METROPOLITAN HOUSING AND COMMUNITIES POLICY CENTER RE S E AR C H RE P O R T Capacities of Health Systems in Climate Migrant Receiving Communities Insights in the US Gulf Coast Aaron Clark-Ginsberg Anita Chandra Alejandro Becerra-Ornelas RAND CORPORATION RAND CORPORATION RAND CORPORATION February 2023 AB O U T T HE U R BA N I NS T I T U TE The Urban Institute is a nonprofit research organization that provides data and evidence to help advance upward mobility and equity. We are a trusted source for changemakers who seek to strengthen decisionmaking, create inclusive economic growth, and improve the well-being of families and communities. For more than 50 years, Urban has delivered facts that inspire solutions-and this remains our charge today. Copyright © February 2023. Urban Institute. Permission is granted for reproduction of this file, with attribution to the Urban Institute. Cover image by Tim Meko. Contents Acknowledgments iv Executive Summary v Key Insights v Policy Recommendations vi Capacities of Health Systems in Climate Migrant Receiving Communities 1 Experiences of Migrants Accessing Health Resources in New Communities 2 Experiences of Health Systems in Receiving Communities When Migrants Arrive 4 Study Methods 4 Data Collection 6 Data Analysis and Development of Results 10 Results 11 Capacities of Health Care Systems Before Migration 11 Needs of the Migrating Populations Upon Arrival 14 Initial Health Care System Responses to Climate Migrants 16 Long-Term Growth and Adaptation 20 Syntheses, Recommendations, and Conclusions 23 Key Insights 24 Recommendations 26 Appendix A. Quantitative Data Sources 28 Appendix B. Qualitative Data Tools 29 Appendix C. Health Services Figures 30 Notes 41 References 42 About the Authors 46 Statement of Independence 48 Acknowledgments This project was funded by the National Academies of Sciences Gulf Research Program as part of a collaborative study. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. This particular report was funded by a grant to the RAND Corporation. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute's funding principles is available at urban.org/fundingprinciples. The research described in this paper was conducted in the Community Health and Environmental Policy Program within RAND Social and Economic Well-Being. The program focuses on topics such as infrastructure, science and technology, community design, community health promotion, migration and population dynamics, transportation, energy, and climate and the environment, as well as other policy concerns that are influenced by the natural and built environment, technology, and community organizations and institutions that affect well-being. For more information, email chep@rand.org. RAND is a nonprofit and nonpartisan institution that helps improve policy and decisionmaking through research and analysis. The authors would like to thank Dr. Vanessa Parks for her careful review of the report, as well as Dr. Benjamin Miller and Ninna Gudgell, members of RAND's team for Research Quality Assurance, which oversees independent peer review of RAND's research products. iv ACKNOWLEDGMENTS Executive Summary Climate shocks and stresses and the process of movement have the potential to influence people's physical, mental, and social health and well-being. In this chapter, we explore one aspect relevant to climate migration and health: how the health care delivery system in receiving communities meets the needs of migrants experiencing the effects of climate change (termed "climate migrants" in this report). We draw on insights from interviews with health care providers and existing county-level data from the Area Resources Health File in three sites in the US Gulf region between 2005 and 2022: Houston, Texas, where migrants relocated from Louisiana following Hurricane Katrina in 2005; Orlando, Florida, where migrants from Puerto Rico relocated after Hurricane Maria in 2017; and Lafourche and Northern Terrebonne Parishes, where migrants from southern coastal areas have relocated in response to ongoing sea level rise and environmental degradation. In this report, we examine how each community's health care system interpreted the needs of climate migrants and how they shifted services in response to those needs. Through this analysis, we aim to support research and policy designed to improve the health and well-being of climate migrants and the communities in which they settle. We provide topline key research insights, policy recommendations, and more study detail on the findings that guide these recommendations. Key Insights Health care systems contend with climate migrants' health concerns, which often represent a complexity of mental and physical needs. People and organizations support the health of climate migrants based on existing capacities and capabilities. Service providers in receiving communities have been hampered by information challenges, financial resource limitations, and lack of centralized coordination. Climate migrants' ability to access health services is contingent on broader social and economic factors before, during, and after migration. CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES v During the period of study, health systems adapted and evolved to meet the needs of climate migrants (e.g., by developing partnerships with community organizations). Policy Recommendations Consider addressing both mental and physical health issues that might result from the intersection of migration stress and stress from other hazards. Support the coordination of organizations that can address upstream social and economic issues that can exacerbate health issues for climate migrants. Plan for climate migrants by reviewing plans for service delivery, coordination of health services with social services provided by supporting organizations, and augmenting data systems to better monitor the health needs of this population. In the following sections, we provide detail on the current research on climate migration and what this migration means for access to health services. We then provide an overview of the three study sites, with descriptions of the disaster, the migrating population, and the sites where climate migrants settled. Finally, we present key findings and future policy and research implications, structured around the following three research questions: What were the health care system conditions that existed in the receiving communities before the migrants' arrival? How have local health care institutions responded to the health needs of migrants? How have the conditions to support the health needs of climate migrants changed over time? This study was conducted as part of the "Capacity and Change in Climate Migrant Receiving Communities Along the US Gulf: A Three-Case Comparison" project led by the Urban Institute. The project explored five operational areas in which receiving communities experience impacts from climate migrations: housing markets, financial institutions and financial health, employment and economic development, health care systems, and social, cultural, and recreational institutions. vi CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES Capacities of Health Systems in Climate Migrant Receiving Communities Research on what happens to climate migrants when they move to a new location is limited in general (Boas et al. 2019), and more specifically to this chapter, is limited with respect to issues of health and health care service access (Sabasteanski 2020, p. 368; C. McMichael, Barnett, and McMichael 2012, p. 646). Gaps in climate migration and health research include research on subpopulations, such as behavioral health impacts and youth (Scannell et al. 2016), access to health services (Schwerdtle, Bowen, and McMichael 2018), how to strengthen health systems to improve their responsiveness to sudden population influxes (Sabasteanski 2020; Ridde et al. 2019; Blanchet, Diaconu, and Witter 2020), and varying effects of sudden versus longer-term hazards on health services (Dannenberg et al. 2019). In this study, we focus specifically on aspects of health services primarily provided through the health care system, inclusive of ancillary health and social service organizations. This is but one component of the larger health system, which includes organizations that influence social and political determinants of health, but this study starts with health services principally. Health care systems are defined as the people and institutions that provide health care services to populations (Piña et al. 2015). These include the hospitals, clinics, and other organizations providing direct physical and behavioral health services to their patients; public health agencies providing surveillance, monitoring, and preparedness and response for the population as a whole; and other social services that support the provision of health care. Although the health care system comprises numerous organizations, health is an outcome of many factors, from the environment to access to food, community, housing, stable jobs, and income. However, by offering services to prevent health problems from occurring, or alleviating them if they do, health care organizations play a crucial role in supporting health and well-being. The concept of health system resilience is useful for understanding how climate migration and health systems, including the health care component of the health system, intersect (Ridde et al. 2019). Resilience is the ability of a system to absorb, adapt, and transform in response to a shock or stress (Manyena 2006). Resilient health systems can react dynamically to shocks and stresses, such as new populations of climate migrants, by changing its components (Kruk et al. 2015). These systems can CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 1 recognize new needs and scale up or reduce services accordingly, ideally before those needs manifest as health crises. Below, we describe existing evidence on climate migration and health systems from a resilience perspective, focusing on the experience of migrants accessing health resources in new communities and the experience of health systems in communities experiencing a migration event. Experiences of Migrants Accessing Health Resources in New Communities Migration in response to a climate shock or stress is not a singular event for migrants but rather an ongoing process. In the immediate term, migrants might have limited knowledge and resources. They may have acute needs and suffer from the loss of place. For many, migration is a period of basic emergency survival focused on reestablishing basic supports. Over the longer term, those conditions might improve as migrants adjust to their new environments, access care and support services, and integrate into their new community, and their health and well-being may improve as a result. However, the process of integration into new settings may never be fully complete and may require continuous reinvestment. There is limited research on how climate migrants access health services in host communities as well as their array of health needs (Ridde et al. 2019). Many migrants may arrive in their host communities with some degree of poor health for several reasons. Climate migrants might have preexisting health challenges before exposure to the climate change–related shock or stress that motivated their move. Specifically, historically marginalized populations are both more frequently exposed to climate change–related hazards and tend to have greater health needs (Romanello et al. 2021). However, we do not know if there are selective aspects of migration: some evidence suggests that it may be migrants in better health condition who end up moving due to climate change; in short, the most unhealthy people may not be able to move (Chen and Lee 2022; Boustan et al. 2020). The exposure to the direct or indirect