The more troubling news from the 2021 Index release is that large differences in health security levels persist across states and communities, with the lowest levels of health security found in geographic areas with the highest levels of social and economic vulnerability. By producing the Index annually since 2013, we can clearly see that health security levels have improved at an uneven pace across the United States in recent years. As a result, large segments of the country are left under-protected and vulnerable to health and economic burdens triggered by COVID-19.

The 2021 release of the Index provides an important window into the consequences of failing to achieve a more equitable health security system across the United States. In earlier releases of the Index—prior to the COVID-19 pandemic—it was difficult to see the clear connections between health security levels and health outcomes as they varied across the country. Now, in the midst of the pandemic, the 2021 Index release clearly demonstrates that areas with lower health security levels experienced significantly higher mortality due to COVID-19. These results document how inequities in health security contribute to inequities in health outcomes within the context of a large-scale health emergency.

Most importantly, results from the 2021 release of the Index demonstrate that gaps and inequities in health security are amenable to solutions. Every state achieved improvements in health security levels in at least one domain over the past eight years and most states also bolstered their overall health security levels. For example, Louisiana achieved one of the largest gains in health security of any state in 2020 despite serving many residents with high levels of social and economic vulnerability and despite confronting simultaneous health emergencies. If all states achieve sustained rates of improvement observed in Louisiana, the nation as a whole can eliminate geographic inequities and reach a strong national health security level of at least 9.0 in as few as five years.

This year’s Index results show that inequities in health security are not inevitable. A uniformly high-functioning system is within reach by targeting additional resources and assistance to places that experience the lowest health security levels and by supporting meaningful approaches to regional coordination and cross-sector collaboration.

We hope the 2021 release of the Index can inform these types of improvements as the United States continues to recover from the pandemic. Please spend some time with the 2021 Key Findings report for a deeper dive into health security patterns and trends observed across the country. For a summary of the health security patterns in your specific area, take a look at the state profile for your individual state.  We invite you to conduct your own analyses of health security measures by downloading the Health Security Data Explorer. For ideas on using the Index data to mobilize change in your community, see the Innovator’s Guide to the National Health Security Preparedness Index and other resources on the Index website.

Glen P. Mays PhD, MPH is the chair and a professor in the Department of Health Systems, Management and Policy in the Colorado School of Public Health at CU Anschutz. His research examines delivery and financing systems for health services, with a focus on estimating their effects on population health and economic efficiency.

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What Can Be Learned from Updated Results?

Results from the 2020 release of the Index show that national health security capabilities continue to gain strength, but at a rate that has slowed down over time. Most states experienced improvements in health security levels over the past year, but at widely varying levels. Large geographic differences in preparedness remain, and these differences have grown larger over time in selected domains. Jurisdictions are responding to a growing array of risks and hazards by stretching constrained human, financial, and technological resources and making difficult trade-offs.

How can states and communities use this updated information? Coronavirus transmissions appear to be leveling off in a growing number of U.S. regions, giving these areas some breathing room and a chance to take stock of their capabilities and needs. With a large set of 130 measures, the Index allows users to identify strengths and weaknesses across a broad range of sectors and capabilities.

As new resources become available through federal coronavirus aid packages, the Index can help emergency preparedness stakeholders identify where vulnerabilities exist and where reinforcements are most urgently needed. Users can quickly identify leading states in each domain of preparedness and in regions across the United States, allowing for peer networking and cross-jurisdictional learning to occur.

What Can Findings Tell Us About COVID-19 Response?

The Index includes many measures that are directly relevant to coronavirus response efforts, including measures of laboratory testing capabilities, epidemiologist staffing, hospital surge capacity, nursing home infection control, household broadband access, and employer-provided paid time off. Effective responses to COVID-19 require coordination of resources across a broad range of public and private sectors. The Index integrates data from a broad range of sectors to offer a comprehensive view of preparedness.

Figure: Higher Scores on the 2020 Health Security Index Are Associated with Significantly Lower Risk-adjusted County COVID-19 Mortality Rates

Note: point estimates with 95% confidence intervals are shown as horizontal lines.  Estimates are derived from risk-adjusted mortality regression models using generalized estimating equations. 

