Issue Category: Public Health Preparedness

Nearly 70 Organizations Call on Congress to Advance the Pandemic and All-Hazards Preparedness & Advancing Innovation Act

March 22, 2019

The Honorable Mitch McConnell Majority Leader U.S. Senate
The Honorable Charles Schumer Minority Leader U.S. Senate
The Honorable Nancy Pelosi Speaker U.S. House of Representatives
The Honorable Kevin McCarthy Minority Leader U.S. House of Representatives

On behalf of the undersigned organizations, representing public health, healthcare providers, emergency managers, environmental health, biotechnology innovators, and researchers, we are again writing to encourage you to advance the Pandemic and All-Hazards Preparedness & Advancing Innovation Act (PAHPAI, H.R. 269), which overwhelmingly passed the House of Representatives in January. A similar version passed the Senate Health Education, Labor & Pensions (HELP) Committee last year. The HELP and Energy & Commerce Committees have made tremendous, bipartisan progress on this important legislation, and it would be a setback for our national health security to further delay reauthorization. The disaster relief package being considered by Congress would be a logical vehicle for PAHPAI.

The recent wildfires, hurricanes and measles outbreaks have demonstrated that all sectors – public health, healthcare and private sector – play a critical role in saving lives during disasters and outbreaks. PAHPA is the backbone of our nation’s health security, providing the U.S. Department of Health and Human Services (HHS) with authorities for preparing the healthcare and public health systems for disasters and strengthening the medical countermeasures enterprise. The legislation addresses gaps we have seen in recent responses, such as the speed of funding for public health emergencies, development and deployment of medical countermeasures for significant threats and preparedness for children in disasters.

The time is now to move this legislation. We are particularly concerned that several authorities have expired as of 2018, including temporary reassignment of state and local personnel, the National Advisory Committee on Children and Disasters, limited antitrust exemption and other provisions critical to HHS contracting. We believe that time is of the essence in reauthorizing these important authorities.

We commend the work of the committed Senators, Representatives and their staff who have devoted considerable thought to this legislation. Our organizations are committed to our nation’s health security, and we remain ready to assist in order to see this legislation enacted into law as soon as possible.

Sincerely,

AABB (formerly known as American Association of Blood Banks)
AFSCME
Alliance for Biosecurity
American Academy of Pediatrics
American Association of Poison Control Centers
American Association on Health and Disability
American Hospital Association
American Public Health Association
American Society for Microbiology
America’s Blood Centers
Asian & Pacific Islander American Health Forum
Association for Professionals in Infection Control and Epidemiology
Association of American Medical Colleges
Association of American Veterinary Medical Colleges
Association of Maternal & Child Health Programs
Association of Public Health Laboratories
Association of Schools and Programs of Public Health
Association of State and Territorial Health Officials
Barnesville Hospital
Berger Health System
Big Cities Health Coalition
Biotechnology Innovation Organization (BIO)
California Life Sciences Association
Central Ohio Trauma System
Child Care Aware of America
Colorado Association of Local Public Health Officials
Commissioned Officers Association of the U.S. Public Health Service, Inc. (COA)
Coshocton Regional Medical Center
Council of State and Territorial Epidemiologists
Entomological Society of America
Fayette County Memorial Hospital
Federation of American Hospitals
Future of Life Institute
Genesis Community Ambulance
Global Health Technologies Coalition
Health Industry Distributors Association
Health Resources in Action
Healthcare Distribution Alliance
Healthcare Leadership Council
Healthcare Ready
Hogg Foundation for Mental Health
Hospital Council of Northwest Ohio
Infectious Diseases Society of America
International Association of Emergency Managers
Johns Hopkins Center for Health Security
Los Angeles County Department of Public Health
Louisiana Public Health Institute
March of Dimes
Mount Carmel Health System
National Association of Counties
National Association of County and City Health Officials
National Association of Federal Veterinarians
National Association of Pediatric Nurse Practitioners
National Association of State Emergency Medical Services Officials
National Center for Disaster Preparedness, Columbia University
National Emergency Management Association National Network of Public Health Institutes
NEHA
Oklahoma City-County Health Department
One Health Commission
One Health Initiative Autonomous pro bono Team
Suburban Hospital Alliance of New York State
The Antimicrobials Working Group (Amplyx Pharmaceuticals, Aridis Pharmaceuticals, Cidara Therapeutics Inc., ContraFect Corporation, Entasis Therapeutics Inc., Iterum Therapeutics Ltd., Melinta Therapeutics Inc., Motif Bio plc, Nabriva Therapeutics US Inc., Paratek Pharmaceuticals Inc., Qpex Biopharma Inc., SCYNEXIS Inc., Summit Therapeutics plc andVenatoRx Pharmaceuticals Inc.)
The Society for Healthcare Epidemiology of America
Trauma Center Association of America
Trust for America’s Health
UCSF Benioff Children’s Hospitals
Virginia Hospital & Healthcare Association

