Hurricane forecasting models predict increased hurricane intensity and frequency due to rising ocean temperatures and rainfall induced by climate change (1–3). The National Oceanic and Atmospheric Administration (NOAA) categorizes hurricane storm surges as “the greatest threat” during a hurricane event due to severe flooding, which accounts for over half of all direct fatalities from hurricanes in the United States (U.S.) (4). The short-term health impacts of hurricanes and hurricane-related flooding—often within the first weeks or months of landfall—have been well-studied and include morbidity and mortality due to injuries, drowning, infectious disease outbreaks, cardiovascular disease, and mental health disorders (5–13). However, the long-term impacts require further investigation. Studies have revealed the impact of multiple hurricanes, suggesting an increased risk of mortality up to 2 years after hurricane landfall (5, 14). Hurricanes are likely to have long-term impacts on populations (15), including adverse physical health outcomes (e.g., cardiovascular disease, diabetes) (16, 17), mental health effects (18–20), and increased hospitalization rates (21). Adverse long-term health outcomes also disproportionately affect certain vulnerable subgroups, such as older adults, racial minorities, and low-income people (22, 23).

Several studies underscore the vulnerability of older adults in the aftermath of extreme weather events due to clinical, functional, and physiological issues (24–26). Older adults have higher rates of multiple medical comorbidities, functional limitations, and cognitive impairment (27). Therefore, they are more likely to require social support and formal caregiving, including the provision of home health aides. During and after extreme weather events, underlying health conditions may amplify the vulnerabilities of older adults, which may be further exacerbated by limited healthcare access and quality after a hurricane’s landfall, as evidenced by increased emergency department utilization among older adults after Hurricane Sandy (28).

Moreover, post-disaster recovery has been shown to have enduring impacts on the social and built environments over the long term (28–31). Although hurricane-related floods recede quickly, they cause lasting socioecological impacts, including property damage, housing displacement, reconfiguration of public infrastructure, and environmental destruction (15). For example, evidence from Hurricane Katrina highlights that the median time to achieve housing stability after landfall was approximately 3 years (32), while lost economic opportunities were noted after Hurricane Sandy due to the widespread closure of local businesses in flood-impacted areas of New York City (NYC) (33). For older adults, the long-term disruption of social infrastructure due to extreme weather may be particularly damaging because of the importance of aging in place (24). Attachment to place is often amplified among older adults due to vital resources and important lived experiences/memories within the place they reside (34), which may be adversely impacted by climate change-related events (35). Although several reports have described the importance of place-based attachment and enduring social networks as protective factors against post-disaster harm (24, 36, 37), it remains unclear whether these factors provide long-term protection. Moreover, while individually the value of aging in place may be beneficial, individuals and communities that choose to do so have the potential to amplify their collective vulnerability to extreme weather without the necessary infrastructure (e.g., support to ensure resilience) (38).

To capture the complex, ecological nature of post-disaster recovery and its related impacts on health and well-being, Abramson et al. proposed the socioecological model of post-disaster recovery, underscoring the importance of neighborhood-level characteristics in shaping post-disaster recovery outcomes (29). Importantly, this model builds on the sociological perspective of post-disaster recovery, treating recovery as a contested space where the structure of governmental responses (e.g., delivery of post-disaster aid), community displacement, and power dynamics influence the allocation of resources for recovery and rebuilding (39).

To characterize these long-term health impacts, our study tested the hypothesis that there will be higher long-term mortality rates in flood-impacted ZIP Code Tabulation Areas (ZCTAs) compared to non-flood-impacted ZCTAs among older adults who remained in their pre-Sandy residences. Therefore, we examined the long-term mortality of community-based Medicare fee-for-service (FSS) beneficiaries aged 65 years and older whose residential ZCTAs were impacted by flooding caused by Hurricane Sandy. Hurricane Sandy made landfall on the Northeastern United States coast in October 2012. It was a category 3 storm that, in its immediate aftermath, killed 125 people and caused an estimated $87 billion in damages (2024 CPI-Adjusted)—making it one of the costliest storms in U.S. history (40–42). The U.S. states that were most affected included New Jersey (NJ), New York (NY), and Connecticut (CT). Hurricane Sandy was particularly catastrophic because of its coastal flooding and storm surge effects; individuals living in flooded regions in NJ, NY, and CT experienced impacts such as unusable transportation systems, home destruction, drowning risks, and power loss. In addition, most of the geographic areas hit by the storm were densely populated, which resulted in millions of people adversely impacted (30).

Hurricane Sandy presents a unique research opportunity to study the long-term health effects of hurricanes since the affected areas historically have not experienced hurricanes compared to other regions of the United States. It will become increasingly important for healthcare systems to understand the long-term mortality risks associated with hurricane-related flooding, as storms increase in number and severity and begin to impact new geographic regions. This will allow healthcare systems to both proactively prepare before a hurricane and respond effectively afterward to address the long-term healthcare needs of older adults.

In this study examining long-term mortality rates among Medicare FFS beneficiaries residing in ZCTAs impacted by flooding from Hurricane Sandy, we found that the overall adjusted mortality risk for older adults was 9% higher at 5 years in flooded regions compared to non-flooded regions. Moreover, regional variation was observed, with flooded ZCTAs in CT and NYC demonstrating the greatest increases in risk—19 and 8% higher, respectively—compared to non-flooded ZCTAs.

