How Shifts in Federal Vaccine Policy Shape State Decision-Making

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How Shifts in Federal Vaccine Policy Shape State Decision-Making

Hill to the Heartland: Federal Health Policy Briefing

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Responsibility for vaccine policy in the United States is shared across federal and state governments. Federal agencies oversee vaccine research, approval and national recommendations, while states retain primary authority over implementation and enforcement. As a result, changes in federal vaccine policy can shape the environment in which states operate, even though states ultimately determine how vaccines are required and administered within their borders. This blog examines key federal developments and considers their implications for states navigating evolving guidance.

What Federal Vaccine Policy Does, and Does Not Do

Federal vaccine policy is shaped by a defined set of agencies and advisory bodies, each with distinctive roles. Together, these entities influence vaccine development, approval, recommendations and coverage, but they do not directly mandate vaccination at the individual level.

The U.S. Food and Drug Administration (FDA) is responsible for evaluating the safety, efficacy and quality of vaccines before they can be authorized or licensed for use. The FDA oversees clinical trial data, manufacturing standards and post-market safety monitoring through systems such as the Vaccine Adverse Event Reporting System (VAERS), which it administers jointly with the Centers for Disease Control and Prevention (CDC).

The CDC provides public health guidance related to vaccine use, including recommended schedules. Within the CDC, the Advisory Committee on Immunization Practices (ACIP), an external panel of medical and public health experts, reviews evidence and votes on vaccine recommendations for specific populations. ACIP recommendations are usually a key link between federal guidance and state-level implementation.

Federal vaccine recommendations also influence insurance coverage. Under the Affordable Care Act (ACA), most private health plans are required to cover vaccines recommended by ACIP without cost-sharing when provided by an in-network provider. In addition, ACIP recommendations guide coverage decisions for public programs such as Medicaid and the Vaccines for Children (VFC) program, which supplies federally purchased vaccines to eligible children at no cost.

The U.S. Preventive Services Task Force (USPSTF), an independent volunteer panel supported by the U.S. Department of Health and Human Services (HHS), issues evidence-based recommendations for preventive services, including some immunizations. USPSTF recommendations play a separate but complementary role in determining which preventive services must be covered by insurers without cost-sharing.

While these federal entities shape the policy environment, states retain authority over vaccine policy implementation. States determine school vaccination requirements, exemption policies, public health strategies and enforcement mechanisms. This means that changes in federal guidance or advisory structures can have downstream effects for states, even when no federal mandate is issued.

A Brief History of Vaccine Policy and Public Response

Public debate around vaccines has accompanied vaccination policy since its origins. The first smallpox vaccine, developed by Edward Jenner in 1796, sparked religious and social opposition. In England, the Vaccination Act of 1853 introduced the world's first vaccine mandate and was met with resistance. In the United States, the Supreme Court's 1905 decision in Jacobson v. Massachusetts affirmed the states' authority to enforce vaccine requirements in the interest of public health.

During the 20th century, vaccination campaigns led by federal and state health authorities dramatically reduced diseases such as polio and measles. At the same time, isolated safety incidents shaped regulatory oversight and public trust. A manufacturing error involving polio vaccines in 1955 caused illness and deaths, underscoring the role of federal regulation and quality control. Later, concerns related to the DTP (diphtheria, tetanus, pertussis) vaccine and the mercury-based preservative thiomersal prompted scientific review and changes in formulation and communication. A now-retracted 1998 study linking the MMR (measles, mumps and rubella) vaccine to autism further influenced public discourse and trust in vaccine policy. These historical episodes highlight how vaccine policy is shaped not only by scientific evidence, but also by regulatory action, transparency and communication.

COVID-19 as a Stress Test for Federal Vaccine Governance

The COVID-19 pandemic placed unprecedented demands on federal vaccine governance. The FDA issued emergency use authorizations (EUAs) for COVID-19 vaccines, while the CDC and ACIP issued evolving recommendations as new evidence became available. Emergency use authorizations for COVID-19 vaccines were first issued in 2020 and were later amended, expanded or allowed to expire as additional evidence became available. The Pfizer-BioNTech, Moderna and Novavax vaccines later received full FDA approval, though in 2025, COVID-19 vaccine recommendations were narrowed by age or risk category.

