The Future of Water Quality: Half Full or Half Empty?

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Lack of running water or indoor plumbing increases morbidity and mortality risk for vulnerable populations.

One-quarter of the world’s population lacks access to safe drinking water, and half lacks basic sanitation. Over 2.2 million Americans, most of whom are minorities or low-income individuals, do not have running water or basic indoor plumbing. This puts the most vulnerable populations at increased risk of water-related morbidity and mortality, which contribute to direct and indirect costs. For example, waterborne diseases cost the US $3.33 billion in direct healthcare costs annually.

Health Implications of US Water Quality

Passed in 1972, the Clean Water Act regulates water pollution and sets quality standards for surface waters, defined as all water naturally open to the atmosphere. The act establishes provisions to control sources of contamination—such as sewage treatment plants, agricultural runoff, industrial discharges, stormwater runoff, and improper medicine disposal—water contamination still occurs in the form of chemicals, heavy metals, microorganisms, radionuclides (such as uranium and radon), and harmful algal blooms.

Increased contaminants in water have been linked to health issues and are particularly harmful to vulnerable populations such as children, people who are immunocompromised, and older adults. Aging or corroding water systems may increase lead exposure, which can contribute to neurological damage and developmental issues. Recent literature shows higher rates of lead exposure among minority children than White children. Agricultural runoff and chemical pollution can also create harmful algal blooms that produce water toxins and threaten freshwater supplies.

Additionally, most Americans have been exposed to per- and polyfluoroalkyl substances (PFAS), a class of 14,000 human-made chemicals that resist decay. PFAS have been linked to cancer, liver problems, birth defects, and kidney disease, and one study estimates they could be contaminating drinking water for over 200 million Americans. Individuals at the highest risk of PFAS exposure include those in low-income and minority communities, who tend to live or work near high-polluting sites.

Climate change contributes to overall water quality in several ways. Rising temperatures can encourage the growth of harmful algae, and changes in precipitation patterns can increase sediment and nutrient runoff. A global increase in carbon dioxide emissions has altered ocean acidity, impacting marine life. Rising sea levels as a result of increased atmospheric warming may increase the risk of water-borne pathogens, create water access issues, and lead to higher levels of flooding. Flooding can threaten a region’s wastewater treatment systems, contribute to sewage issues, and overwhelm aging infrastructure. Overall, these environmental impacts are likely to increase the risk of water-related morbidity and mortality.

Water Access and Health Equity

Though most Americans have access to safe, clean drinking water, some communities still lack access to municipal wastewater systems and adequate drinking water. Underserved groups—including racial and ethnic minorities, low-income populations, immigrants, and rural communities—are at the highest risk of poor water quality and health-related complications. Many vulnerable communities were excluded from mid-20th-century investments in modern water infrastructure and sanitation systems.

Some of these groups are still excluded from community water systems, leading them to rely on poor-quality water sources like private wells. Recent literature suggests one in nine Americans access drinking water from unregulated private wells, 23% of which show some level of water contamination. One study found significantly higher arsenic and uranium levels in regulated public drinking water in minority communities, even after accounting for socioeconomic status. These contaminants are associated with cancer, heart disease, and other health conditions. Furthermore, those without access to indoor plumbing often install their own systems, creating sewage exposure that increases the risk of waterborne disease.

A growing body of evidence focuses on water access and quality, with increasing attention to the link between water access and equity. One study used data from the American Community Survey and Environmental Protection Agency (EPA) to estimate how many households have incomplete plumbing or poor water quality, at the county level. The researchers found that 489,836 households lack complete plumbing, 1,165 community water systems are in “serious violation” of the Safe Drinking Water Act, and 21,035 Clean Water Act permittees are in “significant noncompliance.” Results were regionally clustered, with higher risk of these issues associated with indigeneity, rurality, income level, education, and age, consistent with other studies about the impact of inequitable water access among vulnerable populations.