New Report Finds Nation’s Public Health Emergencies Are Increasing While State Emergency Preparedness Levels Are Mixed

17 States Score in Top Readiness Tier, 20 States and DC in Middle Tier, 13 States in Lower Tier

Report provides action steps for states to improve emergency preparedness; progress will require action by public health agencies, elected officials and state residents

(Washington, DC – February 12, 2019) – Seventeen states place in the top tier of a three-tiered measure of performance on 10 indicators of public health and emergency readiness, according to a new report Ready or Not: Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, released today by the Trust for America’s Health (TFAH). Twenty states and the District of Columbia score in the middle tier and 13 states score in the lower tier.

State public health preparedness, by scoring tier:

 Performance Tier States Number of States
Top Tier AL, CO, CT, FL, ID, KS, MA, MD, MO, MS, NC, NE, NJ, RI, VA, WA, WI 17 states
Middle Tier CA, DC, GA, HI, IA, IL, LA, ME, MI, MN, MT, ND, NH, NM, NV, OK, OR, SC, TX, VT, WV 20 states and DC
Lower Tier AK, AR, AZ, DE, IN, KY, NY, OH, PA, SD, TN, UT, WY 13 states

The report takes an annual snapshot of states’ public health and emergency readiness.  Authored by TFAH since 2003, it documents that all states have made progress in preparedness since 9/11, but, also highlights pressing needs for additional action particularly as weather-related and other public health emergencies become more frequent.

The report, although not a comprehensive evaluation of any state’s overall emergency readiness or response, focuses on key indicators of states’ level of emergency preparedness. It identifies specific action-steps that if taken would improve the jurisdiction’s overall level of emergency preparedness, including dedicated funding for health security initiatives, modernizing and supporting technologies and innovations within public health programs, and building multisectoral collaboration and leadership.

The report’s 10 key indicators of state public health preparedness are:

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 (Grade A) 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.

Key report findings include:

  • A majority of states (31) have made preparations to expand public health and healthcare capabilities in an emergency, often through inter-state collaboration and compacts.
  • A strong majority of Americans (96%) who access water from a community water system, have access to water that meets all applicable health-based standards. Ninety percent of all Americans get their water from a community water system.
  • Most states are accredited in the areas of public health and emergency management, many in both. These accreditations are one measure of a state’s capacity to effectively respond to health threats.

However, areas of concern include:

  • Seasonal flu vaccination rates, already below 50 percent, fell last year. The flu vaccination rate for Americans ages 6 months and older dropped from 47 percent in the 2016 – 2017 season to 42 percent during the 2017- 2018 season.
  • In 2018, 45 percent of employed state residents did not have access to paid time-off, meaning they were more likely to go to work if ill, increasing the potential for infections to spread.
  • Only 28 percent of U.S. hospitals, on average, earned top-quality patient safety grades. Hospital safety scores measure performance on such issues as infection control, intensive-care capacity, nursing staff volume and an overall culture of error prevention.

“Preparedness is key to preventing harm when public health emergencies and natural disasters occur, but, being prepared requires dedicated funding and multi-sector planning and collaboration,” said John Auerbach, President and CEO of the Trust for America’s Health.   “The risks to America’s health security are very real, and in the headlines – from wildfires to floods to food borne illnesses.  These events are wake-up calls.  To stay safe, we need to devote more time and money to emergency preparedness.”

