2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM

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2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
Ready or Not:
ISSUE REPORT

                                  2021
               PROTECTING THE PUBLIC’S HEALTH FROM
               DISEASES, DISASTERS,
               AND BIOTERRORISM
MARCH 2021
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
Acknowledgements
                                                                                The National Health Security Preparedness Index (NHSPI) is a joint
    Trust for America’s Health (TFAH) is a nonprofit, nonpartisan
                                                                                initiative of the Robert Wood Johnson Foundation, the University
    public health policy, research, and advocacy organization that
                                                                                of Kentucky, and the University of Colorado. TFAH wishes to
    promotes optimal health for every person and community and
                                                                                recognize and thank Glen Mays and Michael Childress of the
    makes the prevention of illness and injury a national priority.
                                                                                NHSPI for their collaboration and expertise as well as the Robert
    The Ready or Not report series is supported by generous                     Wood Johnson Foundation for its continued funding support.
    grants from the Robert Wood Johnson Foundation, with
                                                                                Ready or Not and the NHSPI are complementary projects that
    additional support from The California Endowment, W.K.
                                                                                work together to measure and improve the country’s health
    Kellogg Foundation and The Kresge Foundation. Opinions
                                                                                security and emergency preparedness. TFAH looks forward to a
    in this report are TFAH’s and do not necessarily reflect the
                                                                                continued partnership.
    views of its funders.

    TFAH BOARD OF DIRECTORS
    Gail Christopher, D.N.                            Stephanie Mayfield Gibson, M.D.                      Eduardo Sanchez, M.D., MPH
    Chair of the Board                                Director                                             Chief Medical Office for Prevention
    Executive Director                                U.S. COVID-19 Response Initiative                    American Heart Association
    National Collaborative for Health Equity          Resolve to Save Lives
                                                                                                           Umair A. Shah, M.D., MPH
    Former Senior Advisor and Vice President
                                                      Cynthia M. Harris, Ph.D.                             Secretary of the Health
    W.K. Kellogg Foundation
                                                      Associate Dean for Public Health                     Washington State
    David Fleming, M.D.                               Director and Professor
                                                                                                           Vince Ventimiglia, JD
    TFAH Distinguished Visiting Fellow and Vice       Institute of Public Health
                                                                                                           President
    Chair, TFAH Board of Directors                    Florida A&M University
                                                                                                           Collaborative Advocates
    Robert T. Harris, M.D., FACP                      David Lakey, M.D.                                    Leavitt Partners
    Treasurer of the Board                            Chief Medical Officer and Vice Chancellor for
    Senior Medical Director                           Health Affairs                                       TRUST FOR AMERICA’S HEALTH
    General Dynamics Information Technology           The University of Texas System                       LEADERSHIP STAFF
    Theodore Spencer, M.J.                            Octavio Martinez Jr., M.D., MPH, MBA, FAPA           John Auerbach, MBA
    Secretary of the Board                            Executive Director                                   President and CEO
    Co-Founder                                        Hogg Foundation for Mental Health
                                                                                                           J. Nadine Gracia, M.D., MSCE
    Trust for America’s Health                        The University of Texas at Austin
                                                                                                           Executive Vice President and Chief Operating Officer
                                                      John A. Rich, M.D., MPH
                                                      Co-Director of the Center for Nonviolence and
                                                      Social Justice
                                                      Drexel University School of Public Health

    REPORT AUTHORS                                    EXTERNAL REVIEWERS
    Matt McKillop, MPP                                This report benefited from the insights and expertise of the following external reviewers. Although
    Senior Health Policy Researcher and Analyst       they have reviewed the report, neither they nor their organizations necessarily endorse its findings
                                                      or recommendations. TFAH is extremely grateful to these reviewers for their time and expertise.
    Dara Alpert Lieberman, MPP
    Director of Government Relations                  James Blumenstock                                    Shelley A. Hearne, DrPH
                                                      Senior Vice President                                Deans Sommer and Klag Professor for Public
    Rhea K. Farberman, APR
                                                      Pandemic Response and Recovery                       Health Advocacy
    Director of Strategic Communications and Policy
                                                      Association of State and Territorial Health          Director, Center for Public Health Advocacy
    Research
                                                      Officers (ASTHO)                                     Johns Hopkins University Bloomberg School of
                                                                                                           Public Health
    CONTRIBUTING AUTHOR                               Dr. Oxiris Barbot, M.D.
                                                      Adjunct Assistant Professor                          David Fleming, M.D.
    Kendra May
                                                      Columbia University Mailman School of Public         TFAH Distinguished Visiting Fellow and Vice
    Consultant
                                                      Health and Senior Fellow for Public Health and       Chair, TFAH Board of Directors
                                                      Social Justice at the JPB Foundation
                                                      Former New York City Health Commissioner
2     TFAH • tfah.org
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
Table of Contents                                                                                                             Ready or Not

                                                                                                                                             TABLE OF CONTENTS
Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  4
   S
    idebar: COVID-19 and Emergency Preparedness: Tragic Lessons  . . . . . . . . . . . . .  6                                   2021
  Interview: Earning Vaccine Confidence in Communities of Color . . . . . . . . . . . . . .  12

SECTION 1: A
            SSESSING STATES’ PREPAREDNESS  . . . . . . . . . . . . . . . . . . . . . . . .  15
   Indicator 1: Nurse Licensure Compact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  16
   Indicator 2: Hospital Participation in Healthcare Coalitions . . . . . . . . . . . . . . . . . .  18
   Indicators 3 and 4: Accreditation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  20
   Indicator 5: Public Health Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  22
   Indicator 6: Water System Safety  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  24
   Indicator 7: Access to Paid Time Off . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  26
   Indicator 8: Flu Vaccination Rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  28
   Indicator 9: Patient Safety in Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  30
   Indicator 10: Public Health Laboratory Surge Capacity . . . . . . . . . . . . . . . . . . . . .  32
   Indicators Performance Matrix by State . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  34

SECTION 2: RECOMMENDATIONS FOR FEDERAL AND STATE POLICY ACTIONS  . . .  36
   P
    riority Area 1: Provide Stable, Sufficient Funding for Domestic and Global Public
   Health Security  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  36
   Priority Area 2: Prevent Outbreaks and Pandemics . . . . . . . . . . . . . . . . . . . . . . . .  39
   P
    riority Area 3: Build Resilient Communities and Promote Health Equity in
   Preparedness  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  41
   P
    riority Area 4: Ensure Effective Leadership, Coordination, and Workforce . . . . . . . 43
    riority Area 5: Accelerate Development and Distribution of Medical
   P
   Countermeasures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
   Priority Area 6: Ready the Healthcare System to Respond and Recover  . . . . . . . .  47
   Priority Area 7: Prepare for Environmental Threats and Extreme Weather . . . . . . . .  49

APPENDIXES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  50
   Year in Review – 2020 Health Threats Incidents and Actions  . . . . . . . . . . . . . . . .  50
   Report Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  63

Endnotes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  67

   Editor’s note: This report was being prepared during a presidential transition. We
   have included comments in the report where we have noted action on TFAH policy
   recommendations by the Biden administration.
   View this report online at www.tfah.org/report-details/readyornot2021
                                                                                                                                             MARCH 2021
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
Ready or Not   Executive Summary
EXECUTIVE SUMMARY

                       2021        The past year, 2020, will long be remembered as the year more
                                   than 2 million people lost their lives due to a global pandemic. Not
                                   since the 1918 influenza pandemic has a single event so urgently
                                   demonstrated the criticality of a strong public health system. This
                                   Ready or Not report has tracked the country’s level of public health
                                   emergency preparedness since 2003. For nearly two decades, it has
                                   asked the fundamental question: “are we ready?” Unfortunately, the
                                   COVID-19 crisis has provided a clear answer: an emphatic “no.”

