical surveillance establishment to increase their capacity to address pressing future threats to the nation’s welfare, including the evolving climate crisis. Increasingly, extreme weather is responsible for both near-term disasters (more frequent and intense heat waves, dense smoke waves, and cold waves) and the long-term exacerbation of prevalent health conditions (such as heart, lung, and neurological disease). Its increasingly severe  impacts demand a detailed and funded roadmap to attain the DMI’s goals of “real-time, scalable emergency response” capability. 

Patient Care

Syndromic surveillance systems track the impacts of events at a population level, but other resources are needed to directly help individual patients during a disaster. Electronic health records (EHRs) allow medical providers to track relevant information that could help diagnose arising health conditions. Some medical systems have begun tracking nonmedical information to assist in diagnosis, such as the social determinants of health (e.g., housing and food availability) that are linked to improving patient outcomes. However, the environmental conditions a patient has experienced are not typically linked to health records. Improving the links between environmental conditions and EHRs will help patients—for example, by determining if a new asthma diagnosis is related to recent smoke waves—and also support syndromic surveillance.

A similar effect occurs with death records. Death records are typically logged at the patient level with free-form text that is mostly up to a medical professional who is often under time pressure. Text for each death record is later coded to fit into specific cause codes as it is aggregated into population-level datasets such as the National Vital Statistics System. Information about the environmental conditions that contributed to the death can be lost at any step along the process, resulting in the undercount of climate-related mortality. Improved tracking at the individual level will improve accounting at the national level.

Plan of Action

In order to track the health impacts from extreme weather events and thereby enhance the provision of medical care during such events, both disaster and health data must be improved.

Recommendation 1. National accounting for health impacts of the climate crisis

The National Syndromic Surveillance Program provides a world-class starting point for better tracking of climate health impacts, both in terms of technology and a dedicated and knowledgeable workforce.  The following plan will permit the evolution of this underlying infrastructure to provide health systems and policy makers with real-time and forecast impacts.

To modernize real-time monitoring of health impacts:

• CDC should actively support efforts within the NSSP to expand tracking of more conditions tied to the health impacts of extreme weather events.  In parallel, new research initiatives are needed to link these new surveillance syndromes with health system burden and health outcomes to improve the real-world predictive utility of these efforts.
• CDC should work with the Department of Education to track school closures and student absences, and with OSHA to track work-related injuries during extreme weather conditions. The National Institute for Occupational Safety and Health (NIOSH) at CDC will be a key partner in developing worker tracking as they already conduct surveillance including worker absenteeism and mortality. Similar programs should be constructed for schools, for example, leveraging the student attendance counts already collected by states to make a school-absenteeism surveillance program (e.g., by expanding existing efforts like the School-Based Active Surveillance Program or the Youth Risk Behavior Surveillance Program, which each track limited data for different goals).
• CDC should develop guidelines and funding for cities and states to expand their individual syndromic surveillance capabilities. Achieving uniformity across the nation is a major difficulty with expanding the NSSP, and CDC should work with the NSSP Community of Practice to develop, then promote, best practices through partnership with jurisdiction-specific syndromic surveillance.

To improve forecasting capabilities of health impacts:

• Congress should fund the CDC to expand its Center for Forecasting and Outbreaks Analytics (CFA) to include forecasting of environmental conditions and their health impacts. The HeatRisk service is exactly the kind of program that should also be available for smoke and cold—it clearly integrates the best science of health impacts of extreme weather events with best practices for public communications.
• Congress should fund the CDC to expand the CFA to make forecasts of operational needs for hospitals. Many hospitals now operate on a just-in-time system of stocking medical equipment that relies on typical-use rates that rapidly change during an extreme-weather event. A key piece of this operational forecasting should include potentials for cascading failures, as extreme-heat-caused failure of the electric grid is predicted to have major cascading failures in the health system. 

To improve the ability to track health impacts:

• CDC should develop guidance and training on reporting environmental conditions as contributing factors on death certificates, similar to their toolkit on Death Scene Investigation After Natural Disaster or Other Weather-Related Events and other existing training. The guidance and training could be developed by analyzing existing practices from across the county. Additional training for medical providers are listed in a separate memo.
• CDC’s National Center for Environmental Health, as part of their Disaster Epidemiology and Response program, should develop guidance for states on reporting heat-related deaths to the National Vital Statistics System that includes information about how free-form text from medical examiners is coded by state-level health officials. This recommendation builds on the prior recommendation—both are needed to ensure that heat-related deaths are appropriately counted at the national level.
• CDC should expand its use of excess-death and flu-burden methods to provide official estimates of the health impacts attributable to extreme heat beyond those reported on death certificates. Such methods exist and have been used for heat; they should be standardized and regularly applied at the federal level.
• CDC should work with the Environmental Protection Agency (EPA) to expand its BenMAP software to include official estimates of health impacts attributable to extreme heat. The current software provides official estimates of health impacts attributable to air pollution and isused widely in policy. Specifically, EPA should expand its BenMAP software to: (1) include the ability to model deaths due to heat and cold and their consequences (e.g., wildfires, industrial accidents); (2) add the capability to run in real time on real-time environmental data feeds; (3) include forecasting in the tools based on short-term forecast feeds and longer-term climate models; (4) integrate the outputs as a health-impact “nowcast” available with other data feeds such as the Heat and Health Tracker, the Heat Related EMS Activation Surveillance Dashboard, and/or the HeatRisk tool.
• Develop an extreme weather event impact self-report tool and database similar to the USGS “Did You Feel It?” web-based local data collection system.  The resulting  qualitative data will permit more in-depth understanding of the personal, family, community, and health system  impacts of  weather-related emergencies.
• Several actions are needed to support the preceding recommendation, including additional interagency (EPA/CDC/National Oceanic and Atmospheric Administration (NOAA)) collaboration and data sharing. Research is needed to develop the health-impact functions for the BenMAP tool, which could be solicited in a research call such as through National Institutes of Health (NIH) Climate and Health initiative, conducted by CDC epidemiologists, or tasked to a national lab. Additional software development is also needed to cover real-time and forecast impacts in addition to the historic impacts it currently covers.