effects of a climate shock or stress can also create poor health. Strong evidence suggests that direct exposure to a climate-related hazard has negative impacts on health, resulting in physical harm, emotional trauma, and increased allostatic load-the price the body pays for exposure to stress (Schwerdtle, Bowen, and McMichael 2018; Sandifer et al. 2017; Weems et al. 2007; Freudenburg 1993; Ritchie, Gill, and Farnham 2013; Picou, Marshall, and Gill 2004). Evidence of how exposure to indirect effects of climate shocks and stresses shapes health is weaker, partly because of the diffuse nature of climate change's impacts. For example, "excess deaths" from 2 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES Hurricane Maria in Puerto Rico in 2017 were orders of magnitude greater than initial estimates of hurricane deaths-more than 4,000 compared with the 64 initially reported (Kishore et al. 2018). Another example is Hurricane Katrina in New Orleans, Louisiana, where a secondary technological disaster-levee failure-contributed to more than 1,800 additional deaths. Further, the broad mental and behavioral impacts of climate-related job loss, ecological grief, anxiety about the future, or any other climate change outcome are not often captured in primary data about disaster impacts (Cunsolo and Ellis 2018; Palinkas and Wong 2020). Indirect effects may also include the health impacts of relocating in response to a shock or stress, which can be substantial for populations with limited resources who must make long or sudden moves. The process of resettling in a new location can also disrupt health services. People living in a new location may not have the same access to systems that they previously depended on for health, such as their primary care providers or mental health specialists. After Hurricane Maria, Puerto Ricans who had moved to Orlando, Florida, described difficulties accessing critical medical and health services and other challenges reestablishing continuity of care (Scaramutti et al. 2019). They might also be exposed to new health-related hazards (Dannenberg et al. 2019; A. McMichael et al. 2010). For example, some post-Katrina survivors were housed in temporary trailers provided by the Federal Emergency Management Agency (FEMA), which contained formaldehyde (Shapiro 2014) and were not conducive to large gatherings central to community life (Browne 2015). Although the moving and resettlement process generally has negative impacts on health, resettling in the new location can have positive or negative impacts (McNamara et al. 2018; Black et al. 2011; Eriksen and Lind 2009; McLeman and Smit 2006; Hynie 2018). Households that move to a new location may be able to access better employment opportunities, social structures, and health care (Scannell et al. 2016). However, access to these resources is not guaranteed, and being unable to access these services can worsen an individual's health. Households might also reduce their exposure to disease outbreaks, natural hazards, pollution, and other hazards that affect health, but as with access to resources, this shift in location does not guarantee reduced risk overall. For instance, relocations from coastal areas in Mozambique reduced migrants' exposure to coastal flood risk but increased their exposure to diseases and other health hazards (Arnall et al. 2013; Scannell et al. 2016). CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 3 Experiences of Health Systems in Receiving Communities When Migrants Arrive Evidence regarding how health systems respond to influxes of climate migrants is limited, but research on the impacts of other forms of mass migration-such as mass migration driven by conflict or by disasters unrelated to climate change-suggests that when migrants settle in a new location, they can affect health systems in both positive and negative ways. An influx of residents with specialized needs and limited resources could increase demand for services, preventing communities from offering appropriate care levels even when they can access post-disaster mass care or crisis counseling resources. If there are unanticipated surges in the immediate term, health systems might struggle to meet these needs. Initial health system activities might focus on rapidly scaling up and down to provide essential services. Over the longer-term, activities might then shift toward "normal" operations. Stakeholders involved in this transition can shift-for instance, federal and state emergency managers may play a central role in coordinating initial health response (e.g., acute health services) and pass over fuller health care services to the health system. Climate migration and climate migrants can provide adaptive benefits to receiving community health systems. For example, like all migrants, climate migrants bring with them resources and capacities that may be beneficial to health systems. Some may be highly educated health system workers with in-demand skills, and many will contribute to area tax bases or economies in ways that benefit area institutions, including health systems. Climate migration is not a homogenous concept, and thus its impacts on climate migrations and health systems might vary. As noted earlier, populations that are highly vulnerable and marginalized may have greater health needs and more challenges accessing the health system. Migrants leaving in short bursts of movement might have different impacts on a health system than a larger cohort of migrants moving at the same time. Likewise, the receiving health system may be better or worst positioned to support migrants who come slowly over time versus those that arrive in a large cohort. Study Methods We focused on three sites for this exploratory, comparative case study: Houston, Texas; Orlando, Florida; and Lafourche and Northern Terrebonne Parishes in Louisiana (box 1). The Houston case provides the longest time frame from which to observe change: it has been more than 13 years since Hurricane Katrina made landfall in Louisiana in 2005, displacing many residents to the Houston area. 4 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES The Orlando case begins in 2017, when climate migrants began leaving Puerto Rico in response to Hurricane Maria. The ongoing migration from Isle de Jean Charles to Lafourche and Northern Terrebonne Parishes provides a unique opportunity to document a receiving community's capacity amid ongoing migration (i.e., the slower movement over time) induced by sea level rise and land loss. Migration from the island has been ongoing, but we focus on the period following the 2016 US Department of Housing and Urban Development award providing funding for resettlement. BOX 1 Receiving Communities and Disaster Contexts The research team identified three US Gulf Coast communities that were receiving destinations for climate migrants following catastrophic climate change–induced hurricane and environmental loss events. This study examined the capacity of health care systems in receiving communities over time and community responses to migrants' health needs.  Houston, Texas. Houston was a receiving community for climate migrants from New Orleans following Hurricane Katrina in 2005. Many of those who were temporarily sheltered in the weeks following Hurricane Katrina never returned to New Orleans and continue to live in Houston today. Among the case study communities, the Houston case provides the longest time frame from which to observe change over time.  Osceola and Orange Counties surrounding Orlando, Florida. Central Florida was a receiving region for climate migrants from Puerto Rico following Hurricane Maria in 2016, and immigration from Puerto Rico to this region was ongoing for many years before Hurricane Maria. Central Florida provides an opportunity to examine institutional capacity and responses in communities with well-established social, cultural, and economic ties between sending and receiving communities.  Inland Terrebonne and Lafourche Parishes in Southern Louisiana. The communities of inland Terrebonne and Lafourche Parishes have been a receiving destination for many Louisianans- including multiple different Indigenous and tribal populations-displaced from far southern coastal regions that have been experiencing land loss and chronic and severe flooding and hurricanes for decades. This region provides the opportunity to examine impacts from both ongoing and acute disaster events as well as understand receiving community capacity amid longer-term, ongoing migration processes. We use these time periods to demarcate who is a climate migrant in the context of our study: those who arrived before our time periods are not considered climate migrants, while those who arrive after the designated time period are climate migrants. However, we recognize that the reality is much more CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 5 complex than our classification allows. In Isle de Jean Charles, environmental degradation-both related to climate change and not-has contributed to the disappearance of land and shaped migration patterns for at least the past 70 years (Crepelle 2018). Today, environmental degradation continues as a result of both environmental and nonenvironmental factors. In all cases, the factors that turn hazards into disaster began well before the disaster event-for instance, infrastructure and settlement decisions that shaped vulnerability in New Orleans go back 100 years (Horowitz 2020), and Hurricane Maria's impact is rooted in the island's legacy of colonialism (Rodríguez-Díaz 2018; Moulton and Machado 2019). People also move for a complex set of reasons: strong patterns of movement between Puerto Rico and Florida and between Louisiana and Houston existed well before the hazardous events, and the movement was in part a "push" from the climate-related hazard as well as a "pull" toward a familiar place with strong prospects. Although identifying a clear time period is necessary for our analysis and aligns with much of the policy discussion on climate migration, overly focusing on the discrete event as the driver of migration potentially comes at the expense of underplaying the complex processes that shape disasters and movement decisions (Black et al. 2011; Oliver-Smith et al. 2017; Wisner et al. 2004; Blake, Clark-Ginsberg, and Balagna 2021). Thus, while we use these time periods to help organize study findings in this chapter, we also seek to understand complex patterns of movement in future work. Data Collection We centered our data collection on three time periods: before the migration event, the immediate migration event (emergency period), and the longer-term period (adaptation and recovery). The first focuses on the health care aspect of the system in the receiving communities, aligning with our first research question on the conditions that existed in the communities before migrants' arrival. The second period examines the short-term impacts of migration on the health system and follows efforts to scale up services and capacity, aligning with our second research question on how local institutions responded to migrants' health needs. The final period aligns with our query into how conditions to support the health needs of climate migrants changed over time. Together, these periods provide some understanding of climate migration and health systems. The period preceding migration events can provide baseline information about health systems before the migration event. The period immediately following the migration reveals the rapid adjustments the health system made in response to an influx of climate migrants; the ability to rapidly adjust is a necessary part of health system resilience, as noted earlier (Biddle, Wahedi, and Bozorgmehr 2020), and often poses a challenge to health systems (Nelson et al. 2007; Clark-Ginsberg et al. 2022). The longer- term