To gain additional perspectives on pandemic response, Index results can be linked with emerging state and local data on COVID-19 (see figure). To date, states with higher health security levels have experienced significantly lower risk-adjusted COVID-19 deaths per 100,000 population – an encouraging trend that can be monitored over time. The figure above shows how county-level risk-adjusted mortality rates change in response to a one point increase in Index scores. These results can help stakeholders craft targeted responses for regions that face higher mortality risks combined with lower preparedness levels.

What Index Changes Were Introduced in 2020?

The Index measurement set and methodology remain virtually unchanged from last year. We introduced one new measure into the Index based on recommendations from the field: a measure of nursing home compliance with federal standards for infection control. This addition appears particularly relevant to the COVID-19 pandemic, given the heightened infection rates observed in long-term care facilities across the United States.

One notable change to our dissemination process this year is the rethinking of the “Index preview period” used in previous years to give emergency preparedness stakeholders an early look at the results and a structured process to provide feedback. To avoid placing additional demands on these officials during the COVID-19 response and to provide information as quickly as possible to the field, we are releasing the results directly to the field without holding a full review and comment period. One downside of this minimally invasive approach, of course, is that we have fewer opportunities to screen for possible errors in the many data sources used in the Index. Such errors have been rare in previous releases of the Index, but they occasionally do occur in some data sources, particularly those that rely on self-reported information from agencies and facilities. For this reason, we invite Index users to ask questions and provide feedback on an ongoing basis at any time that is convenient by sending an email to our research team at systemsforaction@ucdenver.edu. If we identify the need to correct any data source based on this feedback, we will release corrections as soon as possible on the Index website.

We hope you find useful information and new insight about the geography and dynamics of health security in this latest release of the Index. We look forward to incorporating the lessons learned from current health security experiences into future releases of the Index.

Glen P. Mays PhD, MPH is the chair and a professor in the Department of Health Systems, Management and Policy in the Colorado School of Public Health at CU Anschutz. His research examines delivery and financing systems for health services, with a focus on estimating their effects on population health and economic efficiency.

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So, can you identify the most heavily questioned and hotly contested element of the National Health Security Preparedness Index? Believe it or not, it is the set of measures that indicate what public health laboratories do.

Heterogeneity and Controversy in Lab Testing

The controversy stems from the concept of assurance. And it flows from the many different ways that public health responsibilities get divvied up across state governments.

In most states, multiple laboratories exist, operated by different state agencies.  Public health laboratories are often organized within state health agencies, but sometimes they are organized as independent state institutions or as part of state university systems.  Environmental laboratories are often located within state environmental protection agencies, which may or may not fall under the umbrella of a health-related super agency.  Agricultural laboratories are found within state agriculture agencies.  And of course there are clinical labs located within state hospitals, crime labs located within state law enforcement agencies, and medical examiner’s labs located somewhere in this mix.  Which lab is responsible for testing food samples for pathogens?  Which lab tests air, soil or other environmental samples for harmful substances like lead? Which lab tests public drinking water sources, private wells, or recreational bodies of water?  Which lab tests the white powder found in an office building?

Political dynamics add to the controversies surrounding heterogeneity in laboratory structure. Environmental and agricultural labs conduct testing largely in support of the regulatory enforcement duties carried out by their parent agencies. Some of the tests performed by public health labs also fulfill regulatory purposes, but these labs typically have a broader surveillance mission and a wider scope of responsibilities.  Concerns about industry capture and political interference in testing exist, and examples that fuel these concerns are not hard to find.

Figure 1: State public health laboratory roles in testing for hazards in air, 2016

Source: Association of Public Health Laboratories, 2016

The Solution: Assurance

Long ago, laboratory experts at CDC and at state public health laboratories recognized the problems that can arise when testing capabilities exist in one agency but interpretation and response capabilities reside in other corners of state government.  Information does not always flow seamlessly through government bureaucracies.  The legal authority to act and the scientific knowledge about what to do are distributed unevenly across agencies.  This situation can cause delays in responding effectively to hazards detected through laboratory testing.  And delays can have serious human and economic consequences.

