6 Ways States Can Protect Vaccine Access While the Trump Administration Dismantles the Federal System

According to six former U.S. surgeons general, U.S. Department of Health and Human Services Secretary Robert F. Kennedy Jr.’s actions are endangering the nation’s health.¹ These have included gutting vaccine research; unilaterally rolling back vaccine recommendations; firing experts, including the Centers for Disease Control and Prevention (CDC) director who refused to rubber-stamp recommended vaccine rollbacks; sowing distrust in medical professionals; and threatening to interfere with state vaccine policies.² These actions upend the process for millions of Americans to access vaccines, and they threaten to increase the incidence of preventable serious diseases, particularly among children.³ As the federal government spreads chaos and confusion about vaccines and dismantles the national vaccine infrastructure, the burden to protect and preserve access to lifesaving vaccines must increasingly fall on states and private organizations. States can, and already are, taking action to fill the void, strengthening their policies to safeguard and expand vaccine access, availability, and infrastructure.

State policymakers can take a variety of approaches to bolstering their vaccine infrastructure, and many have already done so. Yet states are challenged by limited resources; lack of political will and increasing partisan divides; and an administration that is actively disassembling federal systems by decimating CDC staff, canceling cutting-edge vaccine research, cutting funds that support state vaccine programs, and more. Despite these challenges, states’ failure to act could have grave consequences.⁴ This report showcases actions that states can take to protect vaccine access and opportunities for progress. These include:

• Aligning vaccine policy with recommendations from leading scientific experts.
• Expanding authority to administer vaccines.
• Eliminating cost barriers by ensuring vaccine coverage.
• Shielding health care providers who follow evidence-based vaccine recommendations.
• Creating interstate alliances.
• Exploring vaccine purchasing arrangements.

These actions are critical to protect individuals and communities from life-threatening diseases.

The Trump administration’s actions to dismantle vaccine infrastructure threaten the health of Americans; trust in science and medicine; access to, availability of, and insurance coverage for vaccines; and vaccine manufacturing.

With no new science to back up his agenda, Secretary Kennedy has delegitimized the CDC’s Advisory Committee on Immunization Practices (ACIP), which makes recommendations for the public’s use of vaccines, by firing experts and replacing them with handpicked vaccine skeptics.⁵ In August, Sen. Bill Cassidy, M.D. (R-LA)—who chairs the U.S. Senate Committee on Health, Education, Labor and Pensions, which oversees the CDC—called for the agency to postpone the September ACIP meeting due to serious concerns about its lack of compliance with a well-established scientific process for considering evidence and about the legitimacy of the committee.⁶ Nevertheless, the committee convened a meeting filled with weak science, false and misleading claims, and flawed processes for assessing evidence. The meeting’s resulting misguided recommendations tarnished its reputation and sowed confusion and doubt about MMRV (measles, mumps, rubella, and varicella), hepatitis B, and COVID-19 vaccines, which has had a chilling effect on already eroding vaccine confidence among patients and parents.⁷

Between the 2023-24 and 2024-25 school years, routine childhood vaccination coverage among kindergartners in the United States decreased for all reported vaccines.⁸ According to a July/August 2025 Washington Post/KFF poll of almost 3,000 parents or guardians of children under age 18, 1 in 6 parents have delayed or skipped some routine childhood vaccines for their children, primarily due to concerns about vaccines rather than access barriers.⁹ This includes 7 percent to 9 percent skipping the polio vaccine and the measles, mumps, and rubella (MMR) vaccines, respectively, increasing the risk of future outbreaks of dangerous, avoidable, and potentially fatal diseases.¹⁰ This decline raises the risk of infectious disease because maintaining vaccination rates above a certain percentage of the population, known as herd immunity, prevents disease transmission and provides some community protection.¹¹

The Trump administration’s actions to reconstitute ACIP could potentially alter insurance coverage, increasing costs for consumers. As prescribed in the Affordable Care Act (ACA), public payers such as Medicare and Medicaid and private health insurers must cover all charges for ACIP-recommended vaccines and CDC-approved vaccines.¹² The Vaccines for Children (VFC) Program also covers ACIP-recommended and CDC-approved vaccines at no charge to low-income children.¹³ As ACIP changes vaccine recommendations, public payers could be forced to change their coverage policies, and private insurance companies could also stop covering them, imposing barriers to access.¹⁴

