Rachel Carson, speaking to the class of 1962 at Scripps College, said, “Your generation must come to terms with the environment. Your generation must face realities instead of taking refuge in ignorance and evasion of truth. Yours is a grave and a sobering responsibility, but it is also a shining opportunity. You go out into a world where mankind is challenged, as it has never been challenged before, to prove its maturity and its mastery—not of nature but of itself.”

Fifty-seven years later, as we stand at the last inflection point of the climate crisis, Carson’s words have a brutal ring. Every region of the U.S. stands to suffer—from unprecedented storm surges in the Northeast to widespread crop failure in the Midwest to dramatic heat extremes throughout the South. By 2050, if we have increased Earth’s temperatures another 0.5 degree Celsius past preindustrial levels, as the Intergovernmental Panel on Climate Change anticipates, the U.S. can expect a wave of climate migrants, mostly internal, fleeing agricultural regions—as temperatures soar past the optimal reproductive range of most staple crops—and coastal cities—as flooding and stronger hurricanes pummel economic powerhouses.

As we push for mitigation policies, we must turn our sights to preparation in terms of infrastructure, economy and, especially, our health systems. American health care is already plagued with complexities, from inflated prices to a reliance on personal resources. It has been said that climate change will exploit our preexisting vulnerabilities, and soon enough, the U.S. will be forced to confront the vast array of limitations our system has to offer.

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There is no question that the climate crisis presents us with a buffet of immediate threats that are difficult to triage. In the absence of meaningful federal action, states and cities have taken it upon themselves to create individualized climate plans ranging from expanding the tip of southern Manhattan to increasing canopy coverage in Los Angeles. Some of these plans include disaster preparedness, and some have even acknowledged the risk of diseases such as malaria and dengue fever, whose insect carriers will have a heyday with a warmer planet.

But few, if any, have acknowledged the health needs of long-term migration. It is precisely this focus, however, that may save communities, reducing the need for migration in some cases and ensuring continuity of care for what could potentially be the most mobile generation of Americans.

It’s hard for us to envision a U.S. full of internally displaced people, let alone enough of them to make climate migration a national priority. That scenario is the stuff of dystopian novels for many—except it’s already happened.

In the 1930s, in what we now call the Dust Bowl, unsustainable agricultural practices, combined with the Great Depression, drove approximately 400,000 Americans from Oklahoma and other states to California in search of work as farmhands. In 2005 the same number of Americans were forced out of New Orleans in what became known as the Katrina diaspora. Many of those migrants never returned to Louisiana. Most recently, in the wake of Hurricane Maria, 130,000 Americans left Puerto Rico. Climate migration is by now old hat in the US—but the health challenges that follow it are rarely confronted.

Climate change will test a number of weaknesses in our health systems. Americans rely on a fragmented insurance scheme, with 49 percent using employer-based plans and another 21 percent on Medicaid, bringing the total percentage of Americans whose insurance is tied to either a job or geographic location to a staggering 70 percent. After Katrina, migrants in Georgia and Texas often found themselves stripped of their Louisiana-based Medicaid after the government’s five-month extension ran out. Passing universal health care—whether in the form of Medicare for all, a more nuanced Medicaid for all or simply a public option that coexists with a tamed private sector—will be critical in the coming years.