                                   The COVID-19 crisis has illuminated          In addition, the pandemic has once
                                   the urgent need for federal, state, local,   again demonstrated and exacerbated
                                   tribal, and territorial leaders to take      the impact of structural racism, both
                                   aggressive steps to shore up the nation’s    historic and current, on the health and
                                   preparedness for all types of emergency      well-being of communities of color and
                                   events. The pandemic put a spotlight         Tribal Nations. Acknowledging the
                                   on a public health system hollowed-          lingering health impacts of slavery and
                                   out by years of insufficient funding.        the treatment of native peoples and
                                   Health departments were overstretched,       addressing current day racist policies,
                                   responding to the pandemic with              systems, and attitudes must be part
                                   archaic technologies1 and with               of building the nation’s resilience.
                                   overworked staff who faced threats           In short, equity is not separate from
                                   and retribution.2 These gaps were            preparedness. Ensuring an equitable
                                   all the more critical in 2020 because        opportunity for the health and well-
                                   the federal government failed to take        being of all residents before a disaster
                                   an evidence based, leadership role in        creates more resilient communities
                                   the pandemic response, with many             during an emergency. Equity must be an
                                   decisions being left to states that would    explicit and foundational principle in all
                                   ordinarily be federally coordinated.         emergency planning. Achieving equity
                                   It also demonstrated the harm that           in all facets of emergency response
                                   can be done when science and public          requires including equity accountability
                                   health expertise are stifled by political    metrics in emergency preparation and
                                   interference and misinformation.             management.
MARCH 2021
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
Foundational capabilities are necessary
throughout the public health system,          “A powerful aspect of this report is its long history objectively
from the Centers for Disease Control          measuring states’ preparedness. This year’s recommendations
and Prevention (CDC) to state,
local, tribal, and territorial health         are almost identical to past years. Had the nation paid more
departments, including:3                      attention to pandemic threats and TFAH’s commonsense and
l   H
     ealth monitoring and assessment,        consistent recommendations, this country would be in a very
    comprising surveillance,
                                              different place today.”
    epidemiology, and laboratory capacity;
                                              Shelley A. Hearne, DrPH
l   A
     ll-hazards preparedness and response;
                                              Johns Hopkins University Bloomberg School of Public Health
l   P
     olicy development and support;

l   P
     ublic communications;
                                              It is also important to note that the      threats. They are not tailored to an
l   C
     ommunity outreach and partnership       infusion of COVID-19 emergency             assessment of a given state’s response to
    development;                              funding was onetime funding—critical       the COVID-19 pandemic, as widescale
                                              to the pandemic response but not           political, funding, economic, and social
l   O
     rganizational and administrative
                                              a solution to the system’s longtime        factors all influenced the virus impact
    competencies (i.e., leadership,
                                              underinvestment.                           and local responses. A state may do well
    governance, and health equity); and
                                                                                         in terms of its ranking in this report but
                                              This report is designed to give
l   A
     ccountability and performance                                                      poorly in its response to the COVID-19
                                              policymakers at all levels of government
    management.4                                                                         pandemic—and vice versa. While no
                                              actionable data and recommendations
                                                                                         state has been spared, what seems to
Today, only half of Americans are             with which they can target policies
                                                                                         have mattered most in the pandemic
protected by a comprehensive local            and spending to strengthen their
                                                                                         response is a state’s socioeconomic and
public health system.5 The Public             jurisdiction’s emergency preparedness.
                                                                                         racial profile, as well as the adherence
Health Leadership Forum estimates             The report’s 10 key public health
                                                                                         of elected leaders and residents to
a $4.5 billion annual shortfall in            preparedness indicators give state
                                                                                         evidence-based public health guidelines.
the spending necessary to meet                officials benchmarks for progress, point
                                                                                         The pandemic has illustrated that
the infrastructure needs of public            out gaps within their states all-hazards
                                                                                         robust and sustained funding, elected
health agencies nationwide.6 This             preparedness, and provide data to
                                                                                         officials’ leadership, and federal-state
shortfall was on display throughout           compare states’ performance against
                                                                                         coordination and planning are key to
the COVID-19 pandemic, as decades             like jurisdictions. These data points,
                                                                                         protecting Americans’ health security.
of chronic underfunding hindered              or ones similar to them, have been the
                                                                                         Moreover, there is no substitute at the
communications, disease surveillance,         focus of this report for over a decade
                                                                                         state or local level for a strong federal
contact tracing, vaccine delivery, and        and are meant to measure readiness
                                                                                         response.
other key health department activities.       for a broad set of health security

                                                                                                                   TFAH • tfah.org    5
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
COVID-19 AND EMERGENCY PREPAREDNESS: TRAGIC LESSONS
    TFAH’s Ready or Not: Protecting the
    Public’s Health from Diseases, Disasters
    and Bioterrorism report has tracked the
    nation’s readiness to respond to a public
    health emergency for nearly two decades.
    During that time, no event highlighted
    the critical importance of this report’s
    purpose—measuring and promoting
    readiness to safeguard Americans’ health
    during an emergency—to the degree the
    COVID-19 crisis has.

    The COVID-19 pandemic is an on-
    the-ground, real-time measure of the
    nation’s public health emergency
    response system—a test the federal
    government failed according to most
    public health experts. An October
    2020 report by Columbia University
    Earth Institute’s National Center for
    Disaster Preparedness estimated that
    the federal government’s inadequate
    pandemic response led to between
    130,000 and 210,00 avoidable
    deaths. The report submits that if
    the United States had implemented
    sufficient testing, earlier lockdowns, a    accreditation, (4) public health funding,     Importance of Federal Leadership
    national mask-wearing mandate, and          (5) access to paid time off, (6) flu          Government at multiple levels shares
    provided federal guidance on social         vaccination rates (as a proxy for a           responsibility for emergency planning
    distancing, over 200,000 lives could        community’s vaccination infrastructure        and response. Under this tiered
    have been saved.7                           and receptivity), and (7) laboratory          structure, when an event requires a
    With a possible single exception (water     surge capacity. TFAH will continue to         larger response than a local entity
    system safety), all of the readiness        measure states on these indicators, as        can provide, government from the tier
    indicators measured annually by this        they play a central role in the standing-     above it—typically a tribal, territorial
    Ready or Not report played a role in        ready, public health protection capacity      or state agency—provides assistance.
    jurisdictions’ COVID-19 response.           that every state needs.                       When a state’s response resources
    Seven were relevant to the effort to        The pandemic has also spotlighted a           are not enough to meet demands
    control the pandemic and save lives:        number of issues not currently measured       during an emergency, the federal
    (1) nurse licensure compact (allowing       by the report but critical and dramatically   government provides support. For a
    jurisdictions to borrow medical             apparent if absent during a health            public health emergency as significant
    personnel when they need to surge           emergency: federal and state political        and contagious as COVID-19, clear
    capacity), (2) hospital participation       leadership, interagency coordination,         communication and strong leadership
    in healthcare coalitions, (3) public        consistent and well-executed public           and coordination by the federal
    health and emergency management             communications, and health equity.            government are essential, elements