Recommendation 2. Improving Patient Care

To integrate environmental conditions into EHRs nationwide:

• Environmental conditions should be integrated with EHRs as part of data modernization efforts within federal medical providers. Examples include the Federal Electronic Health Record Modernization program and Veterans Health Administration (VHA) EHR modernization effort.
• The major EHR providers should pilot the incorporation of environmental data into EHRs beyond the federal medical systems. University medical centers would be ideal test partners for this before expansion to all hospitals nationwide.
• Federal agencies promoting the uptake of EHRs, such as the Centers for Medicare and Medicaid Services (CMS) Promoting Interoperability Program, should include the integration of environmental data in electronic health records in the tools they promote.
• CDC should add “Tracking Disasters” as a key priority in its Data Modernization Initiative and use that program to encourage tracking of disaster-relevant data, such as environmental conditions, along with health records.

To support patients during extreme heat:

• Expand the definition of medical devices to include items that protect against extreme weather. For example, air-conditioning units and other strategies that reduce personal risk of heat illness should be eligible for purchase with health savings accounts and with Medicare/Medicaid.

Conclusion

Deaths from extreme conditions, already high, are forecast to increase in the coming years and decades and potentially define a new modern era. It is vital to prepare our health system for these threats, including accurate accounting of their toll, and better prepare healthcare providers and the public for the conditions they will face.

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.

Extreme heat is the leading weather-related cause of death in the U.S., yet it has never been the cause of a federal disaster declaration. This is because heat events are not explicitly recognized as a cause for disaster declarations under the Stafford Act, which defines federal disaster response activities. This renders those impacted by extreme heat ineligible for the substantial federal funding provided to communities that receive the official disaster declaration. A congressional amendment to the Stafford Act, and related post-disaster guidance, explicitly identifying extreme heat as an eligible disaster, would create significant opportunities for planning, funding, and implementing long-term heat adaptation while prioritizing the most physically and socially vulnerable communities.

While an extreme heat occurrence or heat wave may cause loss of life or labor, most disasters only receive federal declarations if they have excessive economic damage, property damage, and devastation beyond the capacity of a state government, which is less common in a heat event. Thus, amending the Stafford Act would assist the communities placed at an acute disadvantage in recovering and mitigating future heat events in comparison to those impacted by other extreme weather events. Likewise, it would increase U.S. capacity to address the growing challenges from increasingly frequent and extensive extreme heat events. 

An extreme heat disaster declaration, followed by an appropriation from Congress, can unlock federal adaptation funding through the Department of Housing and Urban Development (HUD) Community Development Block Grants for Disaster Recovery (CDBG-DR) and Mitigation (CDBG-MIT), as well as the Federal Emergency Management Agency (FEMA) Hazard Mitigation Grant Program (HMGP). Leveraging these programs for heat adaptation, coupled with an expansion of existing proactive resilience programs such as FEMA’s Building Resilient Infrastructure and Communities, would catalyze heat adaptation planning and innovation across the country.

Challenge and Opportunity

Between 2011 and 2021, 90% of U.S. counties experienced a major disaster due to an extreme weather event. Over that period, not a single disaster declaration was made in response to an extreme heat event; yet, communities suffered from the impacts of extreme heat. Two of the states with the lowest number of disaster occurrences, Nevada and Arizona, had the highest number of deaths from heat-related illnesses between 2018 and 2021, highlighting a major flaw in the federal disaster assistance programs’ ability to protect all communities bearing the impacts of climate change. Over those four years, heat has been among the causes of death for 571 people in Nevada and 1,298 people in Arizona. That’s 4.54 and 4.46 deaths per 100,000 residents, respectively – compared to the U.S. average of 0.35 per 100,000 residents over the same period. Additionally, deaths caused by extreme heat are likely undercounted, as there are no comprehensive or consistent mechanisms for healthcare providers to track or report heat-related deaths. 

In addition to being linked to growing mortality rates, extreme heat magnifies health, social, and economic disparities. According to the Centers for Disease Control (CDC), vulnerable populations — including older adults, infants and children, those with chronic conditions, lower-income individuals, athletes, outdoor workers, and pregnant people — are disproportionately affected by increased heat. Additionally, within cities, areas with less green space, often predominated by BIPOC or low-income communities, are likely to experience greater exposure to extreme heat, with higher rates of adverse outcomes. Increased and prolonged heat events also have economic impacts. Under baseline climate conditions, the United States could lose an average of approximately $100 billion annually from heat-induced lost labor productivity, which could double to nearly $200 billion by 2030 and reach $500 billion by 2050. This includes loss of agriculture due to lower labor productivity and lower crop yields. 

With 2023 breaking the record as the hottest year in recorded history, the United States must urgently reform its disaster assistance policies to incorporate extreme heat through an amendment to the Stafford Act and related post-disaster guidance. Currently, the majority of adaptation funding in the United States is tied to post-disaster recovery programs, meaning communities often do not have access to resources to plan ahead unless they have already suffered. Incorporating extreme heat would open new doors for heat mitigation and adaptation for affected communities through FEMA’s HMGP, as well as HUD’s CDBG-DR and CDBG-MIT. 

Plan of Action

Congress, FEMA, HUD, and the White House all have a role to play to optimize post-disaster funding and policies to address the growing challenges from excessively high temperature days and extended heat patterns.

Congress: Amendment to the Robert T. Stafford Act to Explicitly Identify Heat Events

A congressional amendment to the Stafford Act would ensure a heat event is considered an eligible event for a major disaster declaration, removing any doubt around its eligibility in perpetuity. Section 102 part (2) of the Stafford Act should be amended to: 

Any natural catastrophe (including any hurricane, tornado, storm, high water, wind-driven water, tidal wave, tsunami, earthquake, volcanic eruption, landslide, mudslide, snowstorm, drought, extreme heat or cold temperature, or extended heat or cold wave), or, regardless of cause, any fire, flood, or explosion, in any part of the United States, which in the determination of the President causes damage of sufficient severity and magnitude to warrant major disaster assistance under this Act to supplement the efforts and available resources of States, local governments, and disaster relief organizations in alleviating the damage, loss, hardship, or suffering caused thereby.

FEMA: Build Heat Adaptation Capacity through Heat Disaster Response and Planning

The HMGP is a critical resource for communities that have received a presidential disaster declaration to reduce future risk to lives and property from climate hazards. An amendment to the Stafford Act to address heat eligibility would enable state and tribal governments to request HMGP funding to support extreme heat response activities, such as cooling centers, air conditioners, utility vouchers, surge capacity support for hospitals, and direct interventions for vulnerable populations. Likewise, governments could request funding under HMGP for infrastructure upgrades, including increased tree canopy, green infrastructure, cool pavement, reflective roofs, retrofitting buildings with improved HVAC systems and materials that reflect solar energy to keep indoor temperatures cooler, and power grid enhancements. 

