The seventh annual Ready or Not? Protecting the Public's Health from Diseases, Disasters, and Bioterrorism report, released by the Trust for America's Health (TFAH) and the Robert Wood Johnson Foundation (RWJF), found 20 states scored six or less out of 10 key indicators of public health emergency preparedness.

Nearly two-thirds of states scored seven or less. Eight states tied for the highest score of nine out of 10: Arkansas, Delaware, New York, North Carolina, North Dakota, Oklahoma, Texas, and Vermont. Montana had the lowest score at three out of 10.

"The H1N1 outbreak has vividly revealed existing gaps in public health emergency preparedness," said said Richard Hamburg, Deputy Director of TFAH "The Ready or Not? report shows that a band-aid approach to public health is inadequate.”

Overall, the report found decades of chronic underfunding meant that many core systems were not at-the-ready. Some key infrastructure concerns were a lack of real-time coordinated disease surveillance and laboratory testing, outdated vaccine production capabilities, limited hospital surge capacity, and a shrinking public health workforce. In addition, the report found that more than half of states experienced cuts to their public health funding and federal preparedness funds have been cut by 27 percent since fiscal year (FY) 2005, which puts improvements that have been made since the September 11, 2001 tragedies at risk.