The solution devised by CDC and its state laboratory partners at APHL involve two key ingredients:

1. Recognize that public health testing and reporting capabilities are carried out by a multi-agency system of laboratories in most states.
2. Recommend that a state’s designated public health laboratory take responsibility for ensuring that all necessary health-related testing and reporting capabilities exist somewhere within the state’s laboratory system and are implemented effectively. The laboratory can carry out this assurance function either by directly providing necessary testing and reporting activities itself OR by confirming that another laboratory somewhere within the state system provides these activities effectively.

This “provide or assure” recommendation for state public health laboratories forms the basis of CDC’s and APHL’s Comprehensive Public Health Laboratory System definition and its Core Functions and Capabilities of State Public Health Laboratories framework. Moreover, this recommendation is formalized in the federal Healthy People 2020 health objectives for the nation.

How Does the Index Measure Laboratory Capabilities?

The National Health Security Preparedness Index follows the recommendations of CDC and APHL when measuring public health laboratory capabilities.  In fact, we use a series of measures constructed from periodic surveys that APHL fields with state public health laboratory administrators.  The measures in this series indicate whether or not the state public health laboratory “provides or assures” testing of water, air, soil, and human samples for specific pathogens and hazards.  A state receives credit for having a specified capability if the public health laboratory directly performs the test, OR if it assures that another laboratory entity performs the test.

Figure 2: State public health laboratory roles in testing public drinking water systems, 2016

Source: Association of Public Health Laboratories, 2016

The controversy arises in states where a certain type of test is performed by an environmental or agricultural laboratory, but there is no assurance function performed by the public health laboratory.  In these cases, the capability to test for a certain hazard exists. But the capability to assure that the testing and reporting function is carried out effectively does not exist within the public health laboratory. Such states do not comply with the CDC/APHL recommendation.  By following the CDC/APHL recommendations, the Index measures the assurance capability rather than the testing capability alone.

And as you can imagine, some states don’t agree with this way of measuring laboratory capabilities.

Figure 3: State public health laboratory roles in testing hazardous waste, 2016

Source: Association of Public Health Laboratories, 2016

Testing vs. Assurance: Are We Measuring the Right Stuff?

The CDC/APHL “provide or assure” recommendation for public health laboratory testing reflects the consensus opinion of experts and experienced laboratory professionals at the dawn of the 21^st century.  As a recommendation based more on experience than on rigorous scientific evidence, it should remain open to continued evaluation, critical analysis, and revisions over time.  The Index continues to monitor the scientific and professional literature on this topic, and we stand ready to update our measurement approaches as professional norms and standards evolve.

One issue in need of clarification involves how the assurance function should be defined and carried out by public health laboratories across the U.S.  The APHL surveys used in constructing the Index rely on information that is self-reported by individual laboratory administrators.  The surveys provide little guidance about what is meant by “assurance” and how laboratories should carry out this function in cases where they do not directly perform the testing.  Consequently, it is left up to the interpretation of individual administrators as to whether or not their laboratory carries out the assurance function.

Figure 4: State public health laboratory roles in testing for hazards in soil, 2016

Source: Association of Public Health Laboratories, 2016

Is assurance really all that important? Isn’t it enough to know that testing exists somewhere within the state bureaucracy?

Clearly some people think so.  But in the absence of clear scientific evidence, the Index relies upon well-reasoned professional recommendations like those from CDC and APHL.

It is not very difficult to find real-world examples that support the underlying logic of the “provide or assure” recommendation.  As one example, Arizona’s environmental laboratory has responsibility for testing the safety of public drinking water systems, but it does not have the legal authority to notify the public of potential hazards.  As a consequence, residents of one community waited years to learn that their drinking water supply had seriously elevated levels of uranium contamination from a defunct mine.  The Flint water crisis provides another recent example of the problems posed by organizational complexity in lab testing and response.  In that case, Michigan’s environmental agency held responsibility for overseeing testing of Flint’s drinking water system, but the state’s public health agency had responsibility for monitoring test results for reportable diseases like Legionnaires’.  Delays in connecting the dots between water test results and disease surveillance enabled the hazards in Flint to persist and grow unchecked.

We hope the Index will stimulate further dialogue, discussion, and debate about these important issues in health security.  Publicly accessible data, rigorous analysis, and critical thinking lead the way to a clearer understanding of actions that can strengthen health protections for everyone.

