As States and CDC Split on Vaccines, What’s Next?

Dan Gorenstein (DG): The Trump administration’s overhaul of U.S. vaccine policy is escalating. 

In the last few months, a string of federal decisions have rewritten the list of shots children should get. 

News clip: Well the CDC has adopted new guidance for Hepatitis B vaccines for babies.

News clip: The agency no longer recommending the Covid vaccine for everyone.

News clip: Further reducing the number of vaccines it previously recommended for children from 17 to 11. 

DG: Those big federal shifts are now playing out across states, where most vaccine policy actually gets put into practice.

As of February, at least half of U.S. states have rejected new federal guidance on vaccines for kids.

Michelle Fiscus (MF): It’s just changed from a process that was very routinized and predictable to one that has become really quite chaotic.  

DG: Today we explain how the federal-state partnership on childhood vaccines broke down and what happens to our public health when vaccine policy gets messy.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.

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DG: To help us make sense of this rift between states and the federal government over vaccines, I’m joined by Tradeoffs reporter Melanie Evans, who has been following this since the early days of the Trump administration. 

Hi Melanie.

Melanie Evans (ME): Hey Dan. 

DG: So Melanie, to start, I think it would be helpful to establish a few basics about what vaccine policy typically looks like between the states and the feds. 

Who is in charge of what? What does the federal government control? What power do states have? Things like that.

ME: Well Dan, the feds decide whether a vaccine is safe and effective enough to be publicly released. 

Then the federal CDC, the Centers for Disease Control and Prevention, issues a list of recommended vaccines, with help from a group of scientific advisors.

But these are recommendations. States are the only ones who can require or mandate that someone get a vaccine.

DG: Historically, states have put a lot of weight, though, in those federal recommendations right, Melanie?

ME: Right. For decades, the feds have brought together scientists, major medical groups and doctors and nurses to track the latest science and evaluate the risk and benefit of vaccines.

States trusted this very rigorous, very public process. 

And they relied on federal recommendations to make a whole bunch of decisions, including which vaccines kids need to go to school.

DG: Ok, so bottom line: The feds lack the authority to mandate these vaccines, but they’ve had a HUGE influence on state policy.

ME: Exactly. This whole arrangement is, in many ways, unofficial. 

States are free to do what they want, but since the mid-90s, they’ve followed federal guidance, and it’s created something like a national standard.

For example … nearly every state requires at least nine recommended shots for children entering school, including measles, polio and whooping cough. 

And that’s a big reason we see so few of these diseases.

There’s been a clear, consistent answer for policymakers, parents and doctors about how to vaccinate kids. 

DG: Got it. Thanks, Melanie, that overview is really helpful.

So, let’s get into what’s going on now. What’s happening to this de-facto-national vaccine standard? 

ME: To put it simply, Dan, it’s gone. 

A bunch of states have stopped looking to the feds for guidance on which vaccines kids should get.

No more clear, consistent answer from a single trusted source.

This breakdown in trust in the CDC began during the pandemic, when a lot of Republicans started losing faith in the agency.

Then Democrats started losing confidence after Robert F. Kennedy Jr. took over as health secretary.

DG: Sure. Kennedy is a longtime vaccine skeptic and he’s been busy making lots of changes to U.S. vaccine policy in just the last year.

Melanie, what specific moves has Kennedy made that have really widened this rift with states?

ME: So a big one was firing the head of the CDC last August.

News clip: Tonight we’ve learned Dr. Susan Monarez has been fired just weeks after she was nominated and confirmed by the U.S. Senate.

News clip: Fired because she didn’t align with the president’s Make America Healthy Again agenda.

ME: The CDC director, Susan Monarez, said she was pushed out over vaccine policy. 

DG: I remember this. Several CDC leaders also resigned.

ME: Right, and all this really rattled governors in western States, who threw their health staff into a marathon meeting over a holiday weekend. 

Tao Sheng Kwan-Gett (TK): It was very, very clear that CDC leadership was compromised. 

ME: Health Officer Tao Sheng Kwan-Gett from Washington and his counterparts in California and Oregon hashed out a strategy to respond to possible federal vaccine changes. 

TK: With the departure of these highly respected public health leaders at CDC, we can no longer rely on them to make decisions and public health recommendations based on the best available science.

ME: The three states soon announced they’d follow major medical group’s guidance for vaccines Americans typically get each fall. 

