Heat Deaths Are Predictable: AC, Work, Utility Policy
The protections that would save lives — a federal heat rule, summer shutoff bans, cooling aid, clean-air rules — are stalled, missing, or on the chopping block.
Heat is a means test.
Who gets to keep the AC on.
The heat map is the old redlining map.
OSHA softened enforcement as the heat rose.
Older hearts, strained kidneys, and pregnancy.
When heat and bad air collide.
A medical note that keeps the power on.
Heat is a means test.
About 131 million people, or roughly 4 in 10 Americans, are under an extreme heat warning as I write this. The public guidance is the same every summer. Drink water. Stay out of the sun. Check on older relatives. Find somewhere cool. Good advice, all of it. It also quietly shifts the responsibility off the systems that create heat risk and onto the people who absorb it.
Heat does not kill at random. It is the deadliest form of extreme weather in the United States, tied to about 700 deaths a year on death certificates from 2004 to 2018, and that official count is an undercount. The people it kills are predictable. Heat finds whoever the system has left exposed.
Who gets to keep the AC on.
Start with the single most protective device against heat death: a working air conditioner someone can afford to run. In 1995, a heat wave killed 739 people in Chicago over five days. Most were older and alone. They had no air conditioning, or were scared of the bill. Nearly three decades later, the pattern held. In Maricopa County, Arizona (metro Phoenix), most people who die of heat indoors have an air conditioner that isn’t running, according to the county’s own death reviews. What decided those deaths was whether the machine was on.
So who gets to keep the AC on? About half the U.S. population lives in a state with no protection against summer utility shutoffs. Only 19 states bar disconnection during heat. The main federal program that helps low-income families pay energy bills is the Low Income Home Energy Assistance Program (LIHEAP). It spends most of its money on winter heating, and cooling assistance is optional. Only some states run a summer cooling program. Cooling costs keep climbing. Meanwhile, the administration’s FY2027 budget proposes eliminating LIHEAP entirely, a cut of roughly $4 billion. Congress has rejected that before and will probably do so again. But the federal staff who run the program haven’t been rehired, so states are running it with less support than they had before.
The heat map is the old redlining map.
The exposure is not spread evenly across a city, either. In formerly redlined neighborhoods, summer temperatures can run as much as 13°F hotter than in wealthier areas a few blocks away. Less shade, hotter pavement, worse cooling at night. The heat map and the old redlining maps are nearly identical. The neighborhoods the government graded "hazardous" for lending in the 1930s are the ones running hottest today.
OSHA softened enforcement as the heat rose.
For people who work outside, the exposure is on the job. 479 U.S. workers died from heat between 2011 and 2022. The highest rates were in agriculture and construction — 35 and 13 times the risk of other industries. The danger peaks in the first days on a job, before the body adapts. That is why even young and healthy people can still be at risk. And the safeguards are eroding. There is still no federal heat standard for employers. The proposed rule has sat without a final action date since its hearing closed. In April 2026, OSHA revised its heat enforcement program. It dropped the numeric inspection goal and narrowed the list of high-risk industries. Only a handful of states set their own enforceable heat rules, so whether a worker is guaranteed water, shade, and rest depends on the state.
Older hearts, strained kidneys, and pregnancy.
Most deaths recorded during a heat wave are cardiovascular. Heat raises the heart’s workload, and heat-related cardiovascular mortality can rise by more than 10% during an event. People on dialysis walk a fluid-balance tightrope. Older adults sweat less, and many take drugs — diuretics, some blood-pressure and psychiatric medicines — that blunt the body’s ability to cool. Extreme heat is also linked to a higher risk of preterm birth. Heat likely compounds existing risks rather than acting alone.
When heat and bad air collide.
Heat rarely comes alone. Ground-level ozone forms faster in hot, stagnant air, and wildfire smoke travels on the same heat domes, so a heat wave usually doubles as a bad air day. As I write this, about 45 million people are under a heat warning and an air-quality alert in the same county. The two hazards hit the same organs — heat loads the heart, while ozone and fine-particle smoke inflame the lungs and blood vessels — and they are worse together than apart. In a decade of California data, days with both extreme heat and wildfire smoke drove roughly 8% of respiratory hospitalizations and 5.5% of cardiac ones through the combination alone, with the heaviest toll on Black residents and low-income neighborhoods that have little tree cover.
The rules that hold down the air half of that equation are loosening at the same time. In 2024, the Supreme Court blocked the EPA’s “Good Neighbor” plan, which would have cut the ozone-forming pollution that drifts across state lines — the kind the agency ties to asthma and lung disease. Researchers have proposed a cheap fix: a joint heat–air-quality warning that trips earlier when the two hazards collide. It isn’t running at national scale, so on the most dangerous days the alert that should come sooner comes later, or not at all.
A medical note that keeps the power on.
There is a lever that works today, and clinicians hold it. Nearly every state prohibits utility shutoffs when a doctor documents medical necessity. For a patient with heart failure, advanced kidney disease, or an oxygen concentrator, that letter is a heat intervention. It is underused.
The rest of the levers sit with the people who can actually pull them. OSHA can finalize a standard. Congress and HHS fund cooling assistance. States decide whether to keep the power on in July. Utilities and employers set the rules that govern the machine and the shift. None of that is “make better choices.” It is a choice about who gets protected before the temperature climbs.
We already know how this heat wave ends for most of the people who die in it. They will be old, or poor, or working outside, or sick, or pregnant, often several at once. They will be in the counties where the protection was thinnest. A forecast is not a body count, and heat deaths get undercounted anyway, coded as cardiac or renal. But the map of who is exposed is already on my screen: 131 million people under warning, and in nearly every state a doctor’s letter can still keep one of them from losing power this week.