Within the HMGP, increased set-asides should be given to planning-related activities to build capacity among communities across America. Doubling funding for planning-related activities from 7% to 14% of the recipient’s HMGP funding would create greater opportunities for state, tribal, territorial, and local governments to conduct activities to strengthen their extreme heat preparedness and response, through eligible activities such as:

1. Enhancing the current FEMA-approved mitigation plan by incorporating underserved and highly vulnerable populations in the planning process, risk assessment, and mitigation strategy, namely seniors, the unhoused, agriculture workers, and children.
2. Integrating extreme heat adaptation information/targets from the hazard mitigation strategy into other pre- and post-disaster recovery plans, comprehensive planning, capital improvements, economic development, resource management, or other long-term community planning.
3. Building capability through delivery of technical assistance and training, particularly through green infrastructure and cooling infrastructure workforce development, as well as community education on heat adaptation strategies to prevent physical and financial losses from future heat events. 
4. Evaluating the adoption/implementation of codes and ordinances that reduce risk to extreme heat with a focus on improvements to building codes to improve heat resilience. 

Leveraging FEMA’s HMGP will bolster communities’ heat disaster response while shifting investments toward long-term disaster mitigation planning. Coupling FEMA’s HMGP funding for extreme heat planning with an expansion of FEMA’s Building Resilient Infrastructure and Communities (BRIC) would further enable communities to get ahead of the next disaster, before people suffer. FEMA made a total of $2.26 billion available through BRIC in 2022, and $1 billion in 2023. Meanwhile, the United States experienced 18 separate weather and climate disasters costing at least $1 billion in 2022 and 28 separate events in 2023. To meet the rising demands for proactive planning, FEMA must increase funding allocations for BRIC and prioritize projects that address multiple hazards. 

White House: Launch a Heat Adaptation Design Challenge under the America COMPETES Act 

Under the authority of the America COMPETES Act, the White House should launch a time-bound interdisciplinary planning and design challenge that brings together lived and professional expertise from local, national, and international participants to catalyze community-level long-term climate adaptation and land-use changes for communities in the United States. This model builds on the precedent set by the Rebuild by Design Hurricane Sandy Design Competition and the National Disaster Resilience Competition. 

In 2013, in response to the devastation wrought by Hurricane Sandy, President Obama’s Hurricane Sandy Recovery Task Force and HUD set a new precedent for disaster recovery by launching the Hurricane Sandy Rebuild by Design Competition. The competition, authorized under the America COMPETES Act, set aside almost $1 billion of CDBG-DR funds to launch a nine-month-long interdisciplinary planning and design challenge in the Sandy-impacted region. The competition resulted in seven winning designs, which now have over $4.3 billion invested in them. The Rebuild by Design competition raised the bar for government collaboration with communities in the development of adaptation solutions, demonstrated that innovative ideas attract more dollars, and cast the region center stage of global climate adaptation solutions, attracting local, regional, and international talent. The model was subsequently used in the National Disaster Resilience Competition and the Bay Area Resilient by Design Challenge. These processes have paved the way for reimagining communities to withstand and thrive among growing climate shocks and stressors, while raising the bar for education and collaboration with impacted communities.

To date, a design challenge process has not been used to the same scale to directly address extreme heat adaptation with the support of federal funding. An interdisciplinary design challenge poses a unique opportunity to mobilize planning and design across multiple aspects that contribute to heat mitigation and adaptation, including building and road materials, energy use and storage, land use, architecture, landscape architecture, and engineering while centering the voices of impacted communities. The process could incubate innovative designs like blue-green infrastructure, social infrastructure, and community planning, as well as innovative policies such as tenant protections, energy regulations, and working standards, thereby centering people over property in disaster recovery and propelling the United States to the forefront of the global discourse on adaptation.

A national challenge would create opportunities to incubate (1) exemplary models of comprehensive heat adaptation planning, (2) sector-specific models that agencies could use to guide new and existing grant programs, and (3) heat-adaptive technologies. 

1. Few exemplary models of comprehensive extreme heat adaptation exist in the United States. Only a few governments – namely, Miami-Dade County, the city of Los Angeles, the city of Phoenix,  the state of Arizona, and the state of Maryland – have taken great strides to mitigate the loss of life and economic output from extreme heat events by appointing chief heat officers. As a result, when tasked with taking action to mitigate extreme heat, localities are drawing from a limited toolbox of solutions, often air conditioners and cooling centers. A design competition could spur new ideas for transforming a locality’s physical spaces, including housing, transportation, right of way, parks, and public amenities to reduce risk during extreme heat, address other climate hazards, and provide needed social benefits to communities. 
2. Federal agencies play a key role in deploying funding to improve infrastructure across the United States. A national design challenge with a focus on heat adaptation could catalyze innovative sector-specific solutions that agencies could model in new and existing grant programs. For example, a design challenge that focuses on rethinking public right of way infrastructure to mitigate extreme heat would result in an array of outputs (research, designs, and projects) from which agencies could base new grant criteria. Similarly, this model could be used to specifically incubate ideas for housing, energy, transportation, and agriculture. 
3. The America COMPETES Act improves the competitiveness of the United States through investments in research and technology. A national research and design competition, focused on generating new technologies for communities, households, and individuals to adapt to heat, could seed a new industry in the United States. As rising global temperatures increasingly impact communities around the world, these technologies could thrust the United States to the forefront of global heat adaptation solutions and create domestic jobs and exports. Moreover, these interventions could reduce suffering and save countless American lives.

HUD: Heat Adaptation Planning through CDBG-DR and CDBG-MIT Funds

HUD’s CDBG-DR and CDBG-MIT funds are critical to helping communities recover from an extreme climate event in a way that better prepares them for future events; however, they are not being fully utilized to address extreme heat. These funds are only available to communities that have received a major disaster declaration. The Rebuild by Design Hurricane Sandy Design Competition and the National Disaster Resilience Competition were made feasible through allocations of CDBG-DR funds by HUD to explicitly plan ahead for future impacts from climate change, as opposed to replacing what had previously existed. An amendment to the Stafford Act to create eligibility for heat disasters would allow for an extreme heat design challenge to be supported through an appropriation of HUD CDBG-DR or CDBG-MIT funds in response to a major disaster declaration. A federally funded design challenge would also attract local and international expertise, as well as local governments, as participants would know upfront that there is implementation funding. Furthermore, the funding criteria for all disaster declarations should require that applicants assess heat vulnerability using FEMA’s Risk Rating Index or localized data to prioritize multi-hazard solutions and ensure that all disaster recovery efforts are also incentivized to address heat mitigation. 

