Health insurance as climate adaptation: A practical framework

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