period is a period of potentially positive or negative change, where the health system might 6 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES improve or worsen. Positive change over longer periods of time are fundamental to transformative health system resilience, as seen in a health system that learns and evolves to prevent disasters from occurring in the future (Biddle, Wahedi, and Bozorgmehr 2020). However, positive health system transformation is in no way guaranteed; if officials make the wrong decisions or the wrong conditions are present, maladaptation can occur (Schipper 2020), resulting in weaker health systems. We used a combination of quantitative and qualitative data to understand how the health systems in our sites performed across these three time periods (box 2). As noted in prior sections, health systems and health system resilience are incredibly complex (Sturmberg and Lanham 2014; Saulnier et al. 2021), making mixed methods a useful approach for the study. We drew on literature on health, climate migration, and health system resilience to develop our data collection tools and aimed to collect data capturing the mental and physical dimensions of the health system. We focused on the spectrum of health care providers and intermediaries to capture the breadth of the health system, as well as the health system professionals and health system facilities available in the sites. We also included questions related to social and economic factors shaping health system access, with a particular focus on insurance to reflect the fact that in the United States, health care access is deeply tied to insurance. CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 7 BOX 2 Methodology Millions of people are expected to be displaced by climate change in the United States alone by the end of this century, yet little is known about communities' institutional capacity to effectively receive and support climate migrants or their ability to do so over time as the effects of climate change advance. To support climate migration policy and planning, the Urban Institute led five unique studies of community impacts, capacity, and responses to climate migration across five institutional domains:  Housing markets  Financial institutions and financial health  Employment and economic development  Health care systems  Social, cultural, and recreational institutions Each study used mixed-methods data collected from three US Gulf Coast communities that have received climate migrants following catastrophic climate change-induced hurricane events (see box 1 for more information about the selected sites). Across the five studies, the research team used a mix of complementary qualitative and quantitative research methodologies. Three methodologies were used across the five studies:  Semi-structured, qualitative interviews with institutional experts and community stakeholders  Quantitative analysis of public and private market, institution, and population data  Content analysis of news articles reporting on community institutional responses to regional climate migration The research team reviewed available data types, sources, quality, and site contexts to select the most appropriate data sources and analytic approaches for the study questions at the respective sites. Each methodology and data source was designed to address the overarching and study-specific research questions, such that triangulation and cross-case comparison across communities, themes, and topics were possible even with variations in data sources and analyses across study communities. Research constraints across the five studies related to data scale, data availability, and challenges conducting community research in regions affected by climate change. For a full discussion of study limitations, see the Limitations section in the overarching report, Climate Migration and Receiving Community Institutional Capacity in the US Gulf Coast. Our quantitative and qualitative data collection tools are available in appendices A and B, respectively. We summarize data limitations in table 1 and explain them in more detail throughout the 8 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES chapter. We divided quantitative data into four dimensions: health service utilization, access to health care professionals, health care facilities, and health insurance. We used quantitative data from the Area Health Resources Files (AHRF) published by the Bureau of Health Workforce. The AHRF is a comprehensive dataset that brings together different health files such as the Annual Survey of Hospitals, American Medical Association Physician Masterfiles, Health Center Service Delivery and Look-Alike Sites file, Centers for Medicare and Medicaid Services' Quality Improvement Evaluation System database, and Census Bureau's Small Area Health Insurance Estimates file, among others. Data are published annually, and coverage varies by information source and disaggregation level (e.g., federal, state, or county). In Florida, we used county-level data from Orange and Osceola Counties, and in Louisiana, we used county-level data from Terrebonne and Lafourche Parishes. AHRF's county-level datasets start in 2010, so we were unable to access quantitative data for our Houston site. Data in Louisiana and Florida are not collected annually and did not align directly with our time periods. Instead, we used four time periods: two for before the migration event (2010 and 2015) and two for after the event (2017 and 2019). Quantitative health indicators available to the study team did not capture all elements of the health system. For instance, data are not available on health care quality or access by population (e.g., by gender, age, and migration status). Systematically collected data on the responses of neighbors and friends to the population influxes, which can be key to health care outcomes and how the broader health system responds to the health needs of climate migrants, were also unavailable. These limitations hinder our ability to comparatively analyze quantitative insights with the qualitative data from stakeholder interviews. Our qualitative data consisted of 16 interviews with health system members: 2 from Houston, 9 from Orlando, and 5 from Louisiana. The types of health system members interviewed in each site can be found in appendix B. These data added depth to the quantitative datasets by offering descriptive insights into the quantitative changes, such as the underlying reasons for the changes in services provided and the impacts of those service changes. We developed a guide for types of organizations to target for interviews and identified specific organizations across our sites to interview. We also developed a semi-structured interview guide covering the three time periods of interest, focusing on the migrants' health needs and health system responses. University-based research teams at each study site conducted the interviews using these tools. Interviews are extremely limited by numbers and differences in within-case sampling. There were challenges with memory for the Houston sites, as the migration had occurred in response to a hurricane event 15 years before the interviews began. As such, the three cases are not considered "complete" CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 9 from a case study methodology perspective (Yin 2011). Instead, these collectively provide a broad, initial picture of the ways migration might shape health systems. TABLE 1 Data Limitations Research question Corresponding time period Data limitations 1. What were the health care system Before the migration event  No quantitative data for Houston conditions that existed in the  Quantitative data does not receiving communities before the correspond with year before event migrants' arrival?  Limited coverage of the health system  Limited interviews  Challenges with memory for Houston 2. How have local health care Immediate migration event  No quantitative data for Houston institutions responded to the (emergency period)  No quantitative data available for health needs of migrants? this time period  Limited interviews  Challenges with memory (Houston) 3. How have the conditions to Longer-term period of  No quantitative data for Houston support the health needs of adaptation and recovery  Limited interviews climate migrants changed over  Challenges with memory for Houston time? Data Analysis and Development of Results We structured our analysis around the three identified time periods (before, immediately after, and in the long term) and designed interview questions to capture information about these time periods and identify recommendations and lessons learned. For our quantitative analysis, to make valid comparisons across sites, we present standardized results per 1,000 inhabitants, or as a share of the total population. We also compare the indicators of each county with the state average for any given year. We used a mix of inductive and deductive coding for our qualitative analysis. We developed the deductive components of the coding frame based on the research questions, corresponding time periods, and literature on health systems and migration. To ensure reliability of our codes, we tested this coding frame using an inter-rater reliability exercise. As we coded, we developed additional subcodes based on key themes that emerged over the course of our analysis. We coded interviews using NVivo, a software for qualitative analysis. A copy of our finalized coding frame can be found in appendix B. 10 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES To develop our initial set of findings and main messages, we compared results from our analysis, first within sites and then across sites. Then, we refined our findings iteratively through a series of team discussions aimed at identifying the main results across our time periods and developed topline key insights and policy recommendations. Results We present results temporally, beginning with the capacity of the health care systems before the migration event. Then, we present results on the immediate migration event and the longer-term period of adaptation and recovery. Capacity of Health Care Systems Before Migration The health system in Orlando showed variation across our four main dimensions (utilization rate, medical professionals/workers, capacity, and uninsured), as shown in table 2. Orange County outperformed Osceola County across all dimensions: per 1,000 inhabitants, it had higher utilization rates, more available medical professionals, more facilities, and fewer uninsured people under age 65. It also outperformed the state average across all dimensions. In contrast, Osceola County scored lower than the state average across all dimensions, except for the number of uninsured people under 65, for which the county performed slightly better than the state average (15.00 per 1,000 residents compared with 15.29 per 1,000, respectively). CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 11 TABLE 2 Florida Health System in 2015, Before Increased Migration Osceola Orange State County County average Utilization Hospital admissions 69.35 189.04 90.86 Short-term community hospital admissions 69.35 183.70 82.23 Inpatient visits 277.81 985.95 575.02 Short-term emergency room visits 210.19 656.00 362.86 Long-term emergency room visits 0.00 24.94 15.30 Professionals Medical doctors 1.12 3.02 1.56 Nonfederal medical doctors* 1.16 3.01 1.50 Pediatricians 0.10 0.24 0.09 Psychiatrists 0.02 0.07 0.05 Facilities Hospital beds 1.06 3.63 2.42 Short-term community hospital beds 1.06 3.44 1.82 Nursing home beds 0.00 0.18 0.05 Community health centers* 0.02 0.02 0.05 Community mental health centers* 0.00 0.00 0.00 Short-term community hospitals 0.01 0.00 0.02 Insured Uninsured people under 65* 15.00 14.90 15.29 Source: Area Health Resources Files. Note: Indicators are per 1,000 inhabitants, except uninsured people, which is measured as the share of the total population. *Data are from 2016. As in Orlando, the premigration health system in the Louisiana site varied across the four dimensions of focus (table 3). Terrebonne Parish registered higher rates than Lafourche County across indicators related to utilization. For instance, Terrebonne Parish had 127.0 hospital admissions per 1,000 inhabitants, compared with 107.7 in Lafourche County and the state average of 90.9. Like Terrebonne Parish, Lafourche Parish had higher utilization rates than the state average, except in the number of inpatient and long-term emergency room visits. Terrebonne Parish registered better access to health professionals than Lafourche County and the state average across all indicators except for number of psychiatrists; Lafourche County registered better access than the state average across all indicators. 