6   TFAH • tfah.org
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
that were lacking during the initial         Overcoming the Legacy of Racism               l   Developing a White House led strategy
months of the pandemic response.             The legacy of slavery, genocide,                  focused on addressing the root
Instead, inconsistent messages               and centuries of racism, combined                 causes of disease and on promoting
between federal agencies and the White       with current day interpersonal and                health equity.
House; lack of centralized coordination,     structural racism, is at the root of the      l   Creating a social determinants of
such as for procurement of personal          disproportionate impact COVID-19 has              health line item at the Centers for
protective equipment (PPE); and              had on communities of color and Tribal            Disease Control and Prevention
political interference with guidance from    Nations. These systemic inequities, in            (CDC), authorized and fully funded
scientific agencies—all led to confusion     access to healthcare, housing, education,         by Congress, with sufficient funding
and contradictory policies among states      transportation, and employment, existed           to guarantee grant-funded efforts
and weakened the emergency response.         before the pandemic and have been                 throughout the nation.
TFAH has made a number of policy             exacerbated by it. Health inequities due      l   Requiring all agencies to collect,
recommendations designed to ensure           to disadvantages experienced by racial,           disaggregate, and report health
robust and nonpartisan federal               ethnic, or other population groups are            data in such a way that the impact
leadership during future public health       preventable differences in the burden of          of health conditions, policies, or
emergencies, including:                      disease, injury, and health emergencies           interventions on specific population
                                             and to opportunities to achieve good              groups are known, including health
l Create   a White House Health
                                             health.8 Addressing issues at the                 status data by race, ethnicity, sexual
    Security Directorate, including senior
                                             root of health inequity is imperative to          orientation, gender identity, primary
    advisors to the president with public
                                             ensuring all people, regardless of their          language, and disability status.
    health expertise on health security
                                             race or ethnicity or where they live, have
    issues. This directorate would                                                         The tragedy of the COVID-19
                                             the opportunity for good health and are
    oversee the national biodefense                                                        pandemic, including over 500,000
                                             protected during a health emergency.
    strategy and all interagency                                                           deaths in the United States (as this
    emergency responses.                     TFAH has called on the administration         publication was being prepared) and
l   Ensure full transparency and            and Congress to make advancing                unprecedented harm to the economic
    consistency in federal messaging         health equity and eliminating health          security of millions of American
    from the White House, CDC, ASPR,         disparities a national priority by:           families, will forever be a painful
    FDA, and National Institutes of Health   l   Ensuring that all COVID-19 response      reminder of the critical importance
    (NIH) concerning public health issues        actions prioritize advancing health       of pre-event public health emergency
    to ensure message clarity, avoid             equity, including access to COVID-19      preparations, investments in public
    confusion, and build trust.                  testing and vaccinations.                 health infrastructure, and evidence-
l   Ensure that federal public health       l   Creating a Truth, Racial Healing, and    based policy and communications. The
    officials are fully empowered to make        Transformation Commission, and            pandemic has undeniably demonstrated
    decisions based on science and               provide funding to communities to begin   that historical discrimination coupled
    without undue political influence.           the process of acknowledging a history    with current-day racism impacts a
    Efforts to infuse politics into public       of racism and working to dismantle the    community’s health status and ability
    health decision-making puts the              myth of hierarchy based on race.          to weather a disaster. The COVID-19
    public’s health at risk.                                                               crisis has also painfully reinforced
                                             l   E xpanding funding for initiatives
                                                                                           that national leadership must be
l   HHS should strengthen leadership            serving communities that have been
                                                                                           grounded in science and committed
    by working with states and suppliers         marginalized by disinvestment, and
                                                                                           to addressing structural racism, both
    to ensure adequate stockpiling               ensure that federal funding supports
                                                                                           of which are imperative to saving lives
    and distribution of medical                  processes that meaningfully engage
                                                                                           during an emergency.
    countermeasures and ancillary                the most affected communities in
    emergency response products, such            the planning and implementation of
    as personnel protective equipment.           such initiatives.

                                                                                                                         TFAH • tfah.org   7
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
This edition of the Ready or Not series               other areas—such as paid time off for                 compared with last year, while eight fell
    finds that states have made progress                  workers and hospital patient safety—has               behind. Three states improved by one
    in most of the report’s measured                      stalled. In this 2021 report, Trust for               tier, six states dropped one tier, and two
    areas, especially rates of seasonal flu               America’s Health (TFAH) found that                    dropped two tiers.
    vaccination. However, improvement in                  three states improved their standing

                            TABLE 1: Top-Priority Indicators of State Public Health Preparedness
                                                                          INDICATORS
     1    Incident Management: Adoption of the Nurse Licensure Compact.          6    Water Security: Percentage of the population that used a community
                                                                                      water system that failed to meet all applicable health-based standards.

     2    Cross-Sector Community Collaboration: Percentage of hospitals          7    Workforce Resiliency and Infection Control: Percentage of employed
          participating in healthcare coalitions.                                     population that used paid time off.

     3    Institutional Quality: Accreditation by the Public Health              8    Countermeasure Utilization: Percentage of people ages 6 months or
          Accreditation Board.                                                        older who received a seasonal flu vaccination.

     4    Institutional Quality: Accreditation by the Emergency Management       9    Patient Safety: Percentage of hospitals with a top-quality ranking (“A”
          Accreditation Program.                                                      grade) on the Leapfrog Hospital Safety Grade.

     5    Institutional Quality: Size of the state public health budget          10 Health Security Surveillance: The public health laboratory has a plan
          compared with the past year.                                              for a six- to eight-week surge in testing capacity.