Around the same time, Dan, RFK Jr. ‘s handpicked CDC advisors announced their new recommendations for the Covid vaccine. 

Rather than encouraging everyone over the age of six months to get the shots, the Kennedy advisors said people should talk to their doctors because the risks could outweigh the benefits. 

DG: A break from scientific consensus, right?

ME: Right. Medical societies representing pediatricians, family physicians and OB-GYNs, they all said the decision was out of line with the evidence. 

Some states rejected the Covid guidance, but a few went further, saying they would no longer rely on the CDC for any recommendations. 

Jen Kates (JK): The idea that states would publicly announce that they were departing from federal guidelines on vaccine recommendations just hasn’t happened.

ME: Jen Kates tracks vaccine policy at the health research group KFF.

Jen says this crack in the national standard really blew open over the winter as the feds weakened recommendations around a bunch of childhood vaccines.

For example, instead of saying kids should definitely get vaccinated against Hepatitis B and flu, the CDC said parents should consider it, in conversations with doctors. 

The agency defended the move, arguing its new recommendations are now closer to other developed nations.

Jen said many states weren’t buying it.

JK: That prompted a bunch more states to come on and say we’re not going to follow that. 

ME: Jen watched even more states defect from the federal standards as changes piled up. 

By January, states that had split with the feds on the entire childhood vaccine schedule jumped to 25, plus a few more that rejected some of the new guidance. 

JK: It’s quite a big departure. I’m not aware of that kind of phenomenon happening before, and certainly not at this scale.

DG: And, Melanie, were these all Democratic states or a mix of red and blue?

ME: Most have Democratic governors, but a few are Republican — like Vermont and New Hampshire. 

DG: So in the course of just a few months, we’ve gone from pretty much all states and the federal government working off the same vaccine playbook to this huge split?

ME: That’s right. I reached out to the CDC about this. A spokeswoman told me federal health agencies will work with states and clinicians to get families information they need to quote “make their own informed decisions.” 

But states that split from CDC are really worried new federal guidance has instead made this much harder. States are now trying to adjust their policies. And, truthfully, Dan, it’s a bit messy. 

DG: When we come back, Melanie explains what this rupture will mean for how people get vaccines and the risk of future outbreaks. 

BREAK

DG: Welcome back. Today we’re talking about the growing rift between states and the federal government on children’s vaccines. 

In the last 6 months, the Trump administration made several controversial changes to federal guidance on which shots kids should get. 

Half of states rejected those changes. 

So, now the nation has competing recommendations for kids’ vaccines. To help us understand what this means at a practical level, we asked Tradeoffs reporter Melanie Evans to interview policymakers, epidemiologists and doctors. 

So Melanie, half of states have split from federal vaccine guidelines. That sounds like a big deal. My question is whether this will actually make a difference in who gets which vaccines. 

ME: The short answer to that, Dan, is yes. Here’s one reason why. 

A big job of state health departments is to decide which vaccines to promote to parents and doctors. 

That’s a lot harder to do when you have more than one list of recommended vaccines. That’s what pediatrician Michelle Fiscus told me. Michelle is the chief medical officer for the Association of Immunization Managers. 

Michelle Fiscus (MF): It’s just changed from a process that was very routinized and predictable to one that has become really quite chaotic, where clinicians are having to question whether or not the recommendations they’re making are being made based on the best available evidence or not.

ME: Michelle says all of this shifting guidance – this chaos – could have real consequences.

She used the flu vaccine as an example. 

The CDC in January said parents should talk with their children’s doctor about whether they need the flu vaccine. That is a spilt from medical groups, who continue to endorse the annual shot. 

MF: We have never gotten flu immunization to the levels that we need to And now it’s going to be harder for clinicians to feel like they can make the same confident recommendation that they made three months ago about getting a flu vaccine and that’s going to amount to more illness, more hospitalizations, more unnecessary deaths.

ME: All around the country, Dan, lots of public health folks at the state level are really worried about this loss of a national standard. 

A handful of states have decided the best way to minimize confusion for the public is to partner up. 

Washington, California, Oregon and Hawaii have all agreed to follow the same guidance from the American Academy of Pediatrics.  

In the Northeast, at least seven states have also teamed up. 

DG: So not a national standard, but a regional one. 