12 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES TABLE 3 Louisiana Health System in 2015, Before Increased Migration Terrebonne Lafourche State Parish Parish average Utilization Hospital admissions 127.03 107.73 85.28 Short-term community hospital admissions 116.14 107.73 76.82 Inpatient visits 746.24 443.95 692.68 Short-term emergency room visits 748.72 718.96 464.05 Long-term emergency room visits 4.13 0.00 5.21 Professionals Medical doctors 1.75 1.70 1.19 Nonfederal medical doctors* 1.78 1.72 1.22 Pediatricians 0.12 0.09 0.08 Psychiatrists 0.01 0.04 0.03 Facilities Hospital beds 3.26 2.18 3.44 Short-term community hospital beds 2.65 2.18 2.40 Nursing home beds 0.07 0.00 0.26 Community health centers* 0.02 0.02 0.06 Community mental health centers* 0.00 0.00 0.00 Short-term community hospitals 0.02 0.03 0.05 Insured Uninsured people under 65* 17.50 16.10 14.29 Source: Area Health Resource Files. * Data are from 2016. For our health care facilities dimension, both Terrebonne and Lafourche Parishes had lower levels than the state average on all indicators except for short-term community hospital beds, where Terrebonne Parish registered higher numbers than Lafourche County and the state average. Neither of the parishes of interest nor the state of Louisiana had registered community mental health centers. Lastly, both Terrebonne and Lafourche counties had higher shares of people without access to insurance (17.5 percent and 16.1 percent, respectively) compared with the state average (14.3 percent). The professionals we interviewed across the three sites thought that the health systems had high variability; they collectively created a "patchwork" of a health system, with different providers offering different types and standards of care. They described how available services heavily skewed toward acute physical care, with more limited options for longer-term and preventative care as well as care for mental health. A health care worker in Louisiana noted, "On a per capita basis, I've never seen a place that was so heavy on urgent care, outpatient urgent care, and relatively low on primary care." They also reported a high prevalence of occupational health clinics and speculated that these were linked to the CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 13 petrochemical industry: "They seem to be marketing themselves towards oil field injuries, drug testing, and things like physicals before you can go out on rigs." Respondents in Florida had similar views on service variability. One respondent described how psychiatrist shortages could result in monthslong delays in receiving care. They contrasted this with abundant services for acute physical care: "In every corner, there's a clinic or medical center." The respondents also indicated that health care access varies by population. In Orlando, language is a major driver shaping access, with respondents describing how there are simply not enough Spanish- speaking medical professionals to meet demand. Such unavailability has compounded already limited access to longer-term and preventative care. For instance, one respondent remarked that among the limited number of mental health care workers, even fewer speak Spanish. Respondents in all sites also described how employment status and income can further limit people's ability to access health services. In a system where health care is expensive and health insurance is tied to work, having limited income or being underemployed or unemployed can make accessing health care difficult. And while services exist for people without insurance and people with limited incomes, one respondent noted that there are not enough to match the sheer scale of demand: "Health care for people without insurance is always a tough one…there's great free clinics, awesome opportunities for people to get help, but obviously there's always a waiting list, eligibility requirements, proof of income." Health care access also varied across different groups and subpopulations. For instance, while income, employment, and insurance generally shape health care access, veterans could access health services from the Department of Veterans Affairs (VA) regardless of their current income and employment status. A respondent working for a VA health care center in Houston stated, "We had great services…we are one of the largest VAs in the country." In contrast, "Health services for nonveterans could be sparser." Although VA services vary by location, this respondent believed that Houston offered quality care and greater availability of services. Needs of the Migrating Populations Upon Arrival Health system respondents in Houston and Orlando described the time immediately following migrants' initial move away from their homes as an especially challenging period. 1 A respondent in Orlando offered their perspective on some of the difficulties that many new arrivals faced: 14 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES Any time you have to leave your home and go to a new place, that's a stressor. Then, you have left behind your home because you had to go through the hurricane. Your home was probably destroyed or at least damaged because of the hurricane. Then, you come to a new place where maybe you don't know anybody and you're trying to adjust to all these new situations. You have no job, you might not have any family, you don't speak the dominant language. So, all of those things I think compound, and what we know about stressors in general is that they then increase symptoms in people who already have mental health disorders and physical disorders. For this respondent, the disaster and its impacts, the move itself, and the resettlement in a new place were all stressors on their own that built on each other. Other respondents held similar views and pointed to an array of issues that deeply affected people's health. In addition to dealing with the disaster and the move, some respondents noted that migrants also experienced mental and physical health challenges that preceded the disaster. They mostly identified issues such as diabetes, obesity, hypertension, and other diseases that correspond to poor social and economic conditions. Maintaining access to the health services necessary to manage these health issues could be challenging for those who may had to move suddenly to escape disaster, as was the case for most of the migrants who had left for Orlando and Houston. "People have left, and they didn't have the medication that they needed," said a respondent in Houston. Respondents across all sites thought that stress, trauma, and grief were brought on or exacerbated by exposure to disaster and the move. "They needed more psychological support than any other support," said a health system worker in Orlando, commenting that mental health needs could often be greater than physical health needs. Respondents in Orlando and Houston linked these challenges in part to the move, which magnified the difficulties of living through the disaster. "We worked with a number of people who were depressed because they lost their home in Puerto Rico…they lost their home, they didn't know what was going on at home," said a respondent in Orlando. "Folks were traumatized in leaving their entire lives behind and parts of their family, their employment," said another. These respondents considered loss of place and community and lack of information about what was going on at home as driving mental health challenges and contributing to other problems. Contextualizing how stressors could cascade on each other, another respondent offered their view on the impacts of these crises on families: "Emotionally, families were destroyed. Marriages broke apart." In Texas and Florida, respondents had different perspectives on how migrants' health issues differed compared with those of the host community. While all respondents thought the migrants had high levels of needs, not all believed they were significantly greater than the host population's needs. "It was just amazing how sick they were," said a respondent in Houston. In contrast, a respondent in Orlando thought that the health needs of the migrant population were only slightly greater than the CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 15 health needs of the existing community. In their words, compared with the host population, health needs of migrants were "probably a little bit more severe after having gone through a hurricane experience." Initial Health Care System Responses to Climate Migrants Respondents in Houston and Orlando described how the large and sudden population influx overwhelmed the health systems and resources of their communities. Part of this related to the sheer scale of needs associated with a large population influx, which was beyond what the health systems were set up to handle. As one respondent described, "To have, say, 100,000 people essentially overnight, within a week, in a community where housing is already an issue, it was a lot. The needs became greater." In contrast, Louisiana respondents noted that, since moves occurred more gradually over extended time periods, health systems were able to adapt. One health system worker offered their view on this context: "I think we would absorb a new population; it's been happening insidiously slowly, storm after storm; more people are moving north and moving up those bayous. That changes the demographics in those communities. They've already had to adapt to that." In other words, the slow nature of movement driven by repeated storms led to a trickle of movement that the health system could accommodate. In Houston and Orlando, there was a coalition of stakeholders providing health services to support the new migrants. The health services were diverse-from providing basic medication such as insulin, to bloodwork and other diagnostics, to acute care, to mental health services-and the coalition was broad, including core members of the health system, emergency response organizations, and individual community members and organizations. Respondents saw mental health and physical health services as critical and worked to provide both sets of services. "We were not only able to provide only lab services. We provided mental [health] services," said a respondent in Houston. While private sector organizations offered resources for physical health (one respondent in Houston said that Bayer Scientific "donated a lot of stuff until we were able to pay for some of it"), nongovernmental organizations appeared to play an outsize role in supporting the mental health of migrants. For instance, respondents in Houston and in Orlando commented on the effectiveness of churches in providing support, compassion, and care in ways that positively affected mental health. A respondent in Orlando described churches as "very adapted to working with folks beyond just the application and really lending an ear and some support and love." A respondent in Houston