    Notes: The National Council of State Boards of Nursing organizes the Nurse Licensure Compact. The federal Hospital Preparedness Program of the U.S.
    Office of the Assistant Secretary for Preparedness and Response supports healthcare coalitions. The U.S. Environmental Protection Agency assesses commu-
    nity water systems. Paid time off includes sick leave, vacation time, or holidays, among other types of leave. The Leapfrog Group is an independent nonprofit
    organization. TFAH drew every indicator, and some categorical descriptions, from the National Health Security Preparedness Index, with one exception: pub-
    lic health funding. See “Appendix A: Methodology” for a description of TFAH’s funding data-collection process, including its definition.
    Source: National Health Security Preparedness Index 9

    The Ready or Not report groups states                 a greater share of its hospitals receive              that received an “A” rating—one of
    and the District of Columbia into one                 high marks on patient safety. Montana,                the highest in the nation—rose by
    of three tiers (high, middle, low) based              which elevated from the low tier to the               slightly less than the national average.
    on their performances across the 10                   middle tier, increased its public health              Other steps it could take to improve
    indicators. This year, 20 states and                  funding level in fiscal year 2020. And                its standing include joining the Nurse
    the District of Columbia scored in the                Rhode Island, which rose from the                     Licensure Compact or increasing its
    high-performance tier, 15 placed in the               middle tier to the high tier, did so by               below-average share of residents who
    middle-performance tier, and 15 were                  dramatically increasing its community                 take paid time off from work.
    in the low-performance tier (see Table                drinking-water security.
                                                                                                                Five states fell from the high tier to the
    2). (See “Appendix A: Methodology”
                                                          Two states fell from the high tier to the             middle tier: Alabama, Illinois, Iowa,
    for more information on the scoring
                                                          low tier: Missouri and Pennsylvania.                  New Jersey, and Tennessee. These
    process.)
                                                          Missouri cut its public health funding in             states did not experience significant
    Three states showed notable                           FY 2020 and saw an increase in the share              backsliding overall, but they lost ground,
    improvement, moving up a tier:                        of its residents that used a community                as a number of other states took greater
    Georgia, Montana, and Rhode Island.                   water system with one or more health-                 steps that increased their standing.
    Georgia, which rose from the middle                   based violations. Its flu vaccination
                                                                                                                One state fell from the middle tier to
    tier to the high tier, improved its                   rate ticked up marginally, but by less
                                                                                                                the low tier: Arizona. Arizona’s below-
    standing by achieving accreditation                   than the nation as a whole. Likewise,
                                                                                                                average flu vaccination rate rose, but by
    by the Emergency Management                           Pennsylvania also cut its public health
                                                                                                                less than the nation overall, so its overall
    Accreditation Program and by having                   funding level, and its share of hospitals
                                                                                                                standing fell back.

8     TFAH • tfah.org
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
TABLE 2: State Public Health Emergency Preparedness
                        State performance, by scoring tier, 2020
   Performance                                                                      Number of
                                               States
       Tier                                                                          States
                         CO, CT, DC, DE, GA, ID, KS, MA, MD, ME, MS,
      High Tier                                                                 20 states and DC
                         NC, NE, NM, OK, RI, UT, VA, VT, WA, WI

                         AL, CA, FL, IA, IL, KY, LA, MI, MN, MT, ND, NJ,
     Middle Tier                                                                     15 states
                         OR, TN, TX

                         AK, AR, AZ, HI, IN, MO, NH, NV, NY, OH, PA,
       Low Tier                                                                      15 states
                         SC, SD, WV, WY
Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S.
territories.

TFAH’s Analysis Found:                                during an emergency. What’s more,
A majority of states have made                        every state had public health laboratories
preparations to expand healthcare                     that had plans for how to manage a
and public health capabilities in an                  large influx of testing needs. States had
emergency, often through collaboration.               a plan to surge public health laboratory
Thirty-four states participated in the                capacity for six to eight weeks as necessary
Nurse Licensure Compact, up from 26                   during overlapping emergencies or large
in 2017,10 with Indiana and New Jersey                outbreaks, an increase of six states since
being the most recent adopters.11 The                 2017.
compact allows registered nurses and                  Most states are accredited in the
licensed practical or vocational nurses               areas of public health, emergency
to practice in multiple jurisdictions                 management, or both. As of December
with a single license. In an emergency,               2020, the Public Health Accreditation
this enables health officials to quickly              Board (PHAB) or the Emergency
increase their staffing levels. For example,          Management Accreditation Program
nurses may cross state lines to work at               (EMAP) accredited 42 states and the
evacuation sites or other healthcare                  District of Columbia; 29 states and the
facilities. In addition, hospitals in most            District of Columbia were accredited
states have a high degree of participation            by both groups, a net increase of
in healthcare coalitions. On average, 89              one since November 2019. (EMAP
percent of hospitals were in a coalition,             has now accredited Delaware and
and 17 states and the District of Columbia            Georgia; Maryland transitioned from
had universal participation, meaning                  being accredited by both bodies to the
every hospital in the jurisdiction was                PHAB only, with the EMAP providing
part of a coalition. Such coalitions bring            conditional accreditation.) Eight states
hospitals and other healthcare facilities             (Alaska, Hawaii, Indiana, New Hampshire,
together with emergency management                    South Dakota, Texas, West Virginia, and
and public health officials to plan for and           Wyoming) were not accredited by either
respond to incidents or events requiring              group. Both programs help ensure that
extraordinary action. This increases the              necessary emergency prevention and
likelihood that providers serve patients              response systems are in place and staffed
in a coordinated and efficient manner                 by qualified personnel.

                                                                                                     TFAH • tfah.org   9
2021 Ready or Not: PROTECTING THE PUBLIC'S HEALTH FROM DISEASES, DISASTERS, AND BIOTERRORISM
Seasonal flu vaccination rates, while still   Most residents who received their
                       too low, have risen significantly. The        household water through a community
                       seasonal flu vaccination rate among           water system had access to safe water. On
                       Americans ages 6 months or older rose         average, just 5 percent of state residents
                       from 42 percent during the 2017–2018          used a community water system in 2019
                       season to 52 percent during the 2019–         (latest available data) that did not meet
                       2020 season.12 However, Healthy People        all applicable health-based standards,
                       2030, a set of federal 10-year objectives     down slightly from 7 percent in 2018.
                       and benchmarks for improving the              Water systems with such violations
                       health of all Americans by 2030, set          increase the chances of water-based
                       a seasonal influenza vaccination-rate         emergencies in which contaminated
                       target of 70 percent annually.13              water supplies place the public at risk.

                       In 2019, only 55 percent of employed state    Based on its policy research and
                       residents, on average, used paid time off,    analysis, consultation with experts,
                       the same percentage as in 2018. Those         and review of progress and gaps in
                       without paid leave are more likely to work    federal and state preparedness—with
                       when they are sick and risk spreading         a particular focus on the preparation
                       infection. In the past, the absence of        gaps and shortfalls identified by
                       dedicated paid sick leave has been linked     the COVID-19 pandemic—TFAH is
                       to or has exacerbated some infectious         recommending policy action in seven
                       disease outbreaks.14 This became              priority areas:
                       particularly relevant during the COVID-
                                                                     1. P
                                                                         rovide stable, sufficient funding
                       19 pandemic, as isolation and quarantine
                                                                        for domestic and global public
                       were important tools for controlling the
                                                                        health security.
                       outbreak. The Families First Coronavirus
                       Response Act helped address this issue        2. Strengthen policies and systems to
                       during the early stages of the pandemic for       prevent and respond to outbreaks
                       employers with fewer than 500 employees           and pandemics.
                       and certain public employers, temporarily
                                                                     3. B
                                                                         uild resilient communities and
                       requiring employees to be paid up to 80
                                                                        promote health equity generally and
                       hours of sick leave benefits under certain
                                                                        in preparedness.
                       conditions.15 In January 2021, the Biden
                       administration economic stimulus package      4. E
                                                                         nsure effective public health
                       proposal included extending paid sick            leadership, coordination, and
                       leave to over 100 million U.S. workers.          workforce.