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The Colorado Department of Public Health and Environment (CDPHE) was tops in our recent Innovator Challenge for using the National Health Security Preparedness Index to stimulate intra- and multi-sectorial communication, collaboration, and action to improve health security. The Index team spoke with Dane Matthew, director of Colorado’s Office of Emergency Response, about how the Index is helping the department meet its goals. Below is a snapshot of the conversation.

INDEX TEAM: How did improving Colorado’s health security and preparedness become a priority and how did you translate this into action?

MATTHEW: One of the goals in our strategic plan is to prepare and respond to emerging issues, but assessing readiness and preparedness is a pretty nebulous thing. There are so many factors. The National Health Security Preparedness Index has done that hard work and given us a sense of where we stand and where we can improve.

We decided that to use the Index, we have to figure out how to improve our score—so we formed an internal team to dig into the data and measures to understand where we were successful, where we could make improvements, and where there are missing data that we know exists somewhere. From there, we set goals and benchmarks using the Index measures and weaved them into our implementation plan and our overall strategic plan.

You mention homing in on missing data. Can you tell us what data you are working to collect?

First, we had to identify exactly where there were missing data to understand why. When we looked more closely at the data, we found measures where data were labeled “missing” that CDPHE could add. We realized that the “missing data” could be due to reporting data in a way that was not captured in the Index, potentially lowering our overall score. For example, the number of epidemiologists per 100,000 people was a low-scoring item for us, but we realized this is a measure in Colorado that is collected by the state’s Department of Labor, even though it’s a public health profession. In this case, we just needed to find out where the data are to report accurately. We now know that we have a high number of epidemiologists in the state and our score has improved.

How does this fit into the future goals of the department?

A future step for us will be to look outside of the department. We know some of the measures are beyond public health’s direct control. For example, one measure is the number of doctors per 100,000 people. Now we are thinking, “How can we encourage our local hospital associations to improve this score?” Understanding where the data come from is helping us understand what specific improvements can be made and which community partners we need to speak with.

What are the top preparedness activities in Colorado that you’re looking to improve?

We are very focused on improving a number of preparedness efforts in the state, specifically improving syndromic surveillance capabilities and sharing the generated data. Currently, we do not maintain this information at the state level, only within the Denver metro area. We are working to provide this at the local level across the state to prevent and respond to emerging threats.

Another area to improve, and this ties back into our conversations with community partners, is the number of pediatricians in the state. We are looking to partner with our local hospital associations and other health care stakeholders to improve our pediatrics capabilities—for day-to-day health and well-being, and in the event of a disaster.

What is one of the barriers to preparedness?

One challenge that I’ve been concerned about is the philosophy that just because you don’t have major events requiring massive evacuations on a continual basis, that doesn’t mean you don’t need to prepare for smaller, more localized events. When a community has something happen, we are pretty good about making sure we have a much improved response the next time something similar happens. But it’s easy to lose sight of the need to continually prepare, especially if we haven’t experienced any major emergencies or disasters for a period of time.

What advice would you give to other states using the Index?

Measuring preparedness is incredibly difficult, but the Index is a foundational piece. You can use the Index to better understand your state and departments and begin crucial conversations. Having a tool to help you articulate your readiness is important. I would urge my health security and preparedness peers to utilize the Index and dig into the data and ask, “Did that score equate to a better response or not? Are there small changes that can make a big difference?” Start with the low-hanging fruit and focus on making incremental change.

Dane Matthew, MAEd, MMAS, is the director of the Office of Emergency Preparedness and Response at the Colorado Department of Public Health & Environment.  Since June of 2016, he has led the state’s public health and medical emergency preparedness and response program.  He is ensuring all 64 counties and the nine regional healthcare coalitions in Colorado are prepared to respond to and recover from incidents adversely impacting health and the environment. Matthew’s experience as a military officer, combined with the skills he developed while a firefighter and executive director of a Colorado Special District, make him a skilled strategic planner, leader, and consensus builder. He continues to grow his knowledge of public health and medical EPR and propel Colorado’s program forward to ensure the state is prepared for when someday is today.

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