To further optimize HUD’s funding for disaster recovery and long-term planning, Congress must permanently authorize CDBG-DR. Currently, HUD allocations for CDBG-DR are slow to reach communities. Permanent authorization would remove delays and create greater predictability and certainty for communities to address the loss of life brought on by heat waves. 

Conclusion

In order to address the growing challenges from extreme heat, the U.S. must dramatically shift investments from reactive disaster recovery to proactive disaster risk reduction. In the interim, making this shift will require striking down the barriers to accessing post-disaster funding for communities that need support to respond to and prepare for extreme heat by amending the Stafford Act. A national design competition, funded through post-disaster assistance, could be the mechanism to catalyze this paradigm shift by seeding innovative and exemplary heat adaptation solutions that could be modeled throughout the country. Leadership from Congress, the White House, FEMA, and HUD would ensure communities are able to respond to the impacts of today, and spur innovation and preparation for the impacts of tomorrow.

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.

Extreme heat events are increasing in frequency and intensity every year, leading to devastating human costs such as hospitalization and death. In urban environments, where over 80% of Americans live, these effects are exacerbated by the urban heat island effect. In alignment with the White House’s nature-based solutions efforts to address the effects of climate change, the role of greening has been touted as a life-saving means to protect urban residents from extreme heat, mitigate stormwater, and reduce air pollution. Nonetheless, the benefits of urban forestry have not yet been realized due to unsustainable funding at municipal levels for maintenance and stewardship, limited coordination across branches of government, inequitable distribution of trees, and a lack of analyses that define the economic value of urban forestry. A coordinated, equity-focused, and economically validated federal plan to guide the development and maintenance of urban forestry will allow the full utilization of this critical resource. Achieving this goal requires action at all levels of government; sustainable funding to grow, develop, research, and sustain urban forests; and ongoing leadership from the scientific and forestry communities.

The incoming administration should undertake a multi-agency effort to further develop the science and quantify the benefits of urban forests today and into the future. This will equip urban foresters and their municipal partners with the necessary decision support tools to plant, grow, and maintain urban forests in cities across the United States. Doing this will ensure current forestry investments created by the Inflation Reduction Act (IRA) and Bipartisan Infrastructure Law (BIL) continue to reap maximum benefits into the future. By using environmental economic principles in national accounts and leveraging the Office of Management and Budget’s (OMB) new Ecosystems Services Guidance to capture the true value of urban forests and their ecosystem services to the U.S., the federal government will provide the economic basis for further strategic planning of urban forestry. Additionally, applying the principles of environmental justice ensures decisions will support efforts to overcome the histories of redlining that prevented the expansion of urban forests into disadvantaged neighborhoods. Undertaking these efforts can lead to the realization of the potential benefits of urban forests, estimated conservatively to be over $17 billion annually. 

Challenge and Opportunity

Every year, extreme heat events are increasingly threatening to human health. Recent summers have seen rises in heat-related hospitalizations. In 2023, heat-related hospitalizations increased by 51% compared to 2018. However, federal, state, and local governments are limited in their approaches to addressing extreme heat’s effect on human health and well-being. Public health approaches to tackling this growing problem include the development of coordinated messaging between public health, health systems, and community members to warn of impending extreme events, cooling centers, and the distribution of air conditioner units. Unfortunately, these prevention strategies are often reactive and unsustainable in the long term. They rely on forecasting of extreme heat events to initiate alerts or to establish cooling centers and increase demand for air conditioning, which drives up energy costs and greenhouse gas emissions.

An alternate, longer-term, and more effective strategy is to use trees as a form of natural infrastructure, particularly where the urban heat island effect takes place (i.e., the sustained increased temperatures during the day and night due to heat retention from the built environment). Trees can reduce air temperatures by up to 10ºF, and surface temperatures up to 25ºF. Urban forestry impacts over 80% of Americans, where the urban heat island effect is most pronounced. Although not accounted for in today’s macroeconomic evaluations of gross domestic product, the U.S. Department of Agriculture (USDA) Forest Service estimates that urban forestry currently provides over $17 billion in ecosystem service benefits annually through improvements in air quality, stormwater management, improved physical and mental health, and increased property values. Moreover, urban forestry is cost-effective: for every $1 spent on urban tree management, benefits are estimated to be valued at $1.37 to $3.09. Urban forests, when strategically planted or naturally regenerated and maintained, also have the potential to be a long-term, sustainable, nature-based solution to the rising threat of extreme heat on human health.

The USDA US Forest Service is rapidly expanding tree inventories across the nation, informed by the Ten-Year Urban Forestry Action Plan created by the National Urban and Community Forestry Advisory Council (NUCFAC). Funds for urban forestry have recently been appropriated through the IRA and BIL, which allocated over $1 billion over the next five years to urban forestry. Strategically channeling these funds through federal oversight and technical assistance to address the rising threat of extreme heat will provide the best opportunity to maximize the use of these funds and demonstrate the outcomes of sustaining federal investment at that scale. 

Therefore, to reduce extreme heat in urban areas where most Americans live, a comprehensive urban forestry strategy is essential. This strategy should provide ongoing support within and across cities, and link the science of tree selection, climate-resilient seed propagation, planting, and maintenance with efforts to overcome disparities in urban greening infrastructure. Further, there is an ongoing need to develop the urban forestry workforce and capacity necessary to sustain these investments and ensure their benefits come to fruition. Finally, ongoing research and analysis is needed (anticipated at $50 million annually by NUCFAC) to inform urban and community forestry policy and increase the effectiveness and benefits of greening interventions.

Plan of Action

Creating a strategic plan for urban forestry management to combat extreme heat requires equity-centered coordination across various federal agencies, given the clear disparities in urban greening infrastructure within and across U.S. cities. The strategy must also further the development of research to maximize ecosystem services, incorporating the costs of urban forests over extended periods. 