                       Only 31 percent of hospitals, on              5. A
                                                                         ccelerate development and
                       average, earned a top-quality patient            distribution, including last-
                       safety grade, up slightly from 30                mile distribution, of medical
                       percent in 2019. Hospital safety scores          countermeasures.
                       measure performance on such issues as
                                                                     6. S
                                                                         trengthen the healthcare system’s
                       healthcare-associated infection rates,
                                                                        ability to respond to and recovery
                       intensive-care capacity, and an overall
                                                                        from health emergencies.
                       culture of error prevention. In January
                       2021, the Biden administration’s              7. P
                                                                         repare for environmental threats
                       economic aid package included                    and extreme weather.
                       extending paid sick leave to over 100
                       million U.S. workers.

10   TFAH • tfah.org
Report Purpose and Methodology
TFAH’s annual Ready or Not report series     Foundation, the University of Kentucky,
tracks states’ readiness for public health   and the University of Colorado. (See
emergencies based on 10 key indicators       “Appendix A: Methodology” for a
that collectively provide a checklist of     detailed description of how TFAH
top-priority issues and action items for     selected and scored the indicators.)
states and localities to continuously
                                             While state placements in Ready or
address. By gathering together timely
                                             Not and the NHSPI largely align,
data on all 50 states and the District
                                             there are some important differences.
of Columbia, the report assists states
                                             The two projects have somewhat
in benchmarking their performance
                                             different purposes and are meant to be
against comparable jurisdictions.
                                             complementary, rather than duplicative.
TFAH completed this research after
                                             With more than 100 indicators, the
consultation with a diverse group of
                                             Index paints a broad picture of national
subject-matter experts and practitioners.
                                             health security, allowing users to zoom
                                             out and holistically understand the
Ready or Not and the National Health
                                             extent of both individual states’ and the
Security Preparedness Index
                                             entire nation’s preparedness for large-
The indicators included in this report       scale public health threats. In slight
were drawn from, and identified in           contrast, Ready or Not, with its focus on
partnership with, the National Health        10 select indicators, focuses attention on
Security Preparedness Index (NHSPI),16       state performances on a subset of the
with one exception: a measure of state       Index and spotlights important areas
public health funding-level trends,          for stakeholders to prioritize. TFAH
which reflects how well-resourced key        and the NHSPI work together to help
agencies are to prepare and respond          federal, state, and local officials use data
to emergencies. The NHSPI is a joint         and findings from each project to make
initiative of the Robert Wood Johnson        Americans safer and healthier.

                                                                                            TFAH • tfah.org   11
Earning Vaccine Confidence in Communities of Color

                       Interview with Claude A. Jacob, Dr.PH(c), MPH, the chief public
                       health officer at the Cambridge, Massachusetts, Public Health
                       Department, and Maria Lemus, the executive director of Visión y
                       Compromiso, about barriers—both historic and contemporary—
                       to COVID-19 vaccinations within communities of color. This
                       interview was conducted in December 2020.

                       TFAH: As this report is being finalized,    voice on COVID-19. Given this finding,
                       the United States is nearing a time when    we plan to work closely with our hospitals,
                       many Americans, particularly those          ambulatory sites, and healthcare
                       at the highest risk of infection or the     providers to help spread the message.
                       most serious impact if infected, can be
                                                                   Ms. Lemus: There are many barriers.
                       vaccinated. What are the barriers to high
                                                                   The ones I’m most concerned about are
                       rates of vaccination in communities of
                                                                   myths and misinformation, including
                       color and among Tribal nations?
                                                                   crazy social media propaganda, fear of
                       Dr. Jacob: We are fortunate in              adverse reactions, and problems with
                       Cambridge. Flu vaccine participation is     vaccine accessibility. High rates of the
                       strong and childhood vaccine compliance     uninsured among some populations
                       is also very high, which we view as rough   groups and misconceptions about who is
                       proxies for COVID-19 vaccine acceptance.    at risk are additional concerns.
                       That being said, there is a long and
                                                                   TFAH: The pace of COVID-19 vaccines
                       sordid history of abuse and mistreatment
                                                                   development has been quicker than
                       of these communities by the U.S.
                                                                   many people expected. In some
                       government and healthcare system. That
                                                                   communities this may mean that
                       many Black and Brown people continue
                                                                   the vaccine will be available before
                       to feel deep mistrust of the healthcare
                                                                   communications programs about
                       system is understandable. All of us in
                                                                   the vaccine’s safety and availability
                       healthcare and public health must
                                                                   have fully taken root. What do those
                       understand that this mistrust goes back
                                                                   responsible for vaccine distribution
                       to slavery for Black Americans and the
                                                                   need to do when distributing the vaccine
                       genocide perpetuated against indigenous
                                                                   under these circumstances?
                       people that lasted for centuries.
                                                                   Dr. Jacob: First of all, we need to
                       We have strong relationships with
                                                                   celebrate the news that, so far,
                       community organizations, leaders in the
                                                                   two vaccines have received FDA
                       faith community, and others who are well
                                                                   emergency use authorization. That
                       known and trusted among communities
                                                                   two vaccines were developed, tested,
                       of color, and we will partner with them
                                                                   and manufactured in less than 12
                       to overcome these barriers to vaccine
                                                                   months is a breathtaking achievement.
                       uptake. Recent national and state surveys
                                                                   While we can’t let down our guard on
                       have told us that Americans view their
                                                                   physical distancing, wearing masks,
                       personal physician as the most trusted

12   TFAH • tfah.org
and continuing to practice good hand
hygiene, the COVID-19 vaccine marks
a watershed moment in the pandemic.
We now see the light at the end of
the tunnel. At the same time, it’s
understandable that people have many
questions and deep concerns given how
quickly the vaccine was developed and
approved. For communities of color, the
concern over safety comes with a long-
standing, entrenched, and well-placed
mistrust of the healthcare system.