The effect size of the significant overall adjusted 9% mortality risk found in this study is in line with previous studies that evaluated post-hurricane mortality risk. Quast et al. (16) found that older individuals with diabetes residing in counties affected by Hurricane Katrina had a significant 8% higher all-cause mortality risk at 5 years compared to those who were unaffected. Another study, Bell et al. (55), found that the mortality risk 1 year after hurricane exposure among Alzheimer’s disease and related dementias (ADRD) populations (<65 years) (defined as having a FEMA disaster declaration) was 10.9% higher in counties exposed to Hurricane Harvey and 6.2% higher in counties exposed to Hurricane Irma compared to counties that were unexposed. Our findings, based on data from continuously enrolled Medicare beneficiaries who remained in place, thus emphasize the specific long-term risks to older adults after hurricanes, especially for those who stay in place, at a finer spatial resolution (37).

The socioecological model of post-disaster recovery underscores the role of socioeconomic disadvantage in limiting post-disaster resilience and long-term health outcomes (29). Low-income individuals in flooded areas experience structural disadvantages to such a degree that they can impact their health and well-being in the long term. For example, Hernández et al. (2018) found that Hurricane Sandy uniquely impacted public housing residents by limiting access to healthcare and transportation, while also exacerbating existing challenges such as energy and housing insecurity; for many residents, these challenges contributed to delayed recovery (56).

In line with previous studies identifying disproportionate flooding exposure post-Hurricane Sandy among low-income populations (52), our study found that hurricane-related flooding in NYC disproportionately impacted low-income neighborhoods, as defined at the ZCTA level. NYC ZCTAs exhibited socioeconomic and demographic characteristics previously associated with greater exposure (23), such as the highest proportion of racial minorities and the lowest household income, compared to the other regions (NJ, CT, and NY). In our analysis, these NYC-flooded ZCTAs had significantly higher mortality risk than non-flooded regions compared to NJ and NY, even after adjusting for differences in exposure risk.

By contrast, CT ZCTAs had a higher proportion of White individuals, higher median household incomes, and the lowest proportion of individuals living in overcrowded households compared to all regions. However, CT had the highest mortality risk in flooded ZCTAs versus non-flooded ZCTAs compared to any other region. ZCTAs in NJ and NY had sociodemographic characteristics in between NYC and CT values and exhibited no difference in mortality risk between non-impacted and impacted ZCTAs. This finding highlights the importance of recognizing the complexity of region-specific outcomes—socioeconomic and demographic characteristics alone may not explain the full post-recovery story. There may be other regional nuances that influence long-term health effects post-flood, such as region-specific policies, infrastructure disruption, and disaster relief—all of which warrant further investigation.

There are limitations to our study. First, we conducted only an ecological analysis. Therefore, we are not able to extend these findings to individual mortality risk because understanding the true complexity of disaster recovery and long-term effects requires analyzing both individual- and ecological-level impacts. Nonetheless, systems of disaster preparedness are often ecological in nature (i.e., focused on populations at risk), and thus, understanding the ecological impact has important ramifications for potential strategies in hurricane-related communication, public health responses pre- and post-disaster, and federal and state responses to disasters. Second, our analysis was limited because the area-level SES data from the ADI were not time-varying. Previous studies have shown time-varying social and economic neighborhood-level impacts of hurricanes, including Hurricane Sandy (30, 33). Third, our sample included a 20% national sample of Medicare FFS beneficiaries. Therefore, we excluded Medicare Advantage populations from our analysis, which constitute up to 54% of Medicare enrollees (57). Finally, we examined beneficiaries who remained in the same ZCTA for the entire post-hurricane exposure period. We did not consider those who left. The implications of this are unclear. While data suggest that individuals who can and have the means to leave post-disaster regions exist, particularly among older adults, the desire to remain in place (related to aging in place and place-based attachment) may offset this risk (37). To assess and compare mortality risks within ZCTAs, our study design required us to only consider individuals who stayed in the post-hurricane setting. Despite this limitation, our finding of higher mortality rates in flood-impacted ZCTAs still emphasizes the vulnerability of older adults who stay in place in impacted areas.

Climate-amplified hurricanes and hurricane-related floods are expected to increase in the future, making it crucial from both health systems and policy perspectives to understand the long-term health effects on those who are most vulnerable. As we write this article, the unprecedented flooding brought on by Hurricane Helene has devastated inland areas of the United States, further demonstrating the changing risk of hurricanes and the urgent need for long-term post-disaster preparation (58). Urban areas such as NYC and the tri-state region (NY, NJ, CT) face unique challenges due to high population density, coastal proximity, and public infrastructure vulnerable to flood damage (public transportation, public housing, and energy) (59). More research is needed to understand which populations are most vulnerable on a regional basis, as well as the socioecological factors at both the individual and neighborhood levels influencing long-term vulnerability. At the individual level, future research should continue to evaluate the mechanisms driving long-term mortality related to hurricanes and hurricane-related flooding. For example, chronic stress related to flooding likely increases the risk of cardiovascular disease (CVD), but little is known about long-term CVD risk post-disaster (13), as well as other clinical maladies affecting long-term mortality post-disaster. At the neighborhood level, future research should incorporate spatiotemporal modeling methods to further elucidate the relationships between long-term mortality risk and flooding across regions over time. Lastly, future post-disaster interventions should prioritize environmental justice and use mixed methods approaches to address the structural and distributive factors influencing long-term health outcomes. These interventions must also prioritize the perspectives of those most affected in their design and address the region-specific impacts highlighted in our analysis.