The United States entered 2026 managing its most severe influenza season in nearly a decade, the highest measles case count since 1991, and sustained avian influenza surveillance — all while the federal public health infrastructure underpinning hospital and clinical emergency response was being significantly dismantled. A new report from Trust for America’s Health (TFAH), released May 7, 2026, finds that this convergence of active threats and federal instability represents a defining stress test for the nation’s preparedness architecture — and that many states are not well positioned to absorb the shock.
Ready or Not 2026: Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism measures readiness across 10 indicators and places states into three performance tiers. Twenty states achieved high-tier scores; 17 states and the District of Columbia landed in the middle tier; and 13 states fell into the low tier. The report’s findings carry direct operational implications from laboratory surge capacity and cross-state credentialing to medical countermeasure distribution and mass casualty coordination.
Laboratory Capacity and Surveillance Under Strain
Among the most clinically relevant findings, the report documents that concurrent demands on public health laboratories in 2025 (including confirmatory testing across 48 separate measles outbreaks, a tuberculosis outbreak in Kansas City, sustained H5N1 surveillance, and a severe influenza season) occurred simultaneously with federal funding terminations affecting more than $8.9 billion in Epidemiology and Laboratory Capacity program support. This funding underwrites laboratory staffing, testing operations, and surveillance infrastructure at the state level. While 49 states and the District of Columbia reported having written plans to handle six- to eight-week surges in laboratory testing capacity, the financial disruption threatens the workforce and systems those plans depend on.
The report also flags the March 2025 termination of more than $12 billion in COVID-19-era grants — funding that had been broadened to support infectious disease monitoring, laboratory capacity, emergency preparedness, and mental health services. Court orders blocked terminations for plaintiff states and the District of Columbia, but litigation remained unresolved through year’s end, creating sustained uncertainty for preparedness planning at the health system level.
Workforce Losses Erode Clinical and Emergency Response Expertise
CDC lost approximately one quarter of its civilian workforce between fiscal years 2024 and 2026, with reductions spanning global health, health promotion, scientific research, and communications. The Health Resources and Services Administration, which funds Federally Qualified Health Centers and healthcare workforce development programs for underserved areas, similarly lost approximately one quarter of its staff. The report emphasizes that the loss of federal staff represents an erosion of institutional knowledge and specialized expertise — including unique laboratory capabilities — that states cannot readily replicate.
The report also flags the cancellation of nearly $500 million in contracts funding mRNA vaccine research and development in August 2025, describing the move as a potential disruption to the research, development, and deployment of countermeasures needed for the next public health emergency. For hospital preparedness planners, the proposed FY 2027 budget — released after the report was substantially complete — adds additional concern: it would eliminate the Hospital Preparedness Program entirely and cut the Public Health Emergency Preparedness Cooperative Agreement by approximately 52 percent.
Global Health Disinvestment Raises Pandemic Threat Horizon
The report devotes significant attention to global health security, noting that the U.S. formally completed its withdrawal from the World Health Organization in January 2026, reducing access to global data sources that support outbreak tracking and response. The dissolution of the U.S. Agency for International Development (USAID) and reductions to CDC’s global health programs have further curtailed the international disease surveillance capabilities that historically served as an early warning system for U.S. clinical and public health responders. Several states — including California, Colorado, Illinois, New York, and Wisconsin — announced plans to join the WHO Global Outbreak Alert and Response Network independently in response.
The report frames these moves in stark terms for healthcare system leaders: poorly controlled outbreaks abroad significantly increase the likelihood of global pandemics, with direct consequences for hospital surge capacity, supply chains, and emergency spending.
State Variation and Recommendations for Healthcare Systems
State performance varied considerably across indicators with direct clinical relevance. Hospital patient safety grades — used as a proxy for foundational emergency readiness — ranged from more than half of hospitals earning top ratings in New Jersey, Utah, and Virginia, to zero top-rated hospitals in Iowa, North Dakota, Vermont, and Wyoming. Avoidable mortality rates, a baseline measure of population health resilience, ranged from 201 per 100,000 in Massachusetts to 445 per 100,000 in West Virginia, with pronounced racial and ethnic disparities compounding gaps in most states.
TFAH’s recommendations for strengthening healthcare system readiness include increasing federal investment in the Hospital Preparedness Program, Regional Disaster Health Response System, and National Special Pathogen System; strengthening crisis standards-of-care planning and pediatric readiness requirements; and expanding cross-state provider credentialing policies including interstate compacts and emergency prescription refill protocols. The report also calls for reauthorization of the Pandemic and All-Hazards Preparedness Act, whose most recent comprehensive reauthorization was completed in 2019, and which provides the statutory framework for health emergency preparedness, including the Hospital Preparedness Program itself.
Ready or Not 2026: Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism – Trust for America’s Health (May 7, 2026)