TFAH’s report also includes a number of recommendations across 11 high priority areas.  Among the top priorities:

  • Congress should fund public health and health system preparedness and response as well as global health security.
  • Congress should pass the Pandemic and All-Hazards Preparedness and Advancing Innovation Act.
  • Investment in disease surveillance and data infrastructure needs to be significantly increased.
  • The “last mile” of medical countermeasure distribution, meaning ensuring that important medications or other needed supplies get to the right person at the right time, needs to be strengthen.

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Trust for America’s Health is a nonprofit, nonpartisan organization that promotes optimal health for every person and community and makes the prevention of illness and injury a national priority.  www.tfah.org

TFAH Applauds Passage of Senate Farm Bill

(Washington, D.C., June 29, 2018) – John Auerbach, president and CEO, of Trust for America’s Health (TFAH) today made the following statement regarding Senate passage of “Farm Bill” legislation (the Agriculture Improvement Act – Senate amendment to H.R. 2) to reauthorize key federal agricultural and nutrition programs.

“The Trust for America’s Health is pleased the U.S. Senate has completed work on Farm Bill legislation that will support and promote good nutrition and improved health outcomes. By rejecting the approach taken by the House, the Senate bill largely protects and strengthens the Supplemental Nutrition Assistance Program (SNAP), which serves as a critical lifeline to millions of American children and families that otherwise lack the means to access adequate nourishment and make healthy food choices.

In addition to increases in funding to the Food Insecurity Nutrition Incentive Pilot, the Senate bill includes a Harvesting Health pilot that would help to further promote linkages between health care providers and anti-hunger and nutrition improvement activities.

According to TFAH’s State of Obesity report, roughly two out of every three adults or one out of every three children is either obese or overweight. Obesity remains both a significant public health crisis and a national security issue-being overweight or obese is the leading cause of medical disqualifications for military service, with nearly one-quarter of applicants being rejected for exceeding the weight or body fat standards. Additionally, obesity translates to higher health care costs and poor quality of life.

Many efforts are underway that encourage SNAP recipients to make healthy food choices; for example, incentive programs to use SNAP benefits at farmers’ markets. Such efforts, combined with other prevention programs and policies, have been shown to be effective. We must now continue to invest in and scale such approaches to help Americans eat healthier. SNAP and other Farm Bill programs will be critical to turning the tide against this longstanding health problem.

TFAH looks forward to continuing to work with Congress through the conference process as it develops a final Farm Bill that will lead us in the right direction, towards improving the health and prosperity of all Americans.”

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

New Report: Funding for Public Health Has Declined Significantly since the Great Recession

Core Federal Emergency Preparedness Funding has been cut by More than One-Third Since FY 2002

Washington, D.C., March 1, 2018 – A new Trust for America’s Health (TFAH) analysis—A Funding Crisis for Public Health and Safety: State-by-State and Federal Public Health Funding Facts and Recommendations—finds spending on public health is insufficient.

“A healthy United States is a strong United States. A prepared nation is a safe nation. But persistent underfunding of the country’s public health system has left the nation vulnerable,” said John Auerbach, president and CEO, of TFAH. “The country needs a long-term commitment to rebuild the nation’s public health capabilities – not just to plug some of the more dangerous gaps but to make sure each community will be prepared, responsive and resilient when the unexpected occurs.”

Flat Federal Funding

In Fiscal Year (FY) 2017, the U.S. Centers for Disease Control and Prevention’s (CDC) budget was $7.1504 billion ($21.95 per person). Adjusting for inflation, CDC’s core budget—not including the Prevention and Public Health Fund—has been essentially flat for the last decade.

Because much of CDC’s budget is distributed to states and localities, the impact of budget cuts is experienced directly at the state and local level. Of the roughly 75 percent of CDC funds that go to states and local communities, support ranges from a low of $5.74 per person in Missouri to a high of $114.38 per person in Alaska.

In addition, 12 percent of CDC’s budget consists of the Prevention and Public Health Fund, with about $625 million a year of that directed to state and local efforts. From FY 2013 through FY 2027, the Prevention Fund will receive nearly $12 billion less than the law intended.