Thus, the federal plan of action must be guided by the following principles:

1. Placing environmental justice and equitable urban greening practices at the forefront of a strategic plan.
2. Employing natural capital cost assessments — a key endeavor of the Biden Administration to include environmental-economic appraisal of nature-based solutions — in the development of the potential of public-private partnerships (e.g., US Forest Service Public-Private Partnership Strategy).
3. Specifying cross-agency collaboration to directly quantify the benefits from a diverse range of perspectives. For example, direct healthcare benefits from urban forestry require long-term and causal research on the quantity, distribution, and duration to account for such benefits from an environmental-economic perspective.

Coordinate the Executive Branch. A federal interagency task force consisting of urban forestry experts, healthcare authorities, economic stewards, and heat science specialists should lead the effort to create a national urban forestry strategic plan. This taskforce should be co-led by OMB and the Council on Environmental Quality (CEQ) and should include the following agencies: the USDA Forest Service, Department of the Interior (DOI), Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Department of Commerce Bureau of Economic Analysis, Housing and Urban Development (HUD), Department of Transportation (DOT), the National Oceanic and Atmospheric Agency (NOAA), and other agencies as relevant. The following courses of action should be taken:

• Direct studies to evaluate and directly quantify the ecosystem services and disservices of urban forestry under current and future climate scenarios.
• Dedicate resources to expeditiously create a national inventory of urban forests, indexed by location, species, and age.
• Direct agencies to build methodologies as a first case study to detail how natural capital assessments for nature-based solutions can be undertaken.
• Build a strategic plan for tree planting and maintenance by climate region and city type, including the development of decision support tools for state and city-wide urban foresters to best allocate resources.
• Undertake evaluative work to direct already appropriated funds through the IRA and BIL to urban forestry projects with the highest benefit to communities locally and regionally.

Strengthen the Evidence Base. Empirical data to inform natural capital assessments and the beneficial and detrimental effects on heat mitigation and stormwater mitigation will be required to better analyze and build policies. Areas in need of development include: human health benefits and healthcare return on investment; climate and resilience, especially around forest vulnerabilities; and environmental justice, including lowering the burden of ongoing maintenance on communities. Through the NIH, CDC, National Science Foundation (NSF), Department of Energy (DOE), Environmental Protection Agency (EPA), USDA, NOAA, and National Aeronautics and Space Administration (NASA), funding should be allocated to:

• Undertake studies to quantify and evaluate health-related ecosystem services and disservices of urban forestry under various climate scenarios in the short and long term (NIH, CDC, USDA).
• Quantify the correlation between increased greening and lower air temperatures, reductions in energy demand, benefits to energy efficiency of buildings and homes, and decreases in greenhouse gas emissions (EPA, DOE, NOAA, NASA, USDA).
• Examine the differential impacts of urban forests according to the principles of environmental justice (NIH, USDA, EPA, NSF).
• Determine the future-proofing needs of urban forestry investments across the U.S.’s 12 climatic regions (USDA, NOAA, NASA).
• Reexamine existing correlative studies to determine underlying causation regarding urban forestry human health benefits and ecosystem impacts (CDC, NSF, EPA, USDA).
• Undertake implementation studies to ensure the feasibility, cost, and efficacy of an urban forest intervention to limit the effects of extreme heat on communities (USDA, NOAA, NIH, NASA).

Conclusion 

Extreme heat events are rising in intensity, frequency, and severity, particularly within cities. Existing measures to protect residents against the scourge of these events are limited while they need to be equity-focused, sustainable, and address the rising threat of climate change now and into the long term. The influx of investment in urban forestry from the IRA and BIL has provided the necessary foundation for the benefits of urban forestry as a source of nature-based solutions to combat extreme heat.

A federal strategic plan for urban forestry management to combat extreme heat is necessary to fully capture the benefits of this investment. By employing natural capital assessments, directing cross-agency collaboration, and building the necessary scientific evidence, urban forestry can serve as key infrastructure to create climate resilient communities across the United States.

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.

The federal government needs to maximize existing funds to mitigate heat stress and ensure the equitable distribution of these resources to the most vulnerable households. Agencies could increase Low Income Home Energy Assistance Program (LIHEAP) funding allocations through incentives or by mandating a floor of benefits from these programs be distributed to a well-defined set of vulnerable households. This approach is similar to Justice40, the Biden administration’s signature environmental justice initiative that requires federal agencies to ensure a minimum allocation of 40% of program benefits are received by disadvantaged communities.

Challenge and Opportunity 

In addition LIHEAP, which is administered by the Department of Health and Human Services (HHS), Justice40 covered programs with high potential to mitigate heat stress include: 

• American Climate Corps (Corporation for National & Community Service, CNCS) 
• Greenhouse Gas Reduction Fund (GGRF; EPA)
• Energy Efficiency and Conservation Block Grants (EECBG; DOE)
• Weatherization Assistance Program (WAP; DOE) 
• Building Resilient Infrastructure and Communities (BRIC; FEMA) 

LIHEAP and these five priority programs have combined allocations of about $30 billion in 2024 alone. Allocating even 10% of this collective budget to the most vulnerable communities and households could significantly reduce heat mortality and morbidity.

Since its inception in 1974, LIHEAP has provided more than $100 billion in direct bill payment assistance, more than double the allocation of seven other low-income energy programs combined. LIHEAP provides a formula block grant to all states and territories and more than 150 tribes. The FY24 LIHEAP allocation is $3.6 billion; state allocations vary depending on overall and low-income population and climate.

LIHEAP is disbursed by the HHS Administration for Children and Families (ACF) to state-level HHS counterparts. These in turn distribute funding to subgrantees, including local HHS offices, national NGOs, and community-based organizations. Furthermore, there is often coordination between state and local LIHEAP administrators and utilities, which provide additional low-income energy efficiency, solar and storage programs, and rate discounts. 
HHS understands the impetus for LIHEAP to reduce heat stress. For instance, in 2021, HHS published a “Heat Stress Flexibilities and Resources” memo, which outlined the disproportionate impacts of future heat conditions on communities of color and recommended using a portion of the state allocation for cooling assistance, providing or loaning air conditioners, targeting vulnerable households, and a range of public educational activities. In 2016, the agency designated a national Extreme Heat Week on how LIHEAP can be a part of the solution.