The Trump administration’s approach to vaccine policy at both the Food and Drug Administration (FDA) and the CDC, including the aforementioned ACIP recommendations, has repercussions for vaccine access and availability. The Association of State and Territorial Health Officials estimates that almost 600 state and territorial statutes and regulations reference ACIP recommendations, so that changes to ACIP recommendations automatically modify state policies.¹⁵ In May 2025, Kennedy announced his unilateral decision to remove the COVID-19 vaccine recommendation for healthy pregnant women. Soon after the decision, some pregnant women reported difficulties in getting the vaccine from pharmacies even when recommended by their providers due to confusion among pharmacists about eligibility and whether insurance would cover it.¹⁶

As the Trump administration weakens or reverses vaccine recommendations, threatens to expand legal risks for manufacturers, and sows doubt and distrust in vaccines, the vaccine market—which is already considered a high-risk, low-reward investment for pharmaceutical companies given the high upfront costs and uncertain payoffs—becomes less appealing to manufacturers.¹⁷ If demand falls, pharmaceutical companies could pull their products off the U.S. market or decide not to produce vaccines.¹⁸ If the FDA restricts vaccine approvals, as it did in August 2025 with the COVID-19 vaccine booster, it could further destabilize the market and discourage vaccine manufacturers.¹⁹ Several vaccine manufacturers have already taken action, including Moderna, which lost more than $700 million after the Trump administration canceled contracts for pandemic bird flu vaccine development.²⁰ Decelerating vaccine development in the United States could produce supply shortages, increase costs, and threaten access to childhood vaccines as well as the nation’s preparedness for a future pandemic.²¹

Most critically, the Trump administration’s actions could lead to the resurgence of preventable infectious diseases, resulting in increased illnesses and deaths. According to estimates, routine vaccinations have prevented nearly 508 million cases of illness, 32 million hospitalizations, and more than 1 million deaths among children in the United States born from 1994 to 2023.²² In addition, vaccines protect against significant causes of death among adults, such as influenza, COVID-19, and pneumonia.²³ It follows that reducing access to these vaccines could tragically reverse this progress.

There are already signs of this reversal. From September 2024 to September 2025, declining influenza (flu) vaccination contributed to 280 pediatric flu deaths, the highest number in a nonpandemic flu season in more than 20 years, with 89 percent of deaths among children who were not fully vaccinated against flu.²⁴ Although the United States officially eliminated measles in 2000—a historic public health achievement—recent declines in measles vaccination coverage led to the 2025 measles outbreak, exceeding 1,700 cases of measles across 42 states and New York City, the highest number in 30 years.²⁵

If childhood vaccination rates continue at the current pace, researchers predict more than 851,000 cases of measles in the United States over the next 25 years.²⁶ If vaccination rates were to drop by half, researchers estimate 51.2 million cases of measles over 25 years, 9.9 million cases of rubella, 4.3 million cases of polio, and nearly 200 cases of diphtheria.²⁷ Children would experience an estimated 51,200 cases of brain encephalitis (a severe brain inflammation) from measles, 5,400 cases of paralysis from polio, and 10.3 million hospitalizations and 159,200 deaths.²⁸ In Florida, where the surgeon general recently announced plans to terminate all school vaccine requirements, researchers estimate that measles vaccination could decline by 15 percent over 25 years, leading to 1 million measles cases.²⁹

The failure of the federal government to maintain and support its vaccine infrastructure shifts the burden to states and private health associations and organizations. State and local public health agencies—which rely on the CDC for about 80 percent of their funding as the nation’s first line of defense against chronic diseases, environmental exposures, and infectious outbreaks—must now bolster their vaccine infrastructure at the same time that funding from the CDC is being slashed.³⁰ Drastic budget cuts such as those proposed in the fiscal year 2026 House appropriations bill will affect their capacity to prepare and respond to current and new health threats.³¹ In addition, a decentralized approach in which vaccine systems vary by state raises concerns about confusion among payers, providers, and the public and could reduce access, accurate information, and the herd immunity that protects the public from outbreaks.³²

Yet failure to act also has monumental health and economic consequences. Researchers found that a 2019 measles outbreak in Clark County, Washington, cost $47,479 per case and $3.4 million overall.³³ The public health response to the outbreak was responsible for two-thirds of the costs, with the remainder representing productivity losses and direct medical costs. At a time when public health systems are strapped for resources and the Trump administration’s Big Beautiful Bill threatens clinics, hospitals, and health care providers, there is an economic imperative to avoid disease outbreaks.³⁴

Despite significant challenges, state policymakers can take actions—and many are—to reinforce their vaccine infrastructures, finding opportunities to bolster public health protections, diminish the Trump administration’s threats and dangerous actions, and protect their residents’ health and safety.³⁵

