Is Hawaii ready for the next public health emergency or disaster?
Hawaii is not as ready as it could be, according to the Trust for America’s Health, which ranked the state among 13 low-performance states in its “Ready or Not” report.
The Washington, D.C.-based think tank evaluated each state, using 10 key indicators ranging from public health funding to workforce mobility.
On one hand, Hawaii got high marks for a higher- than-average flu vaccination rate, safe municipal water systems and low avoidable mortality. Hawaii is also among the 14 states that increased public health funding in 2024, and has a laboratory surge capacity plan in place.
On the other hand, Hawaii got low marks for not being accredited for its public health and emergency management programs and its low hospital patient safety ratings.
Hawaii is also not part of the nurse licensure compact, which enables nurses to practice across state lines.
According to the trust, public health emergencies in the U.S. — from measles outbreaks to wildfires and extreme heat — demonstrate the need for consistent investment in public health infrastructure and workforce, and programs that support health in every community.
The report noted that 2024 began “with the continued aftermath of the devastating wildfires in Hawaii, which necessitated multiple renewals of public health emergency declarations due to ongoing health risks, infrastructure challenges, and the prolonged recovery process.”
“These wildfires,” the report said, “highlighted the critical need for appropriate environmental health strategies and long-term support for disaster-stricken communities.”
The rest of the year was packed with powerful hurricanes that devastated multiple states. The H5N1 bird flu, meanwhile, poses a looming threat as it continues to spread through livestock, poultry and wild birds.
A special section on bird flu includes recommendations from public health experts on steps the U.S. should take to prevent it from evolving into the next pandemic.
Hawaii’s low ranking
Hawaii has consistently ranked low in the annual “Ready or Not” reports since at least 2020, according to Matt McKillop, senior health policy research and analyst at the trust.
“Certainly, there were areas where Hawaii stacked up very well against other states,” said McKillop. “I think what contributed to its placement in the low tier, which is consistent with last year, really had to do with a few of the indicators.”
One of these is accreditation by the Public Health Accreditation Board and the Emergency Management Accreditation Program. Hawaii is one of six states that has neither accreditation.
“Most states have been accredited in one or the other or both, which helps them strengthen emergency readiness,” said McKillop. “It means they have well- defined processes in place, along with robust monitoring and evaluation systems.”
Having these accreditation means state agencies have systems in place for emergency response, disease surveillance and risk communication, for instance, and effective coordination across sectors.
“These capabilities can mean the difference, often, between life and death during outbreaks or disasters,” he said.
Additionally, only 8% of Hawaii hospitals received an “A” safety grade from Leapfrog in the fall of 2024, he said, lower than the national average of 27%. Hawaii fared better in 2024, with 25% of hospitals receiving an “A.”
Leapfrog, which has faced some criticism for its methodology, measures patient safety data, errors and infections.
Not having an “A” grade does not mean hospitals in the state are not safe, he said, but indicates there are opportunities for improvement.
Every state, regardless of ranking, has room for improvement, said McKillop, acknowledging that Hawaii did handle the COVID-19 pandemic emergency well, with the lowest U.S. mortality rate in 2023.
States in the low tier just have more room for improvement, he said, and the intention of the study is to provide benchmarks to show where gaps exist.
Dr. Kenneth Fink, state health director, responded in writing that it is actively pursuing alignment with PHAB as a step toward accreditation.
“While we continue to protect and promote the health of the public while responding to public health crises, federal funding rescissions, and a 29% staff vacancy rate,” he said, “we agree with the importance of performance assessment.”
Fink wrote that the department was pleased with Hawaii’s top performances in some areas.
“The report showed why Hawaii remains one of the healthiest states in the nation,” he said. “The report also showed that Hawaii performed better than most states in distributing prevention and treatment opportunities more evenly among racial/ethnic lines, a key indicator of equity in public health and healthcare.”
Such systems are likely to be more resilient in times of public health emergencies, the report noted, and capable of protecting all populations effectively.
The Hawaii Emergency Management Agency did not respond to requests for comment by press time, including whether it is pursuing EMAP accreditation.
Licensure compact
Another reason for Hawaii’s low rating is its absence from the nurse licensure compact, which allows registered and practical nurses with a single, multistate license to practice in any member state.
As of January, 41 states have joined this compact, which gives states the ability to swiftly mobilize health care workers without cumbersome licensure delays.
In 2024 the Hawaii State Center for Nursing and a working group presented to the state Legislature a detailed report nearly 200 pages long on the feasibility and impact of adopting the compact.
