The U.S. is better equipped to manage health emergencies, but progress slowed last year as regional inequities in preparedness persist, according to new data.
The U.S. scored a 6.7 on the 10-point scale of the 2019 National Health Security Preparedness Index. That's a 3.1% boost over the year prior, and a 11.7% increase since the Centers for Disease Control and Prevention launched the index in 2013. At the current pace, it will take a decade to reach a strong health security level of at least 9.
There's been incremental improvement over the past six years, but progress has been relatively slow and there is plenty of room to do better, said Glen Mays, who leads a team of researchers at the University of Kentucky who manage the index.
"States that are lagging behind in surveillance, capacity and environmental testing are less likely to detect health problems and that leads to larger problems like the water crisis in Flint, Mich.," he said. "States that have less capacity to treat a surge in demand will likely see more injuries and potentially more deaths."
The index, which is funded by the Robert Wood Johnson Foundation, analyzes 129 different measures for each state including the prevalence of hazard planning in nursing homes, the number of paramedics and medical volunteers, the degree of community engagement, the level of information management, and other factors including tangentially related infrastructure such as the percentage of bridges that are in good condition. It gathers data from more than 60 sources to measure the ability to protect Americans from infectious diseases, terrorism and extreme weather.
Emergency preparedness efforts are increasingly important as mass shootings become alarmingly commonplace. Measles cases hit a 25-year high. Fires are tearing through California while hurricanes ravage Southern states. Preparedness measures need to match natural and manmade disasters' increasing frequency and intensity, experts said.
A total of 11 states and the District of Columbia had health security levels that were significantly above the national average in 2018, down from 22 jurisdictions a year earlier. Conversely, 17 states had health security levels that fell significantly below the national average, down from 20 states.
A total of 32 states and the District of Columbia experienced one-year gains in health security levels in 2018. Four states saw reductions in 2018 and 14 states saw no change.
Clusters of below-average states remain in the South-Central, Upper Mountain West, Pacific Coast and Midwest regions. Above-average states cluster in the Northeast, Mid-Atlantic, Upper Midwest and Central Rocky Mountain regions.
Texas showed resiliency during Hurricane Harvey, Mays said. Tropical Storm Allison catalyzed a slew of flood protections including new floodgates; above-ground electrical and water-pump systems; and better storage and sourcing of supplies amid shortages. Houston had a strong coalition of regional healthcare systems as well as well-positioned emergency management and public health agencies, Mays said.
But the Florida nursing home where 12 died during Hurricane Irma offered a stark contrast. That was indicative of local security agencies' inability to communicate and share resources, Mays said.
Ninety-three percent of 247 emergency physicians surveyed by the American College of Emergency Physicians said their emergency departments are not fully prepared for surge capacity during a disaster. About half said they would be somewhat prepared; about a quarter indicated they wouldn't be completely ready; and 17% said they were completely unprepared. About three-quarters indicated they don't always have access to real-time data.
Even though the CMS emergency-preparedness rule that went into effect in 2016 spurred more planning, many providers do not prioritize it, said Nicolette Louissaint, executive director of Healthcare Ready, a disaster-response not-for-profit.
Only 13% of those surveyed in the ACEP poll said their hospital has thoroughly reevaluated preparedness plans; 44% said that they had done so to some extent. Twenty-two percent said they had not really reevaluated plans and 8% said they had not done it at all.
Regional differences in preparedness are becoming more evident over time, Louissaint said. While it's worth noting that many states are ramping up preparation, greater investments and resources are needed to continue or bolster that work, she said.
"Without sustained funding, it's nearly impossible for there to be continued improvements," Louissaint said. "It's simple, without the proper funding, we cannot expect to do better."
Some states have been more proactive, like the 31 that did or will adopt the compact this year that allows nurses to practice more freely between states when demand swings, Mays said.
Naturally, more rural states have a harder time coordinating services across fragmented networks.
Healthcare providers often rely on federal funding to train personnel, coordinate with area agencies and stockpile supplies to handle a patient surge. But it is typically not enough as hospitals have had to delay and recalibrate treatment during disease outbreaks, public health experts said.
"It is a shared responsibility," said Mays, adding that organizations need to be proactive whether it is subsidized or not. "No single agency or organization can do everything to protect the public. There is a need for state and regional organizations to play some leadership roles in coordinating activities between different sectors."
The Federal Emergency Management Agency was acutely unprepared for the unprecedented 2017 hurricane season, leaving many providers in Puerto Rico, Texas and Florida in the dark as they tried to recover, an "after-action" report found.
This instability underscores the need to prepare, Mays said.
"More needs to be done," he said. "We would like to see a faster wave of progress given the fact that these events are occurring with more frequency and intensity across the U.S."