Communication will be pivotal
in educating everyone, especially
communities of color, about the safety
and importance of this vaccine. To
start, we need to have communities
of color and physicians of color at the
                                             TFAH: A woeful history of mistreatment    speak to these injustices; they must
decision-making table to inform and
                                             of people of color by government and      denounce them and support remedies.
ensure a vaccine rollout that is equitable
                                             the healthcare system is at the root of   They need to give real-time examples
for all members of our community.
                                             much of the lack of trust in the COVID-   of the efforts being made to engage
Messaging around the vaccine also
                                             19 vaccine within those communities       with and empower communities and
needs to be informed by, and tested
                                             but there are other barriers to vaccine   to correct past wrongs. Only then will
with, communities of color to make
                                             access. What are they and how can they    government be able to be heard and
sure that these communication efforts
                                             be overcome?                              only by using trusted messengers and
resonate. We have a superb opportunity
                                                                                       community navigators.
to work with those on the front line         Ms. Lemus: The understandable
of this pandemic, especially doctors,        distrust of government is going to        It’s also important to remember that
nurses, and physicians’ assistants,          be a huge barrier to the vaccine. A       the reasons for distrust of government
to help amplify the message in core          specific example for my community is      within underrepresented communities
communities. By all accounts, frontline      the Bracero Program, which between        is not only about historical legacies;
medical workers are the most trusted         1942 and 1964, based on a series of       it is based on current-day events and
source of health information and they        bilateral agreements between the U.S.     climates. However, it can be corrected.
are the first to be vaccinated, starting     and Mexican governments, brought          My organization, Visión y Compromiso,
this past December. We should use their      nearly 4.6 million Mexican citizens       has as its mission providing leadership-
voices of trust and reason to speak to       to work on U.S. farms, railroads, and     development and capacity-building
communities of color about the safety        factories. Those workers experienced      opportunities for promotores and
and critical importance of getting this      racial and wage discrimination and were   community health workers in over
vaccine.                                     forced to live and work in substandard    4,000 communities. These community-
                                             conditions. More recently, there          based promotores will have a critical role
 Ms. Lemus: It will be imperative to
                                             have been allegations of unnecessary      to play in reducing vaccine hesitancy
share data about the vaccine without
                                             hysterectomies being performed in ICE     in communities of color. Messaging to
jargon and to have trusted messengers
                                             detention centers.                        convince people to be vaccinated has to
deliver the information. I heard a quote
                                                                                       feature their heroes, their community
recently in response to the question,        The only way to overcome these
                                                                                       leaders, their voices.
“Do you know what’s in Tylenol?”: “No,       histories will be to first acknowledge
but I trust it will help me.”                them. Leaders must acknowledge and

                                                                                                                 TFAH • tfah.org    13
Dr. Jacob: Communities of color have         TFAH: What is the importance of where          uptake in your community? What
     historically had difficulty accessing        the COVID-19 vaccine is available in           resources do you need to be successful?
     healthcare. Lack of transportation,          your community?
                                                                                                 Dr. Jacob: Local public health has
     work schedules, childcare needs, and
                                                  Ms. Lemus: Where the vaccine will be           an important role and responsibility
     competing financial interests—such as
                                                  available is another critical issue. The       in educating communities about the
     paying rent and bills—pose significant
                                                  credibility, location, hours, accessibility,   safety and importance of the COVID-19
     barriers to healthcare, as do other social
                                                  relationship to community, their               vaccine, as it does with all vaccinations.
     determinants of health, such as poverty
                                                  staff, and emissaries are important to         Once the vaccine is made available
     and lack of education. Even with the
                                                  individual and families’ decision to be        to the general public, the Cambridge
     Affordable Care Act—which greatly
                                                  vaccinated. Promotores are important           Public Health Department, through its
     expanded access to health insurance
                                                  also in gathering information to               partnership with city agencies and the
     for everyone—Hispanic, Black, and
                                                  contribute to the vaccine distribution         private sector, will be ready to provide
     some Asian communities have lower
                                                  and administration, planning                   vaccines to residents. Throughout the
     insurance coverage rates than any other
                                                  implementation, and communications.            pandemic, our department has worked
     population. Many of them remain
                                                  Community-based organizations                  hand in hand with city partners, especially
     uninsured altogether.
                                                  must be included in all planning and           first-responders, to provide testing and
     The cost of the vaccine is being covered     execution; they are a big part of the          flu shots, and we will rely on this strong,
     by the federal government through            solution. Partnering with community-           successful relationship to provide the
     tax dollars, but providers can charge        based organizations allows local officials     COVID vaccine. It is critically important
     to administer the vaccine, if they           to scale means and resources.                  to note that we could not do our work
     choose. We need to do everything                                                            without strong financial support. Our city
                                                  Dr. Jacob: As I have already
     we can and work with providers to                                                           manager, Louis A. DePasquale, and the
                                                  mentioned, the Cambridge Public
     eliminate fees they may charge in the                                                       Cambridge City Council have provided
                                                  Health Department has had enormous
     interest of overcoming this public                                                          financial resources to fight this pandemic
                                                  success with COVID-19 testing and flu
     health emergency. When it is available,                                                     and keep our residents and those who
                                                  vaccinations by bringing these services
     we need to bring the vaccine to the                                                         work in Cambridge safe. They have long
                                                  to people in the communities where
     public rather than making people                                                            been committed to the important work
                                                  they live and work. We have taken
     come to the vaccine. In Cambridge,                                                          of the public health department, which
                                                  a traditional grassroots approach—
     the public health department, through                                                       is enhanced by the Cambridge Health
                                                  going door to door in harder-hit
     its partnership with the city’s first-                                                      Alliance led by Dr. Assaad Sayah, who is
                                                  neighborhoods and providing
     responders and others, have made                                                            the commissioner of public health for the
                                                  information in eight languages—to build
     free COVID-19 testing available to all                                                      city of Cambridge.
                                                  trust and understanding. We need to
     residents (regardless of symptoms)                                                          Dr. Claude A. Jacob is the chief public health
                                                  use this same approach with the COVID-
     since July 2020. Starting in November                                                       officer for the City of Cambridge, Massachusetts.
                                                  19 vaccine and build on these robust           He served as the president of the National
     2020, this “no-barrier,” city-funded
                                                  community linkages, which are anchored         Association of City and County Health Officials in
     testing program expanded to seven
                                                  to the long-standing relationships that we     2016–2017.
     days a week (from two days/week) and
                                                  have with partners on the ground.              Maria Lemus is the executive director of Visión
     from two neighborhood sites to four.
                                                                                                 y Compromiso, headquartered in San Francisco,
     These testing sites are geographically       TFAH: As the chief public health               California. Visión y Compromiso provides
     dispersed, and all but one are located in    officer for the city of Cambridge,             leadership, advocacy, and capacity-development
     neighborhoods with disproportionately        Massachusetts, what is your                    training to community health workers.

     high rates of new COVID-19 infections.       department’s role in increasing vaccine

14     TFAH • tfah.org
SECTI O N 1:

Assessing State Preparedness                                                                         Ready or Not

                                                                                                                                  SECTION 1: ASSESSING STATE PREPAREDNESS
Every state needs to be prepared to respond to a variety of                                             2021
potential public health emergencies; such readiness requires
understanding an individual state’s preparedness strengths, risks,
and vulnerabilities. To help states assess their readiness, and to
highlight a checklist of top-priority concerns and action areas,
this report examines a set of 10 select indicators. The indicators,
used consistently year to year, draw heavily from the National
Health Security Preparedness Index (NHSPI), a joint initiative
of the Robert Wood Johnson Foundation, the University of
Kentucky, and the University of Colorado. They capture core
elements of emergency preparedness.