During the pandemic, the speed and scale of the public health response drew heightened attention to vaccine safety and regulatory decision making. Reports of rare adverse events, including myocarditis and cerebral venous sinus thrombosis, prompted federal safety reviews and public discussion. At the same time, vaccine guidance evolved as new evidence emerged. The World Health Organization described this information environment as an "infodemic," defined as an overabundance of information, including false or misleading content, circulating in both digital and physical spaces during a disease outbreak. As digital platforms enabled information to spread rapidly, both accurate updates and harmful claims were amplified. This environment contributed to confusion for some members of the public and renewed debates about vaccine safety, individual rights and government authority.

Evolving Federal Guidance

Since early 2025, efforts led by HHS Secretary Robert F. Kennedy Jr., along with actions by the CDC and ACIP, have changed vaccine recommendations and advisory processes. As state and local leaders respond to community questions about vaccine access, coverage and safety, they are doing so under revised federal guidance that has traditionally informed state policy decisions.

Timeline

Note: February 2025, view Executive Order. September 2025, view AHIP statement.
Source: Kansas Health Institute analysis of vaccine recommendations and advisory processes.

How States Are Responding

In response to these recent federal actions, many states have taken steps to maintain broader access. A September 2025 report by the Kaiser Family Foundation (KFF) found that many states had implemented or announced changes to their vaccine policies that provide access beyond current federal guidance. A follow-up analysis in January 2026 found that 28 states, including the District of Columbia, had announced they would not follow new CDC childhood vaccine recommendations for at least some vaccines, with 25 of those states departing for all routine childhood vaccines. State actions have centered in three areas:

• Pharmacy Access: In seven states, not including Kansas, pharmacists' authority to administer COVID-19 vaccines is directly tied to ACIP recommendations, meaning patients may now need a clinician's prescription to receive a COVID-19 vaccine at a pharmacy. In response, several states have taken action to expand or clarify pharmacists' authority under state law. Some states have also issued executive orders or joined multi-state coalitions to preserve pharmacy access and insurance coverage.
• Insurance Coverage: Thirteen states, not including Kansas, required state-regulated health insurers to continue covering COVID-19 vaccines at no cost. In four of these states, the requirement extends to all vaccines recommended by the state. While federal law requires most insurers to cover ACIP-recommended vaccines without cost-sharing, states have authority to regulate fully insured employer plans and individual and small-group marketplace plans within their borders. Self-insured employer plans, however, remain outside state regulatory authority.
• Sources of Vaccine Guidance: Twenty-eight states (including D.C.) identified non-federal entities as sources for vaccine recommendations. Twenty-five of those states did so for all routine childhood vaccinations, not just COVID-19. Most, including Kansas, indicated they would recommend schedules from independent medical and professional organizations like AAP. A budget proviso added to Substitute for House Bill 2434 (page 121, line k) would direct the Kansas Department of Health and Environment to use state funds in Fiscal Year 2027 to follow and implement the CDC's immunization schedules in effect on July 1, 2026, while still allowing providers to recommend other vaccines and requiring Medicaid to cover those provider-recommended immunizations. The substitute bill was passed favorably out of committee on Feb. 16 and advanced to the House.

Public Confidence in Evolving Federal Guidance

Survey data indicate that the changes have occurred at a time of historically low public confidence in federal health agencies. A January 2026 poll from KFF found that fewer than half of U.S. adults trust the CDC to provide reliable vaccine information or express confidence in federal agencies' ability to make recommendations about the childhood immunization schedule. About one half of adults reported hearing at least "some" about recent schedule changes, and among those aware, twice as many expected the changes to have a negative impact on children's health. Confidence remains high in long-standing childhood vaccinations like MMR and polio, while confidence is lower for vaccines recently shifted from routine to shared clinical decision-making, including COVID-19 and influenza vaccines.

What We'll Be Watching

As federal vaccine policy continues to evolve, KHI will be watching:

• Actions by HHS affecting CDC advisory committees and vaccine recommendations
• Changes to federally funded vaccine research priorities
• Implications for insurance coverage
• How KDHE and local health systems adapt guidance and communication in response to federal changes.

Stay tuned for further updates on policy shifts that may affect health programs and services in Kansas. For related work on how federal policies could impact Kansans, please check out Hill to the Heartland.