LIHEAP Formula Funding Favors Heating Assistance

However, LIHEAP funds have not been sufficiently used for cooling assistance. Nationally, from 2001 to 2019, just 5% of all LIHEAP funds were used for cooling assistance, with heating receiving ten times more funding than cooling. Even among states in the Southeast, just 14% of the budget was for cooling assistance. In 2019, only 21 states opted to provide cooling assistance, compared to the 49 that allocated funding to weatherization and 26 that used LIHEAP for energy education and supplemental energy efficiency programs. 

Some states with the highest heat risk — such as Missouri, Nevada, North Carolina, and Utah —  offer no cooling assistance funds from LIHEAP.  Despite their warm climates, Arizona, Arkansas, Florida, and Hawai’i all limit LIHEAP cooling assistance per household to less than half the available heating assistance benefit.

State uses of LIHEAP funding by category.

Prior efforts to encourage the use of LIHEAP for cooling have not resulted in a sufficient shift of this landmark funding source. LIHEAP was originally developed to provide home heating assistance at a time when winters were more severe and summers less searing. State LIHEAP administrators used the vast majority of their budgets during the heating season; many viewed cooling assistance as a luxury. This is despite the extreme heat events of recent summers, including temperatures topping 115ºF in the Pacific Northwest in 2019 and 31 days in a row of highs above 110ºF in Phoenix in 2023. 

With many households still struggling to pay their winter bills, LIHEAP administrators may be reluctant to shift allocations from heating assistance that already cannot serve even 50% of eligible households. States that do not set aside dedicated cooling assistance funds frequently run out of LIHEAP, which they receive in October, well before summer. Even if crisis funds could theoretically be used to support families in crisis during heat waves, these funds are exhausted by high crisis demand in winter.

The majority of LIHEAP allocations are based on a formula rooted in a state’s low-income population, energy costs, and the severity of a state’s winter climate (its heating degree days). Residential energy costs may account for the number of cooling degree days, but they do not account for variation in electricity prices and have no consideration of population sensitivity (e.g., age) or adaptive capacity measures that are included in many Heat Vulnerability Indices (HVIs).

LIHEAP’s website on extreme heat points to the 2021 “heat dome” in the Pacific Northwest, which saw daily hospitalizations 69 times higher than the same week in 2020. In Washington state alone, 441 people died. The event, previously thought to be a 1 in 1,000-year occurrence, could occur every 5 to 10 years with just 2℃ of global warming (2023 was 1.35℃ warmer than the preindustrial average). 

With advanced forecasts, LIHEAP could be deployed both to restore disconnected electric service and to make payments on extreme energy bills, which may surge even higher with the increase in demand response pricing. In Michigan, for example, DTE Energy offers a dynamic peak pricing rate that has critical peak periods at $1.03 per kWh, eight times higher than its off-peak rate. Maximum demand for electricity for continuous cooling coupled with time-of-use rate structures is a recipe for exorbitant bills that low-income customers will not be able to afford.

The risk to vulnerable households from the absence of cooling assistance is compounded by a lack of disconnection protections from extreme heat. Forty-one states offer protections for cooling, compared to just 20 that prevent utilities from disconnecting households during extreme heat. Heat protections often only kick in when a specific temperature is reached (e.g., 95°F) or even when a particular alert is issued by the National Weather Service, leaving households uncertain about their status.

In the bi-weekly Pulse Survey of the U.S. Census (June 28 to July 10, 2023, the most recent period of extreme heat nationally), 58.5% of national respondents reported keeping their home at an uncomfortable or unsafe temperature at least some months in the last year, with 18.7% reporting these indoor temperatures almost every month. Households that spend more of their income on energy bills allow indoor temperatures to rise up to 7.5°F more than higher-income households before using air-conditioning, thus dramatically increasing their risk of heat stress.

Plan of Action

Recommendation 1. Maximize LIHEAP funding for cooling assistance

Congressional mandate – Congress could require states to use a specific percentage of their LIHEAP allocations for cooling. This percentage could be derived from FEMA’s National Risk Index (NRI), which accounts for exposure to extreme heat, the vulnerability of the population, and adaptive capacity, such as civic resources to provide emergency response. Heat Factor by First Street and Community Resilience Estimates for Heat by U.S. Census offer more granular estimates of heat vulnerability.

Incentives – LIHEAP regularly receives supplemental federal allocations (e.g. CARES Act); HHS could use these as a pool of matching funds to encourage states to leverage non-federal dollars for cooling assistance. States also have an important role to play in leveraging both public and utility funds to match and expand the impact of LIHEAP.

Emergency funds – HHS should release Emergency Contingency Funds to address extreme heat. In the 1990s and 2000s, these funds were regularly used, sometimes in excess of $700 million per year to direct cooling assistance to extreme heat events; these funds could also be used to provide cooling measures like fans, air conditioners, and insulation. These funds have been authorized but not allocated by Congress and not disbursed since 2011.

Report back to state LIHEAP administrators – Peer comparisons can be a powerful source of information and motivation. A study from the 1990s “targeting index” for the share of LIHEAP delivered to the elderly revealed stark differences between Arizona, where the elderly were underrepresented, and Texas, where they were represented above their proportion of the population. An annual dashboard of how a state compares to its close peers (e.g., to other states in its EPA region) in cooling allocations is a low-effort step that could result in significant shifts in state plans and community outreach. 

Expand outreach and education to state LIHEAP administrators and subgrantees – Memos from 2016 and 2021 were insufficient to encourage many state and local budget shifts. Communications should emphasize the significantly greater risk of fatalities from extreme heat than extreme cold. One study simulated indoor temperatures in Phoenix during the 2006 heat wave and showed that by day two, temperatures in single-story homes would peak at 115ºF (46ºC). Another study projected that a five-day heat wave on the order of the record July 2023 temperatures that corresponds with a blackout would result in a fatality rate of ~1% in Phoenix, or about 1,500 deaths.

Recommendation 2. Maximize LIHEAP distribution to the most vulnerable households

While LIHEAP providers do collect significant household data through their intake forms, most states do not have firm guidelines on which households to distribute LIHEAP funds to and use a modified first-come, first-served approach. A small number of questions specific to heat risk could be added to LIHEAP applications and used to generate a household heat vulnerability score (raw or percentile). A list of 10 potential sensitivity factors to assess is included in the Frequently Asked Questions.

In partnership with extreme heat experts, US Digital Service could support the development of an algorithm to assess the likelihood of each household experiencing acute heat stress and the optimal uses of LIHEAP funding to mitigate these threats, at the household level and portfolio-wide.

