Ready or Not 2024: Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism

As the nation experiences an increasing number of infectious disease outbreaks and extreme weather events, TFAH’s Ready or Not 2024: Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism report identifies key gaps in national and state preparedness to protect residents’ health during emergencies and makes recommendations to strengthen the nation’s public health system and improve emergency readiness.

(Washington, DC – March 14, 2024) – The 2024 report, it’s 21st annual edition, found that while emergency preparedness has improved in some areas, policymakers not heeding the lessons of past emergencies, funding cuts, and health misinformation are putting decades of progress in public health preparedness at risk.

The report measures states’ preparedness to respond to a spectrum of health emergencies and to provide ongoing public health services based on nine key indicators and gives federal and state policymakers actionable data to improve emergency readiness. Based on the nine indicators, the report tiers states and the District of Columbia into three readiness levels: high, middle, and low. This year’s report placed 21 states and DC in the high-performance tier, 13 states in the middle-performance tier, and 16 states in the low-performance tier.


Performance Tier States Number of States
High Tier AL, AZ, CO, CT, DC, FL, GA, KS, MA, ME, MS, NC, NE, NJ, OH, PA, RI, SC, TN, VA, VT, WA  21 states and DC
Middle Tier AR, DE, IA, ID, IL, MD, MO, MT, NH, NM, OK, UT, WI  13 states
Low Tier AK, CA, HI, IN, KY, LA, MI, MN, ND, NV, NY, OR, SD, TX, WV, WY  16 states

The report’s findings showed both areas of strength in the nation’s health emergency preparedness and areas that need attention.


Areas of strong performance include:

  • A majority of states have made preparations to expand healthcare and public health laboratory capacity in an emergency. As of the end of 2023, 39 states participate in the Nurse Licensure Compact, which helps facilitate emergency response efforts by allowing nurses to work in multiple member states, both in person and via telehealth, without the need for additional state licenses.
  • The District of Columbia and 46 states have written plans for the expansion of public health laboratory services during health emergencies.
  • Most states (43) and the District of Columbia are accredited in the areas of public health or emergency management, or both.
  • A majority of states (at least 37) and the District of Columbia either maintained or increased their public health funding during FY 2023. Such funding is particularly important because most federal funding in response to the COVID-19 pandemic was one-time funding.


Areas that need attention include:

  • Too few people are vaccinated against seasonal flu. During the 2022-2023 flu season, only 49 percent of the population (ages 6 months and older) was vaccinated against the flu, well short of the 70 percent goal established by Healthy People 2030.
  • On average, only 25 percent of acute care hospitals in states earned a top-quality patient safety grade in a fall 2023 assessment. Hospital safety scores measure performance on issues such as healthcare-associated infection rates, intensive-care capacity, and an overall culture of error prevention – all critical for performing at their best during health emergencies.
  • On average, only 55 percent of U.S. workers used paid time off during the period from March 2018 to March 2023. Access to paid time off is an important readiness measure because workers who go to work sick risk spreading infections in the workforce and throughout the community.

In addition, the report’s special feature discusses the increasing health risks from extreme heat, including for some population groups: people who live in under-resourced communities, people living in urban heat islands or without air conditioning, people who work outdoors, people with chronic diseases, pregnant individuals, infants, children, and older adults. In 2022, more people died in the U.S. due to extreme heat than from any other single type of weather event.

Policy action is needed.

The report includes policy recommendations for action by the administration, Congress, and states including:

  • Increase funding in order to modernize public health data collection and to grow the size and diversity of the public health workforce. The report recommends that Congress allocate $4.5 billion annually to foundational public health capacities.
  • Build healthy, disaster resilient communities by investing in comprehensive public health, prevention, and health equity programs.
  • Strengthen public health communications and efforts to counter misinformation.
  • Ensure paid leave for all employees.
  • Support healthcare system readiness and the medical countermeasures pipeline.
  • Prepare for extreme weather and environmental hazards.


Read the report