Hawaii is generally more prepared for a public health crisis than most states, according to a new report.

The Trust for America’s Health, a nonprofit health policy organization, ranked the Aloha State a 7 out of 10 in its Ready or Not report. That’s slightly higher than California and in the same range as Washington and Oregon.

The report analyzed 10 indicators, worth one point each, such as whether states have paid sick leave and have vaccinated a majority of their population for the flu. Massachusetts and Rhode Island ranked as the most prepared states with 9 points each, and Alaska came in last place with two points.

For fiscal year 2016-2017, Hawaii had the third-highest per capita public health spending rate in the nation, behind only Washington, D.C., and Alaska. Compared to the national average of $36, Hawaii spent about $112 per person — a total budget of $159,900,025.

Hawaii was one of 20 states during that period that vaccinated half of its population for the flu. Nationwide, significantly more children than adults were vaccinated.

Another point in the scoring depended on whether states increased their emergency preparedness score in the National Health Security Preparedness Index from 2015 to 2016. The index is based on factors including a state’s ability to manage resources following a health incident and prevent health problems stemming from environmental hazards.

Hawaii was one of 33 states to increase their index score, earning a 6.4 out of 10. That’s still slightly lower than the national average of 6.8, according to the report.

Seventy-two percent of Hawaii hospitals report meeting core elements of the Antibiotic Stewardship Program, which aims to prevent the spread of antibiotic-resistant infections by ensuring antibiotics are not unnecessarily prescribed. Up to 75 percent of antibiotics are prescribed incorrectly, according to the report.

The Hawaii Department of Health‘s Public Health Preparedness Branch is not accredited by the Public Health Accreditation Board, which the report called “an important benchmark of a public health system capable of responding to a range of health threats, such as an identification and investigation of health hazards, educating the public, maintaining a competent workforce and serving as an expert resource.”

Thirty states are accredited by the board, according to the report.

Like the majority of states, Hawaii does not have laws that mandate paid sick leave for workers. This can increase the spread of contagious illness and disease, the report said, and makes it harder for employees to take time off to take themselves or their children to the doctor.

One in three private-sector employees nationwide don’t have paid sick days, according to the report. Low-wage workers are far less likely than higher paid workers to have the benefit.

The report docked Hawaii a point for opting not to participate in the Enhanced Nurse Licensure Compact, which allows nurses who meet certain core requirements to practice across state lines under all circumstances. In the 24 states that don’t participate in the agreement, nurses can only work in other states when a governor has declared an emergency and requests help under the Emergency Medical Assistance Compact.

Chris Crabtree, director of the Hawaii Healthcare Emergency Management Coalition, said Hawaii’s health care system is stronger than many of those on the mainland, but the state’s isolated location still makes it more vulnerable in emergencies.

In the event of a natural disaster, the coalition would coordinate with health care organizations statewide to aid in recovery efforts. Health care coalitions are also tasked with disaster preparation.

Most supplies arrive to Hawaii by ship, which could be a problem if the supply chain is interrupted. The state is “extremely vulnerable, logistically,” Crabtree said, comparing Hawaii to Puerto Rico, which is still reeling from a devastating hurricane in September.

“We’re 2,500 miles away from California,” he said. “We don’t have the large warehouses where they store medical supplies and such.”

The coalition almost lost its federal funding this year, Crabtree said. But after hurricanes Harvey and Irma, the federal government determined there was a need for such coalitions to unite health care organizations.

It can be difficult to get government to fund “what-ifs” such as emergency preparation efforts, he said.

Crabtree said Hawaii is unique because it has a single health-care coalition.

He took issue with some of the survey’s metrics, particularly those where Hawaii didn’t fare well.

Public health department accreditation costs $35,000 upfront and another $14,000 every year after, and the lack of accreditation doesn’t mean the state isn’t doing good work, Crabtree said. He cited the state’s response to recent outbreaks of the flu, Hepatitis A, mumps and dengue.

The compact allowing nurses to work across state lines can cause problems when states have different requirements, he said. If a nurse is disciplined in one state, it’s unclear what may happen in another state. Hawaii is still covered by the emergency compact, he said, and residents would be “pretty much on our own for 96 hours to a week” following a natural disaster anyway.

Though the report said Hawaii’s public health funding has remained the same or increased over the past two fiscal years, Crabtree said the coalition’s budget has seen severe cuts in recent years.

Sarah Park, state epidemiologist of the health department, said in an email that it’s “important to take into consideration that The Ready or Not report is a snapshot of preparedness, and not a comprehensive analysis.”

The indicators change every year, which makes it difficult for the department to measure its progress, she wrote.

“What we have gained is the understanding that we cannot continue to build critical expertise and partnerships in health emergency preparedness without dedicated funding support,” Park wrote.

Read the full report here: