Ready or Not 2020: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism

Ready or Not provides an annual assessment of states’ level of readiness to respond to public health emergencies and recommends policy actions to ensure that everyone’s health is protected during such events. This 2020 edition reports overall preparedness improvement but also identifies areas that need attention.


Rhea Farberman 202-864-5941 [email protected]
Joy Burk 202-216-8898 [email protected]

Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism is an annual report measuring states’ level of preparedness to protect the public’s health during an emergency. Based on 10 performance indicators and by tracking public health funding, the report ranks states’ level of preparedness into three performance tiers: high, middle and low.

This 2020 edition placed 25 states and the District of Columbia in the high preparedness performance tier, up from 17 last year. Twelve states, down from 20 states and the District of Columbia last year, placed in the middle performance tier and 13 states placed in the low tier, the same number as last year.

 Performance Tier States Number of States
High Tier AL, CO, CT, DC, DE, IA, ID, IL, KS, MA, MD, ME, MO, MS, NC, NE, NJ, NM, OK, PA, TN, UT, VA, VT, WA, WI 25 states and DC
Middle Tier AZ, CA, FL, GA, KY, LA, MI, MN, ND, OR, RI, TX 12 states
Low Tier
AK, AR, HI, IN, MT, NH, NV, NY, OH, SC, SD, WV, WY 13 states


The report measures states’ performance using 10 indicators that, taken together, provide a checklist of a jurisdiction’s level of preparedness to prevent and respond to threats to its residents’ health during an emergency. The indicators are:

Preparedness Indicators 
1 Incident Management: Adoption of the Nurse Licensure Compact. 6 Water Security: Percentage of the population who used a community water system that failed to meet all applicable health-based standards.
2 Cross-Sector Community Collaboration: Percentage of hospitals participating in healthcare coalitions. 7 Workforce Resiliency and Infection Control: Percentage of employed population with paid time off.
3 Institutional Quality:Accreditation by the Public Health Accreditation Board. 8 Countermeasure Utilization: Percentage of people ages 6 months or older who received a seasonal flu vaccination.
4 Institutional Quality: Accreditation by the Emergency Management Accreditation Program. 9 Patient Safety: Percentage of hospitals with a top-quality ranking (“A” grade) on the Leapfrog Hospital Safety Grade.
5 Institutional Quality: Size of the state public health budget, compared with the past year. 10 Health Security Surveillance: The public health laboratory has a plan for a six- to eight-week surge in testing capacity.


Overall the report found that states’ level of preparedness has improved in key areas, including public health funding, participation in healthcare coalitions and compacts, hospital safety, and seasonal flu vaccination.  However, other key health security measures, including ensuring a safe water supply and access to paid time off, stalled or lost ground.

The increasing number of threats to Americans’ health in 2019, from floods to wildfires to vaping, demonstrate the critical importance of a robust public health system. Being prepared is often the difference between harm or no harm during health emergencies and requires four things: planning, dedicated funding, interagency and jurisdictional cooperation, and a skilled public health workforce.”
John Auerbach, President and CEO of Trust for America’s Health.

TFAH’s analysis found that:

  • A majority of states have plans in place to expand healthcare capacity in an emergency through programs such as the Nurse Licensure Compact or other healthcare coalitions. Thirty-two states participated in the Nurse Licensure Compact, which allows licensed nurses to practice in multiple jurisdictions during an emergency.  Furthermore, 89 percent of hospitals nationally participated in a healthcare coalition, and 17 states and the District of Columbia have universal participation, meaning every hospital in the state (+ DC) participated in a coalition.  In addition, 48 states and DC had a plan to surge public health laboratory capacity during an emergency.
  • Most states are accredited in the areas of public health, emergency management, or both. Such accreditation helps ensure that necessary emergency prevention and response systems are in place and staffed by qualified personnel.
  • Most people who got their household water through a community water system had access to safe water. Based on 2018 data, on average, just 7 percent of state residents got their household water from a community water system that did not meet applicable health standards, up slightly from 6 percent in 2017.
  • Seasonal flu vaccination rates improved but are still too low. The seasonal flu vaccination rate among Americans ages 6 months and older rose from 42 percent during the 2017-2018 flu season to 49 percent during the 2018-2019 season, but vaccination rates are still well below the 70 percent target established by Healthy People 2020.
  • In 2019, only 55 percent of employed people had access to paid time off, the same percentage as in 2018. The absence of paid time off has been shown to exacerbate some infectious disease outbreaks. It can also prevent people from getting preventive care.
  • Only 30 percent of hospitals, on average, earned top patient safety grades, up slightly from 28 percent in 2018. Hospital safety scores measure performance on such issues as healthcare associated infection rates, intensive-care capacity and an overall culture of error prevention. Such measures are critical to patient safety during infectious disease outbreaks and are also a measure of a hospital’s ability to perform well during an emergency.

Based on TFAH’s policy research and consultation with topic experts, the report includes recommendations for policy actions that the federal government, states and the healthcare sector should take to improve the nation’s ability to protect the public’s health during emergencies and targets seven priority areas:

  • Provide stable and sufficient funding for domestic and global public health security.
  • Prevent outbreaks and pandemics.
  • Build resilient communities and promote health equity in preparedness.
  • Support the public health workforce and ensure effective leadership and coordination.
  • Accelerate development and distribution, including last mile distribution, of medical countermeasures.
  • Ready the healthcare system to respond and recover.
  • Prepare for environmental threats and extreme weather.

Read the full report