assessed the work of faith-based organizations positively: it "helped a lot because people needed that mental help." 16 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES Although most mental health support was indirect-working with a population rather than providing direct intervention-respondents across sites viewed faith-based groups as having positive impacts. Across sites, respondents described the necessity of helping migrants navigate an unfamiliar health system. Respondents considered this an important task: complexity in the health system made it difficult for migrants to understand what services they were entitled to and how to access those services. A respondent in Louisiana described how the health system's evolution away from a primarily nonprofit system has led to a more "complicated system to navigate now than it was when it was just the charity system." Respondents in Florida made similar remarks on the impacts of a complex system in accessing health services. One respondent noted, "Even though there are a lot of resources available, being able to connect with them is another story." An interviewee's description of Medicare and Medicaid illustrates how a byzantine system could make accessing health services harder: A lot of people don't realize that you have to apply and enroll for Medicare, and there's a window that's three months before you turn 65 and three months after, and if you don't do it right then, you miss out for a lifetime. They send you a little book called Medicare and You that's about 165 pages, that most people don't read, not even professional people. It can be amazing what people don't know. There's a lot of gifts in the United States, but a lot of people don't understand all the benefits. Medicare and Medicaid can be difficult to understand, so we spend a lot of time educating folks. Differences between health systems in states and territories compounded these challenges for Puerto Ricans who were moving from the territory to the mainland. "Florida doesn't have Medicare Expansion, which it made more confusing for the underinsured and uninsured folks," said one health care worker. 2 One way that health systems helped migrants navigate the system was by working with migrants to access medical records, paperwork, and other critical documentation. For example, children needed to provide schools with their vaccination records to attend school in Florida. Health care organizations contacted the Puerto Rico health department to access these records, along with other critical documentation such as driver's licenses and birth certificates. Without documentation, migrants could be functionally invisible to the state. "I don't have my papers, so then I can't see you. It was insane, it was frustrating," described a health care provider who was limited in the support that they could provide to migrants without documentation. Notably, respondents identified technology as helpful in alleviating some of these challenges. The Veterans Affairs Department in Houston, for instance, had quick access to migrants' records because their patient record systems were fully electronic. Respondents also described meeting migrants on arrival in their new locations as a way to connect migrants with the health system. Doing this offered a way of providing information to migrants about CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 17 the new health system and the services they might be able to access. Because migrants from Puerto Rico were all coming into Orlando by plane, meeting migrants on arrival involved the relatively simple task of setting up resources at the Orlando airport. A range of service providers showed up at the airport, including those providing health care services. "We were there, every day, all day, welcoming families, gathering their information, helping direct them to resources within the community," said a respondent working for a nonprofit that established a presence at the airport. Organizations coordinated and referred migrants to other providers when they were unable to provide services. One interviewee described the process as such: We didn't have an official system, but we generally would-if they were uninsured or underinsured-we would either refer them to somebody that did accept their insurance. For instance, we are not a Medicare provider, but we have no problem referring those with Medicare to Medicare providers, or if they were completely uninsured, you know, we do have relationships with, for instance, True Health, which used to be Central Florida Family Health Center. The Houston Astrodome functioned similarly to the airport in Orlando as a central migrant arrival location. "We came up with a strategy, and it was called 'Operation Astrodome' and we set that [health care] lab up," said a health care provider who was at the Astrodome providing services. As with the Orlando airport, many different public, private, and nongovernmental agencies established a presence at the site to provide a broad swath of services, including those related to health. Government agencies in all sites set up formal structures to coordinate organizations providing health resources to migrants and to connect migrants directly to points of care. In Florida, the City of Orlando used the Hispanic Office for Local Assistance (HOLA) to connect migrants with health care services, while also working with coordination structures established at the state level. In Louisiana, the state Department of Health was responsible for coordinating the health response as the designated lead agency for the public health and medical service emergency support function, ESF-8. 3 A representative of the agency explained that, because of how ESF-8 was set up, this role was quite substantial: "ESF-8 public health and medical, as you can imagine, is a very large group of people from hospitals, clinics, public, private, pharmacies, dialysis centers, blood banks, home health agencies, hospice agencies, outpatient facilities, urgent cares, and occupational health-you name it." Some respondents described how existing capabilities and previous experiences with disasters made the response easier. "Before the evacuees came, I think that we were already prepared to do good work," said a respondent in Harris County, Texas. They also noted that the many neighborhood health centers across the county allowed them to "always [be] able to accommodate patients." Resources could at times be more than just material as well: "We've helped with an influx of other refugees, we learned how to roll it. As a faith-based organization, we rely so much on knowing that God is going to 18 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES help us to make things happen or to be able to handle the situation," said a respondent working for a faith-based organization in Orlando. In their case, previous experiences and faith were both important factors contributing to the response. Respondents described making staffing changes in response to the new population. "We shifted one therapist, and we hired a second therapist to take care of the demand that we had," stated a respondent in Orlando. "We had to hire more staff. We had to hire more qualified bilingual staff that kind of understand where this population is coming from," said another respondent, emphasizing the need for staff with Spanish language skills to support Puerto Ricans. Some respondents described relying on volunteer labor in certain circumstances, including for higher-skilled technical positions. A health system worker in Houston described how a pathologist would come in at nights after work to volunteer to run instruments. Others recalled leveraging their interpersonal networks to find staff. "I had relatives you know; nurses, pharmacists, phlebotomists. They all came and helped," said a respondent in Houston. Some thought a shared cultural affiliation enhanced cooperation. One respondent in Florida reflected, "Local authorities that were of Puerto Rican descent or were from Puerto Rico got involved and that made it easier." Along with increasing staff, respondents described shifting the services that they provided. Some scaled up essential services at the expense of services they deemed less essential. "We shut down our gym and we opened up a clinic-a New Orleans clinic just for those veterans," said a respondent in Houston. A respondent described, "We started working on post trauma, because some of the people were impacted in ways that they develop post-trauma symptoms." While these are two examples of targeted health services, others took on a broader mandate: "We just became a clearinghouse. We had a clothing closet, we had a food pantry, we had individuals helping families connect them to English classes, CareerSource, other health care options. We had to scale up quickly," said a respondent in Florida. Many described this period of work-of shifting activities, scaling up, and bringing on staff-as challenging. Feelings of being overwhelmed were common among respondents. "I think for most of us, it was like drinking out of a firehose. No one really anticipated this, and everybody was taking it day by day," said a respondent in Houston. They went on to state that "there was no centralized organization to provide services. It was very improvised." Sentiments were similar in Orlando: "Nobody knew what to do and were trying to figure out along the way," said a health system worker involved in the response. Many respondents thought that health services were stretched, but whether services were stretched to the point of being overwhelmed appeared to vary by service type and organization. "More CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 19 programs for distress need to be created," stated a health system worker, arguing that there were not enough services to meet peoples' needs. In contrast, a respondent from a faith-based organization in Orlando shared, "We were fine with everything; we didn't have a shortage or anything." Other issues compounded challenges in providing services to support migrants. One issue was related to bureaucracy, from having to understand and learn how to navigate complex systems, to filing paperwork, to waiting on various processes necessary to access health services. "When you're here, and you've just left the island and lost everything, the last thing someone wants to do is go through hoops," said one respondent in Orlando. Transportation was another issue shaping health care access. Respondents described Orlando as car-centric and lacking a strong public transportation network. "You need a car in Central Florida," remarked one respondent. While transportation posed a challenge for migrants in Orlando, in Louisiana, migrants were frequently moving to locations that had better transportation environments. A health system worker explained, "If you live 45 minutes down the bayou, you were unlikely to come to a doctor at Houma unless somebody provided transportation to you. Now, if you moved to Houma, if you migrate up, then you have access to a bus system. You might be able to catch a ride with somebody, there's more cars passing by to give you a ride. So, I think if anything, the migration up has helped people access services and health care." Long-Term Growth and Adaptation The health systems in all three sites changed over time, though the changes were in no way uniform. General descriptive trends of quantitative indicators for our two sites with available quantitative data, Florida and Louisiana, are summarized in appendix C. In Florida, indicators related to health system utilization rates were erratic, with Orange County higher than the state average and Osceola County lower than the state average. For health system professionals, both counties registered a continuous increase in the number of medical doctors, but a less clear behavior in the number