Existing data from the Community Resilience Estimates for Heat (CRE) by the U.S. Census shows that more than two-thirds of extreme heat vulnerability is concentrated in just 1.5% of U.S. census tracts across 10 states. Even a small amount of LIHEAP cooling assistance, if effectively targeted, could dramatically reduce the risk of heat stroke and death.

Recommendation 3. Congressional Amendments to the LIHEAP Statute

Congress has revisited the LIHEAP formula in the past and should consider revising the formulas to elevate the role of cooling assistance and disconnection prevention during extreme heat. Rep. Watson Coleman (D-NJ) proposed this in the Stay Cool Act introduced in 2022. As the climate has changed dramatically since LIHEAP’s inception and will continue to in coming decades, Congress could peg an updated formula to an HVI as a national standard to ensure shifts in climate and population would be automatically updated in the annual LIHEAP formula. It could also update household data collection requirements under LIHEAP Statute Section 2605(c)(1)(G).

Conclusion

The number of heat-related deaths continues to rise in the U.S. In the long term, a multipronged strategy that increases funding for energy efficiency improvements, distributed generation and storage, and bill assistance is needed. But in the near term, it is critically important to work with existing resources and maximize the value of LIHEAP to mitigate the pressures of extreme heat. 

Despite some positive spikes, annual LIHEAP allocations have not kept pace with accelerating demand. The number of households eligible for LIHEAP has grown four times faster than available funding; the number of eligible households served has declined from 36% to 16%. As utility bills outpace inflation, per-household LIHEAP allocations have increased without a corresponding increase in the overall allocation.

States have broad discretion on how to use LIHEAP. Overcoming the inertia of budgets dominated by heating assistance is likely to require significant advocacy, both top-down from the federal government and bottom-up from grassroots community organizations that share concerns about vulnerability to extreme heat. 

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.

The escalating frequency and intensity of extreme heat events, exacerbated by climate change, pose a significant and growing threat to public health. This problem is further compounded by the lack of standardized education and preparedness measures within the healthcare system, creating a critical gap in addressing the health impacts of extreme heat. The Department of Health and Human Services (HHS), especially the Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), and the Office of Climate Change and Health Equity (OCCHE) can enhance public health preparedness for the health impacts of climate change. By leveraging funding mechanisms, incentives, and requirements, HHS can strengthen health system preparedness, improve health provider knowledge, and optimize emergency response capabilities. 

By focusing on interagency collaboration and medical education enhancement, strategic measures within HHS, the healthcare system can strengthen its resilience against the health impacts of extreme heat events. This will not only improve coding accuracy, but also enhance healthcare provider knowledge, streamline emergency response efforts, and ultimately mitigate the health disparities arising from climate change-induced extreme heat events. Key recommendations include: establishing dedicated grant programs and incentivizing climate-competent healthcare providers; integrating climate-resilience metrics into quality measurement programs; leveraging the Health Information Technology for Economic and Clinical Health (HITECH) Act to enhance ICD-10 coding education; and collaborating with other federal agencies such as the Department of Veterans Affairs (VA), the Federal Emergency Management Agency (FEMA), and the Department of Defense (DoD) to ensure a coordinated response. The implementation of these recommendations will not only address the evolving health impacts of climate change but also promote a more resilient and prepared healthcare system for the future.

Challenge

The escalating frequency and intensity of extreme heat events, exacerbated by climate change, pose a significant and growing threat to public health. The scientific consensus, as documented by reports from the Intergovernmental Panel on Climate Change (IPCC) and the National Climate Assessment, reveals that vulnerable populations, such as children, pregnant people, the elderly, and marginalized communities including people of color and Indigenous populations, experience disproportionately higher rates of heat-related illnesses and mortality. The Lancet Countdown’s 2023 U.S. Brief underscores the escalating threat of fossil fuel pollution and climate change to health, highlighting an 88% increase in heat-related mortality among older adults and calling for urgent, equitable climate action to mitigate this public health crisis.

Inadequacies in Current Healthcare System Response

Reports from healthcare institutions and public health agencies highlight how current coding practices contribute to the under-recognition of heat-related health impacts in vulnerable populations, exacerbating existing health disparities. The current inadequacies in ICD-10 coding for extreme heat-related health cases hinder effective healthcare delivery, compromise data accuracy, and impede the development of targeted response strategies. Challenges in coding accuracy are evident in existing studies and reports, emphasizing the difficulties healthcare providers face in accurately documenting extreme heat-related health cases. An analysis of emergency room visits during heat waves further indicates a gap in recognition and coding, pointing to the need for improved medical education and coding practices. Audits of healthcare coding practices reveal inconsistencies and inaccuracies that stem from a lack of standardized medical education and preparedness measures, ultimately leading to underreporting and misclassification of extreme heat cases. Comparative analyses of health data from regions with robust coding practices and those without highlight the disparities in data accuracy, emphasizing the urgent need for standardized coding protocols.

There is a crucial opportunity to enhance public health preparedness by addressing the challenges associated with accurate ICD-10 coding in extreme heat-related health cases. Reports from government agencies and economic research institutions underscore the economic toll of extreme heat events on healthcare systems, including increased healthcare costs, emergency room visits, and lost productivity due to heat-related illnesses. Data from social vulnerability indices and community-level assessments emphasize the disproportionate impact of extreme heat on socially vulnerable populations, highlighting the urgent need for targeted policies to address health disparities.

Opportunity

As Medicare is the largest federal source of Graduate Medical Education (GME) funding (Figure 1), the Department of Health and Human Services’ (HHS) Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) play a critical role in developing coding guidelines. Thus, it is essential for HHS, CMS, and other pertinent coordinating agencies to be involved in the process for developing climate change-informed graduate medical curricula.

  Figure 1: Graduate Medical Education Funding Streams

By focusing on medical education enhancement, strategic measures within HHS, and fostering interagency collaboration, the healthcare system can strengthen its resilience against the health impacts of extreme heat events. Improving coding accuracy, enhancing healthcare provider knowledge, streamlining emergency response efforts, and mitigating health disparities related to extreme heat events will ultimately strengthen the healthcare system and foster more effective, inclusive, and equitable climate and health policies. Improving the knowledge and training of healthcare providers empowers them to respond more effectively to extreme heat-related health cases. This immediate response capability contributes to the overarching goal of reducing morbidity and mortality rates associated with extreme heat events and creates a public health system that is more resilient and prepared for emerging challenges. 