Within CDC, the Public Health Emergency Preparedness (PHEP) Cooperative Agreement Program is the only federal program that supports the work of state and local health departments to prepare for and respond to emergencies. Except for one- time, short-term funding to contain the Ebola and Zika viruses, core emergency preparedness funding has been cut by more than one-third (from $940 million in FY 2002 to $667 million in FY 2017) since the program was established.

State Public Health Funding Declining

Spending for public health by states has been declining.  Based on a TFAH analysis (adjusted for inflation), 31 states made cuts to their public health budgets from FY 2015-2016 to FY 2016-2017.  Only 19 states and Washington, D.C. maintained or increased their budgets, making it hard for states to compensate for reduced federal funding.

According to the report, state public health spending is actually lower in 2016-2017 than it was in 2008-2009, as some of the funding cuts that occurred during the Great Recession have not been fully restored—and federal funding has been essentially flat (almost half of state public health spending comes from federal funds).

Local Public Health Funding Decreasing

Since 2008, local health departments (LHDs) have lost 55,590 staff due to layoffs or attrition. In addition, about 25 percent of LHDs reported a lower FY 2016 budget than the previous year, with fewer LHDs reporting an increase in their budget for the current year as compared to the previous.

Recommendations

“Each year, we issue this report to examine the amount of public health funding each state receives and provide an independent analysis of how communities protect the public’s health. With life expectancy declining in the U.S. for the second year in a row—something unheard of in recent memory—policymakers must take the public’s health seriously and allocate the funds needed to improve well-being and prevent illness and injury,” said Auerbach.

The report includes eight key recommendations:

  1. Increase Funding for Public Health – at the Federal, State and Local Levels
  2. Preserve the Prevention and Public Health Fund
  3. Prepare for Public Health Emergencies and Pandemics
  4. Establish a Standing Public Health Emergency Response Fund
  5. Build a National Resilience Strategy to Combat Deaths of Despair
  6. Prevent and Reduce Chronic Disease
  7. Support Better Health and Top Local Priorities in Every Community
  8. Expand the Use of Evidence-Based, High-Impact Strategies to Improve Health in Every Community

The brief was supported by a grant from the Robert Wood Johnson Foundation (RWJF).

Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

 

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Public Health Preparedness

Examples of the need to protect the public’s health from disease, disasters, and bioterrorism abound. The COVID-19 pandemic is a stark example. In addition, during 2023 the U.S. experienced 25 weather-related events that each caused over $1 billion dollars in damages in addition to tragic loss of lives. During August of 2023, an estimated 57 million people were living under an excessive heat warning putting them at risk of heat-related illnesses.

As a nation, we need to do more to ensure that we are adequately prepared to protect the public’s health during emergencies including providing increased and sustained public health funding and fostering multi and cross sector planning and collaboration.

TFAH Releases Special Issue Brief: Racial Healing and Achieving Health Equity in the United States

TFAH Calls for Increased Focus on Addressing Health Inequities and Releases Priority Recommendations to Achieve this Goal

Washington, D.C., January 16, 2018 – Today, Trust for America’s Health (TFAH) released Racial Healing and Achieving Health Equity in the United States, which highlights and acknowledges health inequities, the factors that influences them and highlights policy recommendations that can help the nation achieve health equity.

TFAH issued the brief in conjunction with The Truth, Racial Healing & Transformation’s second annual National Day of Racial Healing, which is intended to identify key steps that will help take collective action to promote positive and lasting change across issues.

“As we mark the annual Martin Luther King Day, we are reminded he said that ‘of all the forms of inequality, injustice in health care is the most shocking and inhumane’,” said John Auerbach, president and CEO, TFAH. “TFAH is proud to be joining the National Day of Racial Healing to acknowledge health inequities in the country and to focus on building a pathway forward toward an equitable and socially just future.”