of medical specialists such as pediatricians and psychiatrists. As with utilization rates, Orange County registered higher levels of health system professionals compared with Osceola County and the state average. Trends on access to health care facilities were also erratic for these counties, with indicators providing no clear trends at the dimension level. Lastly, the share of people without access to health insurance improved in both counties compared with the state average. Indicators were similarly uneven in Louisiana across all dimensions. Both Terrebonne and Lafourche Parishes registered higher utilization rates than the state average in hospital admissions, short-term community hospital admissions, and short-term emergency room visits. Utilization rates 20 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES followed a downward trend over time in these counties. Compared with the state average, both counties also showed higher access to health care professionals in all areas except psychiatry, where levels in Terrebonne Parish were significantly below those of the state overall. The parishes, however, performed poorly on access to health care facilities compared with the state average for many indicators. For instance, the number of community health centers has remained stagnant in each parish, even as the number of community centers across the state has increased. Finally, while both counties improved in the share of people without access to health insurance, improvements were smaller than the state average. Respondents provided additional context for these changes in utilization rates, professionals, facilities, and the share of uninsured individuals. Many described how, in addition to the impacts of the migration-related population influxes, poverty and disaster also affected the migrant populations and the health systems in each site. Respondents in Louisiana particularly emphasized the poverty-related systemic health challenges of the region, which were compounded by repeated exposure to many disasters. "Before Katrina, Rita, BP, or the pandemic, Louisiana has been ranked 49th or 50th for the worst health outcomes by the United Healthcare Foundation for the last 25 years," said a respondent, noting that the state faced numerous health challenges well before the uptick in disasters. These problems were related to diseases of poverty: "The obesity rate, tobacco use, alcohol abuse, diabetes, hypertension. Those are the things that have kept Louisiana, historically, at the bottom," said a respondent. And poverty affected health in ways outside of exacerbating disease: "If somebody doesn't have a safe, affordable place to live, their health is worse," stated a respondent in Louisiana. Some respondents in Louisiana linked these issues to the region's heavy presence of and reliance on the petrochemical industry, which created long-term stress as well as acute disaster. Respondents described the petrochemical industry as affecting nearly every aspect of overall health, exacerbating chronic and acute health problems and shaping people's access to health services. The impacts were partly economic: because Terrebonne's economy is tied to oil, booms and busts could lead to stress, and in a health system where employment and financial resources matter, oil-related disasters could compromise health care access. The 2010 Deepwater Horizon Oil spill was a particularly devastating "bust" with widespread repercussions. A respondent described the impact of the oil spill on communities as such: "What we found out [is] that after Katrina, the most traumatic-maybe more so than Katrina and Rita for the locals-was the BP oil spill. If you deal with folks that are self-sufficient like the commercial fisherman and a large part of the Native American population, they were dependent on their livelihoods from fishing and doing the things that they do. They can accept a natural disaster, it's CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 21 hard but, you know, that's nature. But when a man-made disaster happens, like the BP oil spill-that was more devastating mentally." The pandemic was another disaster affecting the health system. Demand for acute health services surged during the pandemic as people became sick with COVID-19. Access to health care also became more difficult for the many people who lost their jobs because of the economic impacts of the pandemic or who had to quit out of health concerns. As households dealt with these effects and others, well-being also decreased. Over the long term, however, not all disaster impacts were negative for the health systems and their ability to respond to disaster and to new population influxes. Some disasters increased available health system resources. In Louisiana, some of the Deepwater Horizon oil spill settlement money went toward improving health services. "The BP spill brought a lot of medical resources to this region. It resulted in the expansion of our federally qualified health center, which is Teche Action Clinics. They established at least two new clinics, maybe more, as a result of the BP settlement and the health care share of the settlement monies," noted one respondent. Similarly, although their moves were in part outcomes of disaster, migrants also created opportunities for health system adaptation and growth in their new locations. In Louisiana, a respondent described how they thought that migration was occurring at a slow enough pace that health systems could adapt without being overwhelmed: "We expand services as we see the need. So, we would just continue to do that." The influx of patients added to the health system's catchment areas could also prove positive. "As folks relocated from Isle de Jean Charles to the planned community in Gray, that tribe is getting closer to the Thibodaux clinic of Teche Action Clinics, which frankly could use the business because they're only a part-time clinic," said a respondent. Some migrants also had skills that made them valuable health system professionals. A respondent in Houston remarked on the skills of many migrants, "We got a lot of them as far as staff, we had what, about six or seven, maybe even more than that, maybe eight or nine pharmacy technicians. We had a boatload of nurses. Just a plethora of different disciplines, from doctors to housekeepers, to food nutrition." Additional growth came from the response systems to support migrants. In Orlando, HOLA remains committed to helping the Puerto Ricans who left after Hurricane Maria. A HOLA representative shared, "We continue providing those services to these newcomers, also around 50,000 to 60,000 Puerto Ricans who settled permanently in Central Florida after Hurricane Maria. So, we continue helping them, assisting them, connecting them with government agencies, private entities, as well as businesses and community organizations." Other organizations remain committed to maintaining the relationships that 22 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES they built with each other during the initial response. "Right now, [what] happened in the past kind of helped us build more relationships in the community. Now we are very connected. We receive daily referrals from pediatricians and doctors and BCF," said a respondent. In this instance, the response to climate migration catalyzed the development of new relationships that helped strengthen the overall health system. Disasters also functioned as learning opportunities for improving future responses. Many respondents described developing preparedness and response plans after disasters or refining the ones that they had. Others recalled taking new trainings to fill skills gaps. Staff in Orlando, for instance, described learning about the significant mental health burden of rapid response and undergoing more training on crisis support as a result. Repeated response also functioned as practice for future responses. In Louisiana, being forced to respond to disaster after disaster had honed community organizations and government agencies' response abilities. "I think 15 years later, Louisiana's crisis response to disasters is much better than it was," said a respondent. Syntheses, Recommendations, and Conclusions Collectively, the three sites offer early insights into how health systems-particularly the health services aspect of health systems-respond to the health needs of migrants. During the initial emergency period, health systems in Houston and Orlando scaled up rapidly to engage in a diverse set of activities in response to the disaster event, while in Louisiana, this initial period appeared absent (possibly because of the chronic nature of climate change–related migration in the region). Over the longer term, the health system in each site grew and changed, both quantitatively in the services offered and qualitatively in its ability to respond to crisis. Members of the health system had to contend with, and in some cases learn from, other crises to support migration response. These included shorter, acute shocks such as hurricanes and floods, technological disasters, and the COVID-19 pandemic, as well as ongoing stressors related to poverty and historical marginalization. We did not observe many of the activities that members of the health system reported pursuing during these periods in our quantitative data, which focused on health system utilization, professionals, facilities, and levels of insured customers and showed erratic trends. Respondents recounted these activities and described augmenting service provision for new populations; working to overcome barriers related to lack of information, bureaucracy, and language barriers that hindered access; and coordinating with other organizations and providers to connect migrants with appropriate mental and physical health services. Also invisible in the quantitative data were the structural and historical issues CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 23 shaping the health of migrants and the ability of health systems to support migrant populations, from decades of neglect of Puerto Rican infrastructure (Rodríguez-Díaz 2018), to the petrochemical-related environmental degradation in Isle de Jean Charles (Crepelle 2018), to the chronic underinvestment in public health across the United States (Maani and Galea 2020). Key Insights Health care systems will contend with climate migrants' health concerns, both mental and physical. The interplay of health stresses and difficulties in accessing health care services can be exacerbated by overlapping non-disaster impacts on health (including poverty, pollution, chronic stress, and COVID-19), climate disaster impacts, and other stressors. Policymakers and community leaders should also consider the mental health stress from the process of movement itself, which is wide-ranging and experienced by many migrants. Such stress is influenced by several factors including loss of place and community, anxiety related to lack of information about the disaster and recovery in their home location, and the stress of securing resources and creating a home in a new and unfamiliar environment. Repeated exposure to disaster can also compound both physical and mental health issues, as described in other recent work on the devastating effects that cascading crises have on migrants' health and well-being (Calvillo et al. 2022; Pescaroli and Alexander 2015; Hahn et al. 2022; Sansom et al. 2022). People and organizations support the health of climate migrants based on their existing capacities and capabilities. Many organizations mobilized to provide migrants with essential health services. Government, civil society, and private sector organizations played various roles and provided services related to both physical health and mental health. Connecting migrants to a new health system was an essential task, which included helping them