Although state public health departments typically align their vaccine recommendations with ACIP, given the recent failure of ACIP to ground its vaccine recommendations in scientific evidence, states can review and change state laws to align with expert guidance. Existing state approaches include:

• California and Pennsylvania, in September and October, respectively, endorsed COVID-19 vaccine recommendations from national medical professional organizations, such as the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians.³⁶
• In April, Colorado changed a law so that the state health board can consider scientific and medical sources other than ACIP when establishing school vaccine requirements.³⁷
• Massachusetts Gov. Maura Healey (D) introduced language in two supplemental budget bills this summer to give the state’s health commissioner more authority to set vaccine standards.³⁸ Although the move is promising, it could be problematic should a future governor appoint an anti-vaccine health commissioner. For instance, Florida Surgeon General Joseph Ladapo has announced plans to dismantle school vaccine requirements.³⁹

Pharmacists in all 50 states and Washington, D.C., can administer vaccines, but state regulations may limit which vaccines pharmacists can administer, at what ages, and whether patients must have a prescription.⁴⁰ Following Secretary Kennedy’s August announcement of plans to limit eligibility for COVID-19 vaccines, some pharmacies temporarily stopped providing vaccinations, even for people who met the new limited criteria.⁴¹ For example, in 13 states and Washington, D.C., CVS and Walgreens stopped offering COVID-19 vaccines without a prescription.⁴²

During the September ACIP meeting, members narrowly defeated a recommendation to require a prescription for COVID-19 vaccines. Since most adults receive their vaccines at pharmacies, such a measure would pose significant barriers to vaccination, requiring consumers to first make an appointment with (and have access to) a medical provider, which may take weeks and incur a copayment, prompting many people to forgo boosters.⁴³

In some states, pharmacists are prohibited from administering vaccines that are not recommended by ACIP.⁴⁴ Although ACIP has continued to recommend COVID-19 vaccines for people over 6 months of age for now, the FDA approved the COVID-19 booster only for individuals ages 65 and older and for those between ages 5 and 64 with at least one underlying condition.⁴⁵ As a result, in some states, pharmacists may be unable to administer a COVID-19 vaccine to healthy adults without a medical provider’s prescription, since doing so would be considered off-label.⁴⁶

State policymakers can address these barriers. Governors can create standing prescriptions—known as standing orders—that authorize nonphysician providers such as pharmacists and nurses to implement a clinical action without having to obtain individual orders from a physician.⁴⁷ Studies have shown that standing orders increase preventive services such as immunizations, and the CDC has strongly recommended them for adults.⁴⁸ Pharmacy boards determine licensing requirements for pharmacists and pharmacy technicians; define their scope of work and services provided, such as prescriptive authority and vaccine administration; and grant licenses.⁴⁹ Existing state approaches include:

• Colorado, Connecticut, Illinois, Massachusetts, Maine, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, and Washington, D.C., have issued orders that create a standard prescription for all state residents ages 6 months or older to receive a COVID-19 vaccine.⁵⁰
• Colorado recently expanded the authority of pharmacists, and pharmacy interns and pharmacy technicians under their supervision, to prescribe, dispense, or administer vaccines generally and pursuant to standing orders.⁵¹
• New Jersey and New York issued orders, and Rhode Island passed a law, that allow pharmacists to administer COVID-19 vaccines for patients ages 3 and older.⁵²
• The New York order also permits pharmacists to prescribe COVID-19 vaccines.⁵³

The ACIP committee’s September discussion and votes raised concerns of more restrictive recommendations in the future that could limit insurance coverage and increase cost barriers for individuals with public and private health insurance as well as those who are uninsured.⁵⁴ In mid-September, AHIP, the national trade association representing the health insurance industry, announced that its member plans will cover through 2026, at no charge to patients, all vaccines recommended by ACIP before Secretary Kennedy changed the committee’s membership.⁵⁵ However, future changes in ACIP recommendations could affect insurance coverage thereafter. As another layer of protection, states proactively took action to ensure that vaccines would remain covered. Existing state approaches include: 

• California enacted legislation that requires its regulated health insurers to cover state-recommended vaccines at no cost to consumers.⁵⁶
• Pennsylvania’s insurance department ensured that companies operating in the state continue to cover all vaccines covered under ACIP’s 2024 recommendations.⁵⁷ The Pennsylvania legislature has advanced a bill that would require private insurers to cover vaccines that are recommended by the Pennsylvania Department of Health.⁵⁸
• Massachusetts Gov. Healey issued a bulletin requiring insurance carriers to cover vaccinations recommended by its health department regardless of federal guidance. She also submitted a supplemental budget request that included state funding to cover the nonfederal cost of children’s vaccines.⁵⁹
• Maine Gov. Janet Mills (D) and Wisconsin Gov. Tony Evers (D) issued orders requiring insurance plans to cover state-recommended vaccines without cost-sharing.⁶⁰