TFAH has issued the following set of recommendation to help the nation to achieve health equity:

  • Create strategies to optimize the health of all Americans, regardless of race, ethnicity, income or where they live.  All levels of government must invest in analyzing needs and increasing effective policies and programs to address the systematic inequities that exist and the factors that contribute to these differences, including poverty, income, racism and environmental factors. Solutions should feature community-driven tactics, including using place-based approaches to target programs, policies and support effectively.
  • Expand cross-sector collaborations.  Improving equity in health will require supporting and expanding cross-sector efforts to make communities healthy and safe.  Efforts should engage a wide range of partners, such as schools and businesses, to focus on improving health through better access to high-quality education, jobs, housing, transportation and economic opportunities.
  • Fully fund and implement health equity, health promotion and prevention programs in communities. And, partner with a diverse range of community members to develop and implement health improvement strategies.  Federal, state, local and tribal governments must engage communities in efforts to address both ongoing and critical health threats.  The views, concerns and needs of community stakeholders, such as volunteer organizations, religious organizations and schools and universities, must be taken into account in this process.  Proven, effective programs, such as the U.S. Centers for Disease Control and Prevention’s REACH (Racial and Ethnic Approaches to Community Health) program should be fully-funded and expanded.
  • Collect data on health and related equity factors – including social determinants of health – by neighborhood.  There should be a priority on improving data collection at a very local level to understand connections between health status and the factors that impact health to help identify concerns and inform the development of strategies to address them.
  • Support Medicaid coverage and reimbursement of clinical-community programs to connect people to services that can help improve health.  Medicaid should reimburse efforts that support improved health beyond the doctor’s office – for example asthma and diabetes prevention programs and other community-based initiatives can help address the root causes that contribute to inequities.
  • Communicate effectively with diverse community groups.  Federal, state, local and tribal officials must design culturally competent, inclusive and linguistically appropriate communication campaigns that use respected, trusted and culturally competent messengers to communicate their message. Communication channels should reflect the media habits of the target audience.
  • Prioritize resiliency in health emergency preparedness efforts.  Federal, state, local and tribal government officials must work with communities and make a concerted effort to address the needs of low-income, minority and other vulnerable groups during health emergencies. Public health leaders must develop and sustain relationships with trusted organizations and stakeholders in diverse communities on an ongoing basis—including working to improve the underlying health of at-risk individuals, sub-population groups and communities, so these relationships are in place before a disaster strikes.  Communication and community engagement must be ongoing to understand the needs of various populations.
  • Eliminate racial and ethnic bias in healthcare.  Policies should incentivize equity and penalize unequal treatment in healthcare, and there should be increased support for programs to increase diversity in and across health professions.  In addition, efforts should be increased to train more healthcare professionals from under-represented populations so that the workforce reflects the diversity of the patient population.
  • Incorporate strategies that foster community agency—or a community’s collective ability and opportunity to make purposeful choices—into the design, implementation and governance of multi-sector collaborations. Building community agency can contribute to improved community health by yielding a deeper understanding of the challenges and opportunities influencing a community, and relies on an asset-based approach to leverage existing community strengths and resources. Multi-sector collaborations should include dedicated resources for fostering and measuring community agency. Efforts should maximize and bolster community voice and power as a means to influencing larger policy- and systems-level changes (including those within and outside of the traditional health sector).

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Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.  Twitter: @HealthyAmerica1

Half of States Scored 5 or Lower Out of 10 Indicators in Report on Health Emergency Preparedness

Report Finds Funding to Support Base Level of Preparedness Cut More than Half Since 2002

 

Washington, D.C., December 19, 2017 – In Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, 25 states scored a 5 or lower on 10 key indicators of public health preparedness. Alaska scored lowest at 2 out of 10, and Massachusetts and Rhode Island scored the highest at 9 out of 10.

The report, issued today by the Trust for America’s Health (TFAH), found the country does not invest enough to maintain strong, basic core capabilities for health security readiness and, instead, is in a continued state of inefficiently reacting with federal emergency supplemental funding packages each time a disaster strikes.

According to Ready or Not?, federal funding to support the base level of preparedness has been cut by more than half since 2002, which has eroded advancements and reduced the country’s capabilities.

“While we’ve seen great public health preparedness advances, often at the state and community level, progress is continually stilted, halted and uneven,” said John Auerbach, president and CEO of TFAH.  “As a nation, we—year after year—fail to fully support public health and preparedness. If we don’t improve our baseline funding and capabilities, we’ll continue to be caught completely off-guard when hurricanes, wildfires and infectious disease outbreaks hit.”

Ready or Not? features six expert commentaries from public health officials who share perspectives on and experiences from the historic hurricanes, wildfires and other events of 2017, including from California, Florida, Louisiana and Texas.