navigate new bureaucracies, linking them to appropriate service providers, working with other organizations to coordinate resources, and providing essential information about the health system and available services. The actions by these organizations and individuals were collective, emergent, and often driven by altruism, aligning with a large and well-established body of research documenting how people and institutions "step up" and support each other in the aftermath of a crisis (Rodriguez, Trainor, and Quarantelli 2006; Drabek and McEntire 2002, 2003; Saunders and Kreps 1987). What is striking is that this collective altruism occurs even when affected people and groups have relatively few ties to their new environment or the individuals and organizations supporting them. 24 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES Service providers in receiving communities have been hampered by information challenges, financial resource limitations, and lack of centralized coordination. Government agencies set up coordination structures to help facilitate response. However, the scale of need and the diverse and sometimes disparate array of providers offering health services, coupled with challenges in navigating the health system, made providing support during the emergency period difficult. Coordination challenges are perennial to disaster response, which frequently involves novel sets of stakeholders working at a rapid pace (Moynihan 2009; Comfort et al. 2004). Key factors that must be addressed to facilitate health service provider response to climate migrants include better data systems and flow of information, human and financial resources, and more centralized coordination around migrants' needs. Climate migrants' ability to access health services is contingent on broader social and economic factors before, during, and after migration. Vulnerability is the central factor shaping access to care and the impacts of movement on health. Providers reported that migrants with preexisting conditions had greater health needs following their move. People with more tenuous employment or those who lacked the resources to navigate the health system had a harder time accessing health services. Health conditions and health system access are upstream of the disaster and the migration event-an outcome of deeper, longer-term, and politically determined factors that marginalize certain groups or populations (Dawes 2020). Health systems need to adapt at the system level and better recognize the process of disaster rather than just focusing on the acute event. As in other disaster situations (Wisner et al. 2004; Oliver-Smith et al. 2017), this vulnerability is socially produced-which is to say, it is a function of human decisions related to who has what under a system that creates winners and losers. During the periods of study, health systems adapted and evolved to meet the needs of climate migrants. The health systems in the study sites were subject to numerous shocks and stresses related to and beyond the disaster event. The systems evolved and changed in response to these events: some areas leveraged the additional resources to make longer-term investments in the health system, while others learned from the acute response to develop new relationships with other health system organizations or to improve preparedness plans. Although these changes demonstrate a certain level of adaptiveness aligned with ideas of health system resilience-which hold that resilient health systems are those able to respond quickly to change (Kruk et al. 2017; Behrens, Rauner, and Sommersguter-Reichmann 2022; Biddle, Wahedi, and Bozorgmehr 2020)-evolution and learning was not systematic but rather occurred as a byproduct or unintentional outcome of the responses. Thus, components of learning and adaptation might be missing or underinvested. CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 25 Recommendations Climate migrants have diverse health needs, and health care providers should consider addressing both mental and physical health issues that might result from the intersection of migration stress and stresses from other hazards. Exposure to the disaster and preexisting conditions can exacerbate or compound migrants' health issues. As such, health systems need to be prepared to capture those needs upon engagement or intake and identify a service mix that can attend to both concerns. Given the gravity and breadth of climate impacts, health care providers may need additional training and ongoing support to understand potential climate impacts on individuals and households. Providers should aim to better monitor the hazards that health care consumers experience-for example, through patient screeners and/or mapping of ZIP codes of residences in the origin community-including the acute and chronic stresses from climate change. Support the coordination of organizations (such as civil society organizations and local government agencies) that can address upstream social and economic issues, which exacerbate health issues for climate migrants. Many organizations work to provide both acute and longer-term mental and physical health services for climate migrants. The support that these organizations provide is part of a chain of support in the larger system shaping health. This system also includes actors contributing to or undermining health and well-being upstream; economic systems that shape the livelihood options available to migrants; built infrastructure that influences housing, transportation, and protections from hazards; and the natural environment that provides a space for recreation, community, and other aspects of well-being. Local, state, and federal governments should make efforts to coordinate with actors shaping these upstream issues to improve health, including powerful larger private and public sector organizations as well as community or civil society organizations with the capacity and skills to work effectively at the local level. Centering coordination on the population (climate migrants) rather than a specific geography (the home or host location) should ensure continuity of care and reduce potential upstream economic and social issues from occurring during the relocation period. Health care providers, health systems (and payors where relevant), and researchers can plan for climate migrants by reviewing plans for service delivery, coordinating health services and social services provision, and augmenting data systems to better monitor the health needs of climate migrant populations. Climate migration may occur suddenly, but it does not need to be a surprise. People will move in response to growing climate change–related shocks and 26 CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES stressors. Proactively planning for climate migrants will help reduce the surprise of a large population influx and the resulting improvisation and potential for being overwhelmed. Developing approaches to monitor health needs and scale rapidly will improve the adaptiveness of the health system and should result in better health outcomes for climate migrants in the immediate period, and more strategic approaches can strengthen health systems over the long term. Researchers can support the implementation of these recommendations in several ways. First, more work is needed to clarify and enumerate who climate migrants are and where they are located, understand climate change–related shocks and stresses and their impacts, and identify viable policies for supporting migrants' needs. This requires better data to track climate migrants and the evolution of health system services in new locations, including the role of community actors and larger health system providers. Second, research should focus on better understanding the mental health dimensions of climate migration-both the mechanisms contributing to mental health challenges and approaches for addressing those challenges, including for different populations. This investigation should go beyond exposure to the climate-related shock or stress to account for the long-term construction of vulnerability and potential for cascading and converging crises after the event. Lastly, studies are needed on resilient health systems, not just the health care within those systems. Given the large scale of health systems and numerous actors and institutions shaping health, efforts should focus on how to develop policies, financing, and networks for coordination that are truly collaborative, involve key community and large actors, and lead to a coherent approach to developing health system agility and adaptive capacity. CAPACITIES OF HEALTH SYSTEMS IN CLIMATE MIGRANT RECEIVING COMMUNITIES 27 Appendix A. Quantitative Data Sources TABLE A.1 Summary of Quantitative Data Sources by Dimension Dimension Variable Original data source Health system Hospital admissions AHA Annual Survey of Hospitals utilization Short-term community hospital admissions AHA Annual Survey of Hospitals Inpatient visits AHA Annual Survey of Hospitals Short-term emergency room visits AHA Annual Survey of Hospitals Long-term emergency room visits AHA Annual Survey of Hospitals Health system Nonfederal medical doctors AMA Physician Masterfiles professionals Medical doctors AMA Physician Masterfiles Pediatricians AMA Physician Masterfiles Psychiatrists AMA Physician Masterfiles Health system Hospital beds AHA Annual Survey of Hospitals facilities Short-term community hospital beds AHA Annual Survey of Hospitals Nursing home beds AHA Annual Survey of Hospitals Community health centers HRSA Health Center Service Delivery and Look-Alike Sites file, Data Warehouse Community mental health centers Centers for Medicare and Medicaid Services Quality Improvement Evaluation System (QIES) database. Short-term community hospitals AHA Annual Survey of Hospitals Uninsured Uninsured people under 65 US Census Bureau's Small Area Health Insurance Estimates (SAHIE) file Notes: AHA = American Hospital Association. AMA = American Medical Association. 28 APPENDIX Appendix B. Qualitative Data Tools This appendix contains the tools used for our qualitative research: our respondent identification guide, interview guide, and interview coding framework. TABLE B.1 Respondents Interviewed, by Location and Type Site Respondent type Florida Government (legislative) Florida University Florida Government (executive) Florida Health care provider Florida Firm (insurance) Florida Nonprofit Florida Community organization Florida Nonprofit Florida Religious Louisiana Nonprofit Louisiana Government (health) Louisiana Nonprofit Louisiana Health care provider Louisiana Government (Houma Nation) Texas Government (health) Texas Government (health) APPENDIX 29 TABLE B.2 Interview Guide Question category Interview questions and language Background questions 1. Can you please state your name, title, organization, and what you currently do? 2. Please describe what you were doing during and immediately following the migration, including the organization you worked for (if different from current organization)? 3. Can you describe the main mission of that organization? How much of their activities focus on the migrant population (roughly)? State of health system before As you know, we're focusing on the health services in communities arrival receiving climate migrants. These are the basic services needed to maintain mental and physical health, which include things such as medical care, dental, vision, and mental health. Let's go back a bit in time to talk about what it was like when people started arriving in the community. 1. In your opinion, how would you describe the quality of the health services being offered right before the migration event? 2. How would you describe the ability of the population to access the health services being offered before the migration event? 