Based on states’ standing across the 10 indicators (see “Appendix
A: Methodology” for scoring details), TFAH placed states into
three performance tiers: high, middle, and low. (See Table 3.)

        TABLE 3: State Public Health Emergency Preparedness
                        State performance, by scoring tier, 2020
   Performance                                                                      Number of
                                               States
       Tier                                                                          States
                         CO, CT, DC, DE, GA, ID, KS, MA, MD, ME, MS,
      High Tier                                                                 20 states and DC
                         NC, NE, NM, OK, RI, UT, VA, VT, WA, WI

                         AL, CA, FL, IA, IL, KY, LA, MI, MN, MT, ND, NJ,
     Middle Tier                                                                     15 states
                         OR, TN, TX

                         AK, AR, AZ, HI, IN, MO, NH, NV, NY, OH, PA,
       Low Tier                                                                      15 states
                         SC, SD, WV, WY
Note: See “Appendix A: Methodology” for scoring details. Complete data were not available for U.S.
territories.

Importantly, the implications of                      and administrators. Moreover, some
this assessment, and responsibility                   indicators are under the direct control
for continuously improving, extend                    of federal and state lawmakers, whereas
beyond any one state or local agency.                 improvement in other indicators
Such improvement typically requires                   requires multisector, statewide efforts,
                                                                                                                                  MARCH 2021

sustained engagement and coordination                 including by residents.
by a broad range of policymakers

                                                                                                                TFAH • tfah.org   15
INDICATOR 1: ADOPTION      Workforce shortages can impair a state’s   in nurses from other member states,
                                ability to effectively manage disasters    without harmful delays, or to send
     OF NURSE LICENSURE
                                or disease outbreaks, potentially          nurses to other member states that
     COMPACT                    resulting in poorer health outcomes for    were experiencing acute shortages. For
                                those affected. This reality was starkly   example, New Jersey, which experienced
     KEY FINDING: 34 states     illuminated by the COVID-19 pandemic       one of the most severe outbreaks in
                                as healthcare capacity in some parts of    spring 2020, began implementing the
     participate in the Nurse   the country was overwhelmed by the         NLC, immediately qualifying out-of-
     Licensure Compact.         number of people needing care. In          state nurses with a multistate license
                                an event like a pandemic, the ability      to practice.17 “I think the COVID-19
                                to quickly surge qualified medical         outbreak is going to cause the states
                                personnel by bringing healthcare           that are not in the compact now to
                                workers from out of state is a key         really take a second look at it,” says NLC
                                component of healthcare readiness.         Director Jim Puente. “If the NLC was
                                                                           expanded to all 50 states, none of the
                                This indicator examines whether states
                                                                           guesswork with emergency orders would
                                have adopted legislation to participate
                                                                           be necessary because nurses could travel
                                in the Nurse Licensure Compact
                                                                           to other states where they are needed.
                                (NLC). Launched in 2000 by the
                                                                           No applications, fees, or background
                                National Council of State Boards of
                                                                           checks would be necessary.”
                                Nursing, the NLC permits registered
                                nurses and licensed practical nurses       As of December 2020, 34 states had
                                to practice with a single multistate       adopted the NLC, with Indiana and New
                                license—physically or remotely—in any      Jersey being the most recent adopters.18
                                state that has joined the compact. The     This was a net increase of two since 2019
                                NLC provides standing reciprocity, with    and eight since 2017. Toni Herron, the
                                no requirement that an emergency be        education compliance officer of the
                                formally declared.                         Indiana State Board of Nursing, which
                                                                           joined the compact on July 1, 2020,
                                Throughout much of 2020, the COVID-
                                                                           said that the NLC “presents innovative
                                19 pandemic placed extraordinary
                                                                           ways for our Indiana nurses to improve
                                pressure on hospitals across the country
                                                                           both access to care for patients, while
                                as surging infections sent admissions
                                                                           simultaneously reducing the regulatory
                                soaring. States that were members of
                                                                           burden on licensees.” 19
                                the NLC were well positioned to bring

16    TFAH • tfah.org
TABLE 4: 34 States Participate in the Nurse Licensure Compact
                         Participants and nonparticipants, 2020
                      Participants                                      Nonparticipants
Alabama              Louisiana            North Dakota     Alaska                 Nevada
Arizona              Maine                Oklahoma         California             New York
Arkansas             Maryland             South Carolina   Connecticut            Ohio
Colorado             Mississippi          South Dakota     District of Columbia   Oregon
Delaware             Missouri             Tennessee        Hawaii                 Pennsylvania
Florida              Montana              Texas            Illinois               Rhode Island
Georgia              Nebraska             Utah             Massachusetts          Vermont
Idaho                New Hampshire        Virginia         Michigan               Washington
Indiana              New Jersey           West Virginia    Minnesota
Iowa                 New Mexico           Wisconsin
Kansas               North Carolina       Wyoming
Kentucky
Note: Indiana and New Jersey joined the NLC in 2020.
Source: National Council of State Boards of Nursing.20

                                                                                                 TFAH • tfah.org   17
INDICATOR 2: HOSPITAL           The federal Hospital Preparedness          information about available beds and
                                     Program (HPP), which is managed            ICU capacity, and training healthcare
     PARTICIPATION IN                by the HHS Office of the Assistant         workers on PPE use, treatments,
     HEALTHCARE COALITIONS           Secretary for Preparedness and             and testing guidelines.25 During a
                                     Response, provides cooperative             pandemic, coordination across a region
                                     agreements to states, localities,          is essential to alleviate pressure on any
     KEY FINDING: Widespread
                                     and territories to develop regional        single facility, to promote cooperation
     hospital participation in       coalitions of healthcare organizations     and information sharing for supplies
     healthcare coalitions was       that collaborate to prepare for, and       and bed availability, and to facilitate
                                     in many cases respond to, medical          training of healthcare personnel.26
     common in 2017*; only           surge events.21 Coalitions prepare         The extent to which healthcare systems
     four states (California, New    members with critical tools, including     leveraged the resources of their
                                     medical equipment and supplies,            coalitions during the pandemic is a
     Hampshire, Ohio, and South
                                     real-time information, enhanced            subject that requires further research.
     Carolina) reported 70 percent   communication systems, and exercises
                                                                                On average, 89 percent of hospitals
                                     and training for healthcare personnel.22
     or less of their hospitals                                                 in states belonged to a healthcare
                                     A healthcare coalition must contain a
     participated in coalitions                                                 coalition in 2017, with universal
                                     minimum of two acute-care hospitals,
                                                                                participation, meaning every hospital
     supported by the HHS Hospital   emergency medical services, emergency
                                                                                in the state was part of a coalition, in 17
                                     management, and public health
     Preparedness Program.                                                      states (Alaska, Colorado, Connecticut,
                                     agencies.23 Healthcare coalitions
                                                                                Delaware, Hawaii, Louisiana,
                                     invest in local capacity to prepare
                                                                                Minnesota, Mississippi, Nevada, North
                                     for and respond to events, reducing
                                                                                Dakota, Oregon, Rhode Island, South
                                     jurisdictions’ reliance on federal
                                                                                Dakota, Utah, Vermont, Virginia,
                                     medical assets during disasters.
                                                                                and Washington) and the District of
                                     Broad and meaningful participation by      Columbia. (See Table 5.) However,
                                     hospitals in healthcare coalitions means   some states, such as Ohio (25 percent)
                                     that when disaster strikes, systems are    and New Hampshire (47 percent)
                                     in place to coordinate the response,       lagged behind.
                                     freeing hospitals to focus on clinical
                                                                                The pandemic exposed major gaps in
                                     care. In the past, healthcare coalitions
                                                                                healthcare preparedness, mentioned
                                     have assisted in patient transfer,
                                                                                in TFAH’s 2020 report, including
                                     evacuations, and information sharing
                                                                                coordinating surge capacity across
                                     in events such as Hurricane Harvey
                                                                                the healthcare system;27 building and
                                     in 2017.24 More recently, the COVID-
                                                                                maintaining preparedness for high-
                                     19 pandemic presented the most
                                                                                consequence infectious diseases;28
                                     intense, widespread, and prolonged
                                                                                preparedness of facilities that serve
                                     test of U.S. hospital systems in a
                                                                                people at higher risk, such as long-term
                                     century, threatening at several points
                                                                                care facilities; and lack of training and
                                     to overwhelm facilities’ capacities.
                                                                                preparedness for events in healthcare.29
                                     Healthcare coalitions performed
                                                                                Experts have also identified additional
                                     roles such as facilitating the transport
                                                                                gaps, such as pediatric surge capacity,30
                                     of equipment and supplies, sharing
                                                                                burn capacity and other specialty

