Preparedness is usually reported as a federal budget line, which makes it easy to ignore. It arrives in your life as something narrower: whether the emergency department near you can absorb a surge, whether the state lab can run enough tests in a week, and whether your child's school district has a workable plan.
Trust for America's Health scored all 50 states and the District of Columbia against 10 readiness indicators in its latest Ready or Not report, placing 20 states in a high-performance tier, 17 states and DC in a middle tier, and 13 states in a low tier. The indicators include healthcare workforce mobility through the Nurse Licensure Compact, public health department accreditation, state public health funding, community water system safety, access to paid sick leave, flu vaccination rates, patient safety in hospitals, and avoidable mortality.
None of this indicates an imminent threat. Preparedness planning is about response capacity, and a scorecard describes readiness, not a warning. What it does tell you is which parts of the system in your state would be doing the work.
The Hospital Layer
Surge capacity is the term for a hospital's ability to expand beyond normal operations, and researchers generally break it into four components: staff, stuff, space, and systems.
Staff is usually the binding constraint. Beds without nurses are not capacity. During major emergencies, states have relaxed licensing to allow out-of-state or retired clinicians to practice, which is why the report tracks workforce mobility. Stuff covers stockpiles, ventilators, and protective equipment. Space involves converting non-clinical areas and discharging safely. Systems means the protocols and interagency coordination that make the other three usable.
The report also treats patient safety performance as a preparedness measure, on the reasoning that hospitals maintaining care quality in normal conditions are better positioned to hold it during a surge. Among its recommendations is bolstering healthcare system readiness through cross-state credentialing and investment in healthcare readiness programs.
For patients, the practical translation is emergency department wait times, whether elective procedures get postponed, and whether a hospital can accept transfers from smaller facilities. Rural hospitals with thin margins and no intensive care beds are the first to run out of options, and they are also the ones that have been closing.
The Laboratory and Pharmacy Layers
Public health laboratory surge planning is one of the indicators, and it determines how quickly a new pathogen gets characterized and how many people can be tested in the early weeks of an outbreak, which is precisely when testing changes the trajectory.
The context the report describes is a demanding one. During 2025, the country faced the most severe influenza season in nearly a decade, the highest annual measles case count since 1991, continued H5N1 avian influenza cases, and wildfires, hurricanes, and extreme heat, all while federal public health funding, staffing, and operational support were destabilized. TFAH president and chief executive J. Nadine Gracia framed the conclusion plainly at a briefing on the findings: As a nation, we remain less prepared for public health emergencies than we need to be. The full report was released in May, drawing on data from 2024 and 2025.
Pharmacies function as the distribution endpoint for the medical countermeasure system. Antivirals, vaccines, and treatments flow from federal stockpiles through state allocation to retail and hospital pharmacies. Whether pharmacists can administer vaccines, and to which age groups, is set by state scope-of-practice law and changed substantially during COVID-19 through federal PREP Act declarations that preempted some state restrictions.
That authority is not permanent. Where it lapses, the practical effect is fewer places a person can get vaccinated quickly, which matters most for people without a primary care clinician.
The School District Layer
Schools sit at the intersection of exposure and economics. They are where respiratory viruses circulate efficiently, and closing them removes parents from the workforce, including healthcare workers.
District planning covers ventilation, illness reporting to the health department, exclusion policies for sick students, immunization records, and feeding children who depend on school meals if buildings close. School nurses are the operational layer, and many districts share one nurse across buildings.
Paid sick leave access is a preparedness indicator for the same reason. When workers cannot afford to stay home, transmission continues in workplaces and schools regardless of what any plan says.
The Federal Layer That Funds All of It
The Pandemic and All-Hazards Preparedness Act authorizes the programs underpinning most of this, including medical countermeasure development, the Strategic National Stockpile, and the National Disaster Medical System. Its authorization lapsed in 2023 and has not been renewed.
The report's recommendations follow from the same diagnosis, and TFAH states them as policy positions: provide stable, flexible, and sufficient funding for preparedness, workforce, and data modernization; restore federal public health workforce capacity; and expand readiness for extreme weather and environmental health threats. The organization's announcement of the findings warns that national preparedness depends on stable federal systems as well as state capacity.
Two caveats belong with the rankings. Trust for America's Health is an advocacy organization, and its recommendations are policy positions; the underlying indicator data are drawn from federal and state sources, but the tier placements reflect the organization's chosen weighting. And a top-tier ranking is not a finish line. Jennifer Nuzzo, who directs the Pandemic Center at Brown University School of Public Health, told a discussion of the report that being in the top tier does not mean a state has everything covered, as Maryland Matters reported.
What This Means for Your Household
Nothing here requires action today, and treating a preparedness scorecard as an emergency alert would be the wrong reading. Coverage of the report has emphasized the wide variation between states rather than any single threat.
What is worth doing is knowing where you would go. Identify your county or city health department and whether it issues alerts you can subscribe to. Know which hospital serves you and whether it has an emergency department, since many rural facilities no longer do.
Keep routine vaccinations current for everyone in your household. Vaccination is the part of preparedness individuals control.
If you take a daily medication for a chronic condition, ask your pharmacist about the refill timing that keeps you from running out during a disruption, and whether your plan permits an extended supply. Keep a written list of your medications, doses, and allergies somewhere you can reach without your phone.
If you have a child with a medical condition, confirm that the school has current care plans, medication authorizations, and emergency contacts on file. Ask who covers when the nurse is at another building.
For people who depend on electricity for medical equipment, ask your utility about a medical priority registration.
Frequently Asked Questions
What does the report measure? Ten indicators of state readiness, including healthcare workforce mobility, public health funding, laboratory surge planning, paid sick leave access, hospital patient safety, and water system safety.
Does a low score mean my state is unsafe? No. The tiers describe response capacity, not current risk, and the report does not indicate an imminent threat.
What is surge capacity? A hospital's ability to expand beyond normal operations, generally described in terms of staff, supplies, space, and systems. Staffing is usually the limiting factor.
Why do pharmacies matter in preparedness? They are the distribution endpoint for vaccines and antivirals. What pharmacists may administer depends on state scope-of-practice law and any federal emergency authorities in effect.
What is PAHPA? The Pandemic and All-Hazards Preparedness Act, which authorizes federal preparedness programs including the Strategic National Stockpile. Its authorization lapsed in 2023.
Is the report independent? Trust for America's Health is an advocacy organization. Its indicator data come from federal and state sources, but the rankings reflect its own weighting and its recommendations are policy positions.
What can I do at home? Keep vaccinations current, know your local health department and nearest emergency department, maintain a written medication list, and confirm your child's school has current health forms.