Databases to Track Local Water Quality

Another major challenge in addressing water quality and access is the lack of consistent, standardized data collection. An overall dearth of research on the current state of water quality, the impacts of poor water quality on human health, and the disproportionate effects of water insecurity and contamination on vulnerable and underserved groups. Nevertheless, new tools are emerging to close the research gap.

The County Health Rankings model shows community health markers and indicators for future health and provides resources to help communities select and implement effective policies and programs. The model primarily measures health factors (e.g., health behaviors, clinical care, socioeconomic factors, physical environment) and health outcomes. Within these measures are two related to air and water quality: air pollution particulate matter and drinking water violations.

Another tool is the Environmental Working Group’s national Tap Water Database. In 2021, the group found that over 320 toxic substances have been detected in US drinking water systems, noting an additional 56 chemicals since the previous database update conducted in 2019. The national tap water database contains a report of toxic contaminants in drinking water by ZIP code and safety assessments. Researchers analyzed water contaminant tests from 50,000 water systems and found contamination from many pollutants, including PFAS and lead. While there are over 85,000 chemicals governed by the Toxic Substances Control Act, the EPA only regulates 90 contaminants found in drinking water and has not added a new substance to its regulated list since 2006. The presence of toxic substances in drinking water does not mean they are noncompliant with federal drinking water standards. EPA’s legal limits are relatively high and do not consider the effects of chemicals mixing with one another. Overall, regulations are slow to reflect scientific evidence.

Policy Landscape

The impact of source contamination and pollution could be mitigated by systemic improvements, such as stakeholder coordination, comprehensive water protections, and additional funding for infrastructure and management. Although the current level of federal funding for water infrastructure is only 14% of what it was in the 1970s, there is momentum toward improving water quality in the policy and regulatory arena.

For the first time in almost three decades, the EPA set legal limits for contaminants in drinking water. On March 14, 2023, the EPA set legal drinking water limits for six PFAS. The rapid regulation of PFAS signals a federal desire to address water contamination. The EPA set legal limits of four parts per trillion (ppt) for perfluorooctane sulfonic acid (PFOS) and perfluorooctanoic acid (PFOA), but recent evidence shows that no level of water exposure is safe. The “advisory health limits” for these compounds are 0.02 and 0.004 ppt respectively, which is a significant reduction from the previous limit of 70 ppt. Despite attempts to phase out PFOS and PFOA, environmental and blood levels remain high because of the slow degradation process. However, the EPA’s move to limit PFAS focused on only six of 14,000 compounds, leading advocates to call for federal regulation of the entire chemical class.

At the global level, experts convened in March 2023 at the first global water conference in almost 50 years. Voluntary commitments to a new water action agenda came from more than 700 local and national governments, nonprofits, and businesses. Although these pledges will be monitored at future United Nations gatherings, they did not specify levels of funding. It will be difficult to hold stakeholders accountable without a formal global agreement like the Paris Climate Accords, more rigorous scientific data, and an international finance mechanism that treats water as a global common good. Public health experts and advocates critiqued the lack of representation at the conference; while the private sector and Northern hemisphere were well represented, few water experts and water insecure communities in the global South shared their perspectives. Progress for water equity will require stronger financial investments, accountability, incentives, and a more collaborative approach.


Stakeholders aiming to address poor water quality and ensure adequate access would benefit from collaboration with other groups to generate evidence and develop more robust research methods. Additionally, stakeholders can consider the following actions:

  • Develop national water action plans
  • Build capacity-building support
  • Invest in water infrastructure
  • Enforce primary drinking water standards
  • Promote innovative water efficiency programs
  • Encourage collaboration among health departments and providers
  • Foster community collaboration to understand needs, priorities, and resources

For additional information on how climate change impacts human health and a more detailed list of recommendations by stakeholder type, download Avalere’s 2022 white paper.

Avalere has robust expertise in healthcare marketplace and regulatory trends, data collection and analytics, and strategy development. To learn more about how we can provide valuable insights to maximize the impact of your programs to advance health equity and improve patient and public health, connect with us.

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