States can adopt safeguards to offer legal protections to health care providers that follow evidence-based vaccine recommendations, such as protecting providers who offer off-label COVID-19 vaccines to people who fall outside the FDA-approved ages.⁶¹ For example, California provides health care providers, including pharmacists, with liability protection for off-label vaccination.⁶²

With limited resources, states may find that interstate collaboration serves many purposes, from aligning public messaging to providing more uniform vaccine recommendations. Interstate alliances may also increase capacity to prepare for and respond to emergencies that cross state borders. Existing state approaches include:

• California, Hawaii, Oregon, and Washington created a West Coast Health Alliance to provide unified vaccine guidance to their residents.⁶³ Thus far, the alliance has issued recommendations for influenza, COVID-19, and respiratory syncytial virus (RSV) vaccines. The alliance is considering coordinated lab testing, data sharing, and group purchasing.
• Ten states in the northeast (Connecticut, Delaware, Maine, Maryland, Massachusetts, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont) and New York City formed the Northeast Public Health Collaborative, with work groups that focus on vaccine recommendations and purchasing, data and laboratory capacity, emergency preparedness and response, and disease monitoring.⁶⁴ The collaborative thus far has issued fall 2025 COVID-19 vaccination recommendations.
• Fourteen states and Guam have formed the Governors Public Health Alliance to strengthen critical functions such as emergency preparedness, disease tracking, and response to health threats and to share resources including data, information, and expertise.⁶⁵ The alliance plans to buy vaccines and supplies in bulk.

The CDC purchases vaccines directly from manufacturers at a negotiated discounted price and distributes them to states to provide no-cost access to ACIP-recommended vaccines.⁶⁶ Section 317 of the Public Health Service Act provides fixed, discretionary dollars for vaccinating uninsured and underinsured adults.⁶⁷ The VFC program funds vaccines for children under age 19 who are uninsured, underinsured, Medicaid eligible, or of American Indian or Alaska Native descent.⁶⁸ The CDC’s vaccine orders account for 52 percent of national childhood vaccine supply, encouraging vaccine manufacturing.⁶⁹

Although individual states lack the purchasing power of the federal government, some states are exploring regional alliances that could negotiate a discounted price if the federal government fails to do so. Multistate drug purchasing pools and a northeast regional consortium, which purchased medical equipment and supplies during the COVID-19 pandemic, demonstrate the feasibility of states pooling their purchasing power to lower prices and secure supplies during shortages.⁷⁰ Existing state examples are the Northeast Public Health Collaborative and the Governors Public Health Alliance, both of which are exploring joint vaccine purchasing.⁷¹

Finally, states must guard against actions that will reduce immunization rates. According to an Associated Press investigation, state legislators in 2025 have introduced 350 bills that create barriers to vaccination, discourage vaccination, or spread false information about vaccines; at least 26 of these bills have been enacted in 11 states.⁷² States have also loosened school vaccine requirements.⁷³ Although all states and Washington, D.C., have required documentation of immunizations for children to attend public school since 1980, Idaho, and potentially Florida, is now the exception.⁷⁴ At a recent conference of anti-vaccine activists who are associated with Secretary Kennedy, participants voiced support for a state-by-state strategy to eliminate school vaccine requirements despite more than 80 percent of parents nationally and in Florida—according to a recent KFF-Washington Post survey—being opposed to removing public school vaccine requirements for polio and measles in their state.⁷⁵ Vaccine coverage is lower in states with high vaccine exemption rates, increasing the risks of individuals contracting infectious diseases and failure to prevent community transmission.⁷⁶

With the federal government stripping away vaccine infrastructure, states are on the hook to protect the health and safety of their residents. Despite the many challenges they face, states have opportunities, individually and collectively, to protect their populations from vaccine-preventable diseases. They can identify and address weaknesses in their existing laws and policies and solidify their authority to implement public health measures.⁷⁷ States can align their policies with evidence-based recommendations, safeguard and expand vaccine access, protect providers, form alliances across state lines, and counter dangerous and false information by signaling to their residents how they can best protect themselves and their loved ones from dangerous diseases.

The author would like to thank Alex Cogan, Paige Shoemaker DeMio, Emily Gee, Topher Spiro, and Senior Fellow Steve Woolf from the Center for American Progress for their reviews, as well as Northe Saunders with American Families for Vaccines. The author also would like to thank Kierra Jones and Brian Keyser for fact-checking.