A survey in the report indicated a majority of nurses, 81%, agreed or strongly agreed Hawaii should become a member of the compact.
The Healthcare Association of Hawaii, a nonprofit trade group, also supports joining the compact, which requires a change to state law, according to President and CEO Hilton Raethel.
“One of the primary reasons for a licensure compact is to be able to bring nurses into the state on an as-needed basis if we need to in the event of a disaster or emergency,” said Raethel, “without having to rely on an emergency proclamation.”
During the COVID-19 pandemic, emergency proclamations helped waive licensing requirements so out-of-state nurses could fill in at overflowing hospitals.
Following the 2023 Maui wildfires, Gov. Josh Green signed more emergency proclamations, including a waiver of state licenses for doctors, nurses and other health care workers to ease shortages while recovering from the disaster.
But emergency proclamations generally expire in 60 days and constantly need to be renewed. Even now a 21st emergency proclamation is still in place, effective until June 3.
Some concerns about the compact include a potential exodus of Hawaii nurses who could more readily leave the state, but Raethel says nurses who want to move can and already are doing so.
There is no bill at this legislative session addressing the issue this year, but Raethel said HAH will continue to advocate for Hawaii’s membership in the compact.
Looking ahead
The Trust for America’s Health, which is a nonprofit and nonpartisan group, warns that stable, sufficient funding for public health is more important than ever and that the report is a call to action for states to prepare for emergencies ahead of time.
“The only way to stay ahead of outbreaks is to shore up prevention, detection, and response capacities across the country,” said the report, which has been published annually for 22 years.
The trust is concerned about federal cuts and reorganizations, said McKillop, just as the U.S. faces a measles outbreak, severe weather disasters and a portentous battle against bird flu.
It calls for the Centers for Disease Control and Prevention to continue funding states — about 80% of its domestic budget — for public health preparedness, along with its national immunization program and other initiatives. It also calls for Congress to reauthorize the Pandemic and All- Hazards Preparedness Act.
“We know that public health systems in every state depend on CDC funding and expertise,” said McKillop.
To address avian influenza, the trust said the U.S. must “act decisively to prevent it from evolving into a new pandemic.” Though the CDC says the current risk to the public is low, the viruses can evolve to become more transmissible between humans.
McKillop said the group is seeing similarities to some of the early challenges of the COVID-19 pandemic, including the inadequate testing, tracking and monitoring of the virus’ spread.
“It’s a great mistake to be weakening our public health infrastructure at this time,” he said, “because we know these cuts mean slower outbreak response, fewer vaccinations, reduced support for mental health, overdose prevention and food safety.”
The disruptive changes risk undoing years of progress in building more resilient, equitable health systems, he said.
“We have urged the administration to pause, reassess and work with experts to strengthen rather than dismantle our health protection systems,” he said.
HAWAII’S ‘READY OR NOT’ RANKING
Low-performance tier (13 states)
Alaska, Hawaii, Louisiana, Michigan, Minnesota, Mississippi, Montana, Nevada, New Mexico, Oregon, South Dakota, West Virgina, Wyoming
Middle-performance tier (16 states)
Alabama, Arkansas, Arizona, California, Iowa, Illinois, Indiana, Kansas, Kentucky, North Dakota, Nebraska, New York, Oklahoma, South Carolina, Tennessee, Texas
High-performance tier (21 states and D.C.)
Colorado, Connecticut, District of Columbia, Delaware, Florida, Georgia, Idaho, Massachusetts, Maryland, Maine, Missouri, North Carolina, New Hampshire, New Jersey, Ohio, Pennsylvania, Rhode Island, Utah, Virgina, Vermont, Washington, Wisconsin
How Hawaii did based on 10 indicators
1. Participation in the nurse licensure compact for workforce mobility: Hawaii is not part of compact.
2. Accreditation for public health: Hawaii not accredited.
3. Accreditation for emergency management: Hawaii not accredited.
4. State public health funding: Hawaii increased funding.
5. Water safety: 0% in Hawaii served by municipal system in violation of health standards.
6. Paid time off use: Hawaii at 57%, above national average of 55%.
7. Influenza vaccination rates: Hawaii at 51%, above national rate of 47%.
8. Hospital patient safety: Leapfrog: 8% of Hawaii hospitals got an A rating, compared with 27% nationally.
9. Laboratory surge capacity: Hawaii has surge plan in place.
10. Avoidable mortality: Hawaii ranked third in avoidable mortality and first for equity.
Source: Trust for America’s Health “Ready or Not: Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism”