18    TFAH • tfah.org
care needed for emerging threats,                     *This summary reflects the latest available
and ongoing stress on the healthcare                  data (2017). Because these data are no
system’s ability to provide emergency                 longer being updated, TFAH will consider
care. While healthcare coalitions                     replacing this measure in future assessments.
can help address some of these
vulnerabilities, systemwide approaches
to preparedness are needed.

            TABLE 5: Widespread Participation of Hospitals in
                        Healthcare Coalitions
          Percent of hospitals participating in healthcare coalitions, 2017
 States                                                Percent of Participating Hospitals
 AK, CO, CT, DC, DE, HI, LA, MN, MS, NV, ND,
                                                                          100%
 OR, RI, SD, UT, VT, VA, WA
 ID, WI                                                                    98%
 GA, WV                                                                    97%
 KS                                                                        96%
 AL, NE, NC, OK                                                            95%
 ME                                                                        94%
 KY                                                                        93%
 WY                                                                        92%
 TN                                                                        91%
 MI                                                                        90%
 MD                                                                        89%
 IL                                                                        88%
 MO                                                                        87%
 NY, PA                                                                    86%
 MT                                                                        83%
 MA, NJ                                                                    82%
 AR                                                                        81%
 IA, TX                                                                    80%
 IN                                                                        75%
 FL                                                                        73%
 AZ                                                                        72%
 NM                                                                        71%
 CA                                                                        70%
 SC                                                                        56%
 NH                                                                        47%
 OH                                                                        25%
Note: This indicator measures participation by hospitals in healthcare coalitions supported through the
federal Hospital Preparedness Program of the Office of the Assistant Secretary for Preparedness and
Response. The latest available data is from 2017.
Source: NHSPI analysis of data from the Office of the Assistant Secretary for Preparedness and
Response, U.S. Department of Health and Human Services.31

                                                                                                          TFAH • tfah.org   19
INDICATORS 3 AND 4:            The Public Health Accreditation Board      threats. The priority capabilities that
                                    (PHAB), a nonprofit organization that      the PHAB and the EMAP test include
     ACCREDITATION                  administers the national public health     identification, investigation, and
                                    accreditation program, advances quality    mitigation of health hazards; a robust
     KEY FINDING: Most states are   within public health departments by        and competent workforce; incident,
                                    providing a framework and a set of         resource, and logistics management;
     accredited by one or both of
                                    evidence-based standards against which     and communications and community-
     two well-regarded bodies—the   they can measure their performance.        engagement plans.35,36 States sometimes
                                    Among standards with direct relevance      aim to meet applicable standards but do
     Public Health Accreditation
                                    to emergency preparedness are              not pursue accreditation.
     Board and the Emergency        assurances of laboratory, epidemiologic,
                                                                               As of December 2020, 29 states and the
     Management Accreditation       and environmental expertise to
                                                                               District of Columbia were accredited
                                    investigate and contain serious
     Program—but eight are not                                                 by both the PHAB and the EMAP—a
                                    public health problems, policies, and
                                                                               net increase of one (Delaware and
     accredited by either.          procedures for urgent communications
                                                                               Georgia are now accredited by the
                                    and maintenance of an all-hazards
                                                                               EMAP; Maryland transitioned from
                                    emergency operations plan.32 Through
                                                                               being accredited by both bodies to the
                                    the process of accreditation, health
                                                                               PHAB only, with the EMAP providing
                                    departments identify their strengths
                                                                               conditional accreditation) since
                                    and weaknesses, increase their
                                                                               November 2019. Nevada is once again
                                    accountability and transparency, and
                                                                               accredited by the EMAP, alongside an
                                    improve their management processes,
                                                                               additional 12 states that have received
                                    which all promote continuous quality
                                                                               accreditation from one or the other.
                                    improvement.33
                                                                               (See Table 6.) “Over the last eighteen
                                    Emergency management, as defined           months we have worked diligently
                                    by the Emergency Management                to review our processes, plans, and
                                    Accreditation Program (EMAP),              relationships,” said the director of
                                    encompasses all organizations in a         Delaware’s Emergency Management
                                    given jurisdiction with emergency or       Agency, A.J. Schall. “Over that time,
                                    disaster functions, which may include      we learned a tremendous amount and
                                    prevention, mitigation, preparedness,      modernized procedures.”37
                                    response, and recovery. The EMAP
                                                                               Just eight states (Alaska, Hawaii,
                                    helps applicants ensure—through
                                                                               Indiana, New Hampshire, South Dakota,
                                    self-assessment, documentation, and
                                                                               Texas, West Virginia, and Wyoming)
                                    peer review—that they meet national
                                                                               received no accreditation from either
                                    standards for emergency response
                                                                               body. A state without an accreditation
                                    capabilities.34
                                                                               has not necessarily been denied
                                    The PHAB and the EMAP each provide         accreditation; the state may not have
                                    important mechanisms for improving         pursued accreditation. This analysis
                                    evaluation and accountability.             includes state-level accreditations
                                    Accreditation by these entities            only, it does not include accredited
                                    demonstrates that a state’s public         local or tribal health departments. In
                                    health and emergency management            some instances, local public health
                                    systems are capable of effectively         departments have an accreditation in
                                    responding to a range of health            states that do not.

20    TFAH • tfah.org
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