The report also examines the nation’s ability to respond to public health emergencies, tracks progress and vulnerabilities, and includes a review of state and federal public health preparedness policies. Some key findings include:

  • Just 19 states and Washington, D.C. increased or maintained funding for public health from Fiscal Year (FY) 2015-2016 to FY 2016-2017.
  • The primary source for state and local preparedness for health emergencies has been cut by about one-third (from $940 million in FY 2002 to $667 million in FY 2017) and hospital emergency preparedness funds have been cut in half ($514 million in FY 2003 to $254 million in FY 2017).
  • In 20 states and Washington, D.C. 70 percent or more of hospitals reported meeting Antibiotic Stewardship Program core elements in 2016.
  • Just 20 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2016 to Spring 2017—and no state was above 56 percent.
  • 47 state labs and Washington, D.C. provided biosafety training and/or provided information about biosafety training courses (July 1, 2016 to June 30, 2017).

The Ready or Not? report provides a series of recommendations that address many of the major gaps in emergency health preparedness, including:

  • Communities should maintain a key set of foundational capabilities and focus on performance outcomes in exchange for increased flexibility and reduced bureaucracy.
  • Ensuring stable, sufficient health emergency preparedness funding to maintain a standing set of core capabilities so they are ready when needed. In addition, a complementary Public Health Emergency Fund is needed to provide immediate surge funding for specific action for major emerging threats.
  • Strengthening and maintaining consistent support for global health security as an effective strategy for preventing and controlling health crises. Germs know no borders.
  • Innovating and modernizing infrastructure needs – including a more focused investment strategy to support science and technology upgrades that leverage recent breakthroughs and hold the promise of transforming the nation’s ability to promptly detect and contain disease outbreaks and respond to other health emergencies.
  • Recruiting and training a next generation public health workforce with expert scientific abilities to harness and use technological advances along with critical thinking and management skills to serve as Chief Health Strategist for a community.
  • Reconsidering health system preparedness for new threats and mass outbreaks.  Develop stronger coalitions and partnerships among providers, hospitals and healthcare facilities, insurance providers, pharmaceutical and health equipment businesses, emergency management and public health agencies.
  • Preventing the negative health consequences of climate change and weather-related threats. It is essential to build the capacity to anticipate, plan for and respond to climate-related events.
  • Prioritizing efforts to address one of the most serious threats to human health by expanding efforts to stop superbugs and antibiotic resistance. 
  • Improving rates of vaccinations for children and adults – which are one of the most effective public health tools against many infectious diseases.
  • Supporting a culture of resilience so all communities are better prepared to cope with and recover from emergencies, particularly focusing on those who are most vulnerable.   Sometimes the aftermath of an emergency situation may be more harmful than the initial event.  This must also include support for local organizations and small businesses to prepare for and to respond to emergencies.

The report was supported by a grant from the Robert Wood Johnson Foundation (RWJF).

Score Summary: 

A full list of all of the indicators and scores and the full report are available on TFAH’s website.  For the state-by-state scoring, states received one point for achieving an indicator or zero points if they did not achieve the indicator.  Zero is the lowest possible overall score, 10 is the highest.  The data for the indicators are from publicly available sources or were provided from public officials.

9 out of 10: Massachusetts and Rhode Island

8 out of 10: Delaware, North Carolina and Virginia

7 out of 10: Arizona, Colorado, Connecticut, Hawaii, Minnesota, New York, Oregon and Washington

6 out of 10: California, District of Columbia, Florida, Illinois, Maryland, Nebraska, New Jersey, North Dakota, South Carolina, South Dakota, Utah, Vermont and West Virginia

5 out of 10: Georgia, Idaho, Maine, Mississippi, Montana and Tennessee

4 out of 10: Alabama, Arkansas, Iowa, Louisiana, Missouri, New Hampshire, Oklahoma and Pennsylvania

3 out of 10: Indiana, Kansas, Kentucky, Michigan, Nevada, New Mexico, Ohio, Texas, Wisconsin and Wyoming

2 out of 10: Alaska

 Trust for America’s Health is a non-profit, non-partisan organization dedicated to saving lives by protecting the health of every community and working to make disease prevention a national priority.

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