The inclusion of ICD-10 coding education into graduate medical education funded by CMS aligns with the precedent set by the Pandemic and All Hazards Preparedness Act (PAHPA), emphasizing the importance of preparedness and response to public health emergencies. Similarly, drawing inspiration from the Health Information Technology for Economic and Clinical Health Act (HITECH Act), which promotes the adoption of electronic health records (EHR) systems, presents an opportunity to modernize medical education and ensure the seamless integration of climate-related health considerations. This collaborative and forward-thinking approach recognizes the interconnectedness of health and climate, offering a model that can be applied to various health challenges. Integrating mandates from PAHPA and the HITECH Act serves as a policy precedent, guiding the healthcare system toward a more adaptive and proactive stance in addressing climate change impacts on health.

Conversely, the consequences of inaction on the health impacts of extreme heat extend beyond immediate health concerns. They permeate through the fabric of society, widening health disparities, compromising the accuracy of health data, and undermining emergency response preparedness. Addressing these challenges requires a proactive and comprehensive approach to ensure the well-being of communities, especially those most vulnerable to the effects of extreme heat.

Plan of Action

The following recommendations aim to facilitate public health preparedness for extreme heat events through enhancements in medical education, strategic measures within the Department of Health and Human Services (HHS), and fostering interagency collaboration.

Recommendation 1a. Integrate extreme heat training into the GME curriculum. 

Integrating modules on extreme heat-related health impacts and accurate ICD-10 coding into medical education curricula is essential for preparing future healthcare professionals to address the challenges posed by climate change. This initiative will ensure that medical students receive comprehensive training on identifying, treating, and documenting extreme heat-related health cases. Sec. 304. Core Education and Training of the PAHPA provides policy precedent to develop foundational health and medical response curricula and training materials by modifying relevant existing programs to enhance responses to public health emergencies. Given the prominence of Medicare in funding medical residency training, policies that alter Medicare GME can affect the future physician supply and can be used to address identified healthcare workforce priorities related to extreme heat (Figure 2).

Figure 2: A model for comprehensive climate and medical education (adapted from Jowell et al. 2023)

Recommendation 1b. Collaborate with Veterans Health Administration Training Programs. 

Partnering with the Department of Veterans Affairs (VA) to extend climate-related health coding education to Veterans Health Administration (VHA) training programs will enhance the preparedness of healthcare professionals within the VHA system to manage and document extreme heat-related health cases among veteran populations.

Recommendation 2. Collaborate with the Agency for Healthcare Research and Quality (AHRQ) 

Establishing a collaborative research initiative with the Agency for Healthcare Research and Quality (AHRQ) will facilitate the in-depth exploration of accurate ICD-10 coding for extreme heat-related health cases. This should be accomplished through the following measures:

Establish joint task forces. CMS, NCHS, and AHRQ should establish joint research initiatives focused on improving ICD-10 coding accuracy for extreme heat-related health cases. This collaboration will involve identifying key research areas, allocating resources, and coordinating research activities. Personnel from each agency, including subject matter experts and researchers from the EPA, NOAA, and FEMA, will work together to conduct studies, analyze data, and publish findings. By conducting systematic reviews, developing standardized coding algorithms, and disseminating findings through AHRQ’s established communication channels, this initiative will improve coding practices and enhance healthcare system preparedness for extreme heat events.

Develop standardized coding algorithms. AHRQ, in collaboration with CMS and NCHS, will lead efforts to develop standardized coding algorithms for extreme heat-related health outcomes. This involves reviewing existing coding practices, identifying gaps and inconsistencies, and developing standardized algorithms to ensure consistent and accurate coding across healthcare settings. AHRQ researchers and coding experts will work closely with personnel from CMS and NCHS to draft, validate, and disseminate these algorithms.

Integrate into Continuous Quality Improvement (CQI) programs. Establish collaborative partnerships between the VA and other federal healthcare agencies, including CMS, HRSA, and DoD, to integrate education on ICD-10 coding for extreme heat-related health outcomes into CQI programs. Regularly assess the effectiveness of training initiatives and adjust based on feedback from healthcare providers. For example, CMS currently requires physicians to screen for the social determinants of health and could include level of climate and/or heat risk within that screening assessment.

Allocate resources. Each agency will allocate financial resources, staff time, and technical expertise to support collaborative activities. Budget allocations will be based on the scope and scale of specific initiatives, with funds earmarked for research, training, data sharing, and evaluation efforts. Additionally, research funding provided through PHSA Titles VII and VIII can support studies evaluating the effectiveness of educational interventions on climate-related health knowledge and practice behaviors among healthcare providers.

Recommendation 3. Leverage the HITECH Act and EHR.

Recommendation 4. Establish climate-resilient health system grants to incentivize state-level climate preparedness initiatives

HHS and OCCHE should create competitive grants for states that demonstrate proactive climate change adaptation efforts in healthcare. These agencies can encourage states to integrate climate considerations into their health plans by providing additional funding to states that prioritize climate resilience.

Within CMS, the Center for Medicare and Medicaid Innovation (CMMI) could help create and administer these grants related to climate preparedness initiatives. Given its focus on innovation and testing new approaches, CMMI could design grant programs aimed at incentivizing state-level climate resilience efforts in healthcare. Given its focus on addressing health disparities and promoting preventive care, the Bureau of Primary Health Care (BPHC) within HRSA could oversee grants aimed at integrating climate considerations into primary care settings and enhancing resilience among vulnerable populations.

Conclusion

These recommendations provide a comprehensive framework for HHS — particularly CMS, HRSA, and OCCHE— to bolster public health preparedness for the health impacts of extreme heat events. By leveraging funding mechanisms, incentives, and requirements, HHS can enhance health system preparedness, improve health provider knowledge, and optimize emergency response capabilities. These strategic measures encompass a range of actions, including establishing dedicated grant programs, incentivizing climate-competent healthcare providers, integrating climate-resilience metrics into quality measurement programs, and leveraging the HITECH Act to enhance ICD-10 coding education. Collaboration with other federal agencies further strengthens the coordinated response to the growing challenges posed by climate change-induced extreme heat events. By implementing these policy recommendations, HHS can effectively address the evolving landscape of climate change impacts on health and promote a more resilient and prepared healthcare system for the future.

This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.