This article discusses the development of pandemic response plans over the past several years and reviews existing plans from 14 states, including policies that address potential need to ration scarce resources during a public health crisis.

Public health and emergency preparedness professionals have modeled and planned for major pandemics for many years, including during a major exercise last year coordinated by the U.S. Department of Health and Human Services. Many states have detailed guidance on allocating scarce resources, though typically these plans are not mandatory and individual hospitals and hospital systems make decisions for policies within their facilities. Most states’ guidance prioritizes patients most likely to survive with intervention, and some also prioritize health care workers and pediatric patients.

The article notes that some state plans explicitly rely on the availability of additional resources from federal and state stockpiles, but preparedness experts acknowledge that local, state, and federal caches are likely to be inadequate to address a widespread shortage. High resource usage in response to H1N1 in 2009 and lack of funding to resupply stockpiles further reduced capacity. Models and exercises to respond to hypothetical public health crises routinely indicate that resource capacity may be exceeded during a large-scale crisis.

Rationing of life-sustaining care such as ventilators has not been reported to date in the U.S., but appears to have occurred in other countries.

The article is based on reviews of pandemic response and crisis standards of care plans from Alabama, Arizona, California, Colorado, Florida, Illinois, Michigan, Minnesota, Missouri, New Jersey, New York, Ohio, Texas, and Wisconsin.