3. Were there variations between populations in their ability to access services? How did factors such as race/ethnicity, age, gender, and income shape access? Which subpopulations had a harder time accessing services? 4. How have the health needs of this population evolved in the years since their arrival? Health needs of new residents Let's talk a bit more about the health needs of the new arrivals. 1. Do you recall the main health needs of these new arrivals? 2. Were any of the health needs of these new arrivals particularly different from those of the populations you were already serving? 3. For new arrivals with different needs, do you know the cause? Do you know if any health issues were caused by the disaster, the move, or settling in the new location? For instance, this could include disaster- specific health conditions such as respiratory disease from exposure to this disaster or other disasters, stress from the move or from integration into a new community, etc. 4. Did different groups of new arrivals have different health needs? 5. How did factors such as race/ethnicity, age, gender, income, and others shape migrants' health needs? 6. How have the migrants' health needs evolved in the years since their arrival? 30 APPENDIX Health system providers Let's talk more about your organization's ability to meet the needs of these migrants. 1. First, how were you connected with these migrants? Do you know if any patients or clients in this group were referred to you by other organizations or individuals? Which organizations or individuals? Did you have any sort of agreement for service referrals with them? 2. Second, of the new migrants you served, how well were you able to meet their health needs as an organization? a. Were there any key gaps in services or other services you could not provide, for whatever reason, to these migrants? b. Did you have a harder time meeting the health needs of any specific subpopulations (e.g., based on race/ethnicity, age, gender, or income)? 3. What, in your view, were some of the main contributors to those gaps in services? For instance, were there enough resources available in your facility? Did cultural differences or language barriers create access issues? 4. How much of an increase in demand for new services did these migrants create? Did this increase in demand affect your organization or your ability to provide for other populations? Were any of the subpopulations you mentioned previously as having a harder time accessing services particularly affected by this increase in demand? 5. Did your organization prepare for this new population's arrival and the potential increase in service demands? a. If yes, what did your organization do? If not, why not? How did your organization figure out what might be needed for this new population, and how to scale up or modify resources? 6. How were these migrants able to pay for services? Cash, private insurance, or government insurance such as Medicare or Medicaid? a. Were there issues with payment or challenges with paying for services? Health system intermediaries Let's talk more about how your organization supported these migrants. 1. When this group began arriving, how were you able to assess their potential health needs? 2. How well was this group of people able to access health services? a. What barriers made accessing services difficult? Barriers might include high cost of care, inadequate or no insurance, other financial difficulties, lack of availability of services, lack of culturally competent care, and language challenges. b. Were there any specific subpopulations that had a harder time accessing services (e.g., based on race/ethnicity, age, gender, or income)? 3. How did you identify where to refer these groups? Which organizations or individuals did you refer to these migrants to? Did you have an agreement for service referrals? 4. Did your organization prepare for this new population's arrival? a. If yes, what did your organization do? If not, why not? How did your organization figure out what might be needed for this new population, and how to scale up or modify resources? APPENDIX 31 Conclusion 1. Reflecting back on your work, if a similar migration event occurred again, what would you do differently? What would you do the same? a. Do you have any recommendations for other organizations working to provide or facilitate access to health services? b. Do you have any recommendations for federal agencies looking to support climate migrants or the communities where they settle? 2. Who else should we talk to for this study? What other organizations are important for this study? 3. Do you know of any datasets that capture the level and quality of available health services that we can access? Are there any documents that might be useful for this study? Datasets can include required reporting to public health officials, insurance providers, and clinical researchers. We are interested in data at the county level for the 2000– 2020 period for Houston and for the 2015–2020 period for Orlando and Lafourche and Terrebonne Parishes. Documents can include relevant reports, articles, or other outputs related to this migrant population you have produced or know of. 4. Is there anything we have not talked about during this interview that would be important for this study? 32 APPENDIX TABLE B.3 Interview Coding Framework Code Subcode Description 1. Background 1.1 Respondent background Information about the 1.2 Organization background and services it provides respondent and organization. Most likely from the introductory set of questions. 2. Before 2.1 Migrants and migration background Information about the state of 2.2 Case-site background the health system immediately before climate migrants started arriving. Most likely from interview question section 2. Information about migrants and their health needs Most likely associated with section 3 migrant-specific questions. 3. During 3.1 What happened: timeline of activities and impacts Information on how the health 3.2 Services organization provided to migrant system adjusted to meet migrants' needs, including 3.3 Health needs of migrants scaling up and down, health 3.4 Challenges migrants faced accessing services and system intermediaries and meeting needs barriers, and perceived needs. 3.5 Health system intermediaries Combination of sections 3–5. 4. After 4.1 Assessment of response and health system Longer-term reflection on 4.2 Lessons learned health system growth and change, including exposure to 4.3 Suggestions for future other crises and any key 4.4 COVID-19 and other shocks and stressors takeaways. Mix of sections 3–6. 5. Other 5.1 Notetaker summaries Anything that does not fit in the 5.2 Good quote other categories that might be helpful for the research. 5.3 Statistics from respondent Thoughts, ideas, good quotes, 5.4 Do not know how to code questions about coding, etc. APPENDIX 33 Appendix C. Health Services Figures FIGURE C.1 Florida – Health System Utilization Rates 34 APPENDIX FIGURE C.2 Florida – Access to Health System Professionals APPENDIX 35 FIGURE C.3 Florida – Access to Health System Facilities 36 APPENDIX FIGURE C.5 Florida – Access to Health Insurance FIGURE C.6 Louisiana – Health System Utilization Rates APPENDIX 37 FIGURE C.7 Louisiana – Access to Health System Professionals 38 APPENDIX FIGURE C.8 Louisiana – Access to Health System Facilities APPENDIX 39 FIGURE C.9 Louisiana – Access to Health Insurance 40 APPENDIX Notes 1 Compared with respondents in Houston and Orlando, respondents in Louisiana spoke less about the acute needs of migrants in the immediate period. This could be for any number of reasons. First, the magnitude of issues associated with the shock and stress of migration in Louisiana could be less than that of the other two sites, either because of the lower scale of the disaster or because the move was less jarring (to a closer location offering greater continuity with the original community). Second, there may have been more advanced planning that resulted in less of a "scramble" to reestablish access to services, either because of the more gradual nature of the hazard or because health services were making more of a concerted effort to maintain continuity of care. Finally, the differences may simply reflect data limitations related to the limited number of interviews for the Louisiana site or discrepancies in how interview protocols were operationalized during the interviews. 2 For more information on Medicaid expansion, see "Medicaid expansion & what it means for you," Healthcare.gov, accessed December 2022, https://www.healthcare.gov/medicaid-chip/medicaid-expansion- and-you/. 3 Emergency support functions (ESFs) are part of the federal incident management and response architecture under the National Response Framework. ESF-8 covers public health and medical services functions as the mechanism for coordinating federal and state, local, tribal, and territorial (SLTT) government resources for public health emergencies. See "Emergency Support Function #8 – Public Health and Medical Services Annex," Federal Emergency Management Agency, January 2008, https://www.fema.gov/pdf/emergency/nrf/nrf-esf- 08.pdf. 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His projects span the disasters gambit, with a recent focus on three primary areas of inquiry: disasters and community, disasters and health, and disasters and measurement. Clark- Ginsberg also leads RAND's Mass Migration Strategy Group, where he supports RAND's community of researchers engaging in mass migration research. He earned his PhD at University College Dublin, where he undertook disaster-focused fieldwork in 10 low- and middle- income countries with the international NGO Concern Worldwide. Anita Chandra is vice president and director of RAND Social and Economic Well-Being and a senior policy researcher at the RAND Corporation. The division manages RAND's Center to Advance Racial Equity Policy as well as other centers on climate, housing, drug policy, policing, and civil justice. She leads studies on civic well-being and community planning, disaster response and resilience, public health emergency preparedness, health and health equity, child health and development, and effects of military deployment on families. Throughout her career, Dr. Chandra has engaged government and nongovernmental partners to consider cross-sector solutions for improving community well-being and building more robust systems, implementation, and evaluation capacity. This work has taken many forms, including engaging with federal and local government agencies on building systems for emergency preparedness and resilience both in the United States and globally; partnering with private sector organizations to develop the science base around child systems; and collaborating with city governments and foundations to modernize data systems and measure environmental sustainability, well-being, and civic transformation. Dr. Chandra has partnered with community organizations to conduct broad-scale health and environmental needs assessments, examine the integration of health and human service systems, and determine how to integrate equity and address the needs of historically marginalized populations in human service systems. These projects have occurred in partnership with businesses, foundations, and other community organizations. Dr. Chandra earned a doctorate in public health in population and family health sciences from the Johns Hopkins Bloomberg School of Public Health. Alejandro Becerra is a research economist at the Mexican Central Bank (Banxico). Before joining Banxico, Becerra was a PhD fellow at the Pardee RAND Graduate School and an assistant policy 46 ABOUT THE AUTHORS researcher at the RAND Corporation. At RAND, he worked on multidisciplinary projects focused on climate change and disaster management. 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