ME: Exactly. By banding together, states hope to give a clear, consistent answer to doctors and parents who might be a little lost or frustrated with all the changes. 

DG: Ok. So, the conflicting recommendations are going to make vaccine decisions more difficult for parents and doctors. 

Another question I have Melanie is whether this rift is going to change which shots kids are required to get.

ME: Remember, mandates have always been set by states.

So in states that have broken with the CDC, vaccine requirements will likely stay the same … but states may need to change laws to make that happen.

DG: And what about the rest of the states?

ME: Well, there are a few that are using this moment to try to get rid of mandates entirely.

News clip: All of them. All of them. Every last one of them.

ME: That’s Florida Surgeon General Joseph Ladapo last September, making an argument that’s shared by many who oppose mandates.

News clip: Who am I as a government, or anyone else, who am I as a man standing here now, to tell you what you should put in your body.

ME: Ladapo is moving ahead with removing mandates for some shots.

Idaho last year prohibited all school mandates.

For now, these states are outliers. We’ll have to wait to see what happens to mandates in the rest of states that stick with CDC guidance. 

But after decades of vaccine policy being designed to get more people vaccinated, we’re now seeing real momentum and powerful support, including from the nation’s health secretary, for policies that prioritize letting people opt out.

DG: And, Melanie, what about money? A lot of the cost of these vaccines are picked up by either insurers or the federal government. 

ME: That’s right Dan. Federal law requires almost all insurers to cover CDC-recommended vaccines at no cost to patients. Nothing.  

When it comes to low-income kids, the feds actually pick up the tab … and last year they shelled out nearly 8 billion dollars.

So far, nothing much has really changed here. 

But states are worried it could. So many of them are working on contingencies to make sure vaccines stay free for as many people as possible.

For their part, insurance companies have promised to keep covering all vaccines through at least the end of 2026.

DG: So, this has the potential to be quite disruptive, it sounds like, and expensive for states and patients … but it hasn’t yet. 

ME: That’s right. 

DG: So, where does that leave us, Melanie? We know with fewer people vaccinated, we see more infections. 

As states strike out on their own, is there anything to be gained? Is there an upside? Is there an argument that states can be more responsive to local needs, laboratories to test new ideas? 

ME: Sure, Dan, this is a valid argument for a lot of policy. But here’s where lawyers and scientists and doctors that I spoke with say it falls short for vaccines.

We know what works. 

Dorit Reiss (DR): Vaccines are victims of their own success.

ME: That’s Dorit Reiss. She’s a public health law professor at the University of California San Francisco. 

So many of us have grown up without the threat of infection, she said, without fear and the consequences of outbreaks. And that’s because vaccines are incredibly effective.

DR: I think we’re going to learn why we need to worry about these diseases. Of course, the problem with this kind of learning is the cost. It comes in people’s life and and and health and that’s horrible, and we don’t want that. 

ME: The thing is Dan, we’ve been through this before.

In the 1960s and ‘70s, as new vaccines emerged, each state came up with their own policies. They were all over the map. 

I talked with one person who was there, who investigated what is really a textbook example of what happens when states have different vaccine policies. 

Philip Landrigan landed in Texarkana in the fall of 1970.

That city is split between Texas and Arkansas, and hundreds of kids there had come down with measles.

Philip Landrigan (PL): 95% of the cases were on the Texas side, and only 5% of the cases of measles were on the Arkansas side of the state line. 

ME: Arkansas, Philip learned, required students to get the measles vaccine and ran campaigns to immunize kids. 

PL: Texas, on the other hand, was all about free enterprise. 

ME: No vaccine requirement in Texas. No “go get vaccinated” campaign. And parents had to pay if they wanted their kid to get a measles shot.

In the fight to get every state to adopt vaccine mandates, lots of public health people used Texarkana as this case study for their effectiveness. 

It took about a decade from the Texarkana outbreak for all states to require vaccines.

During that time, the U.S. averaged about 35,000 measles cases a year. Hundreds of people died.

The lesson here is clear: policy matters. 

Arkansas kept kids protected with its strategy. That’s good news for the states sticking with mandates and medical society recommendations.

DG: Those policies can save lives.

But, Melanie, at the same time, it’s also true Arkansas residents were at risk from the outbreak across the border — and some got sick. 

The reality is there’s only so much each state can do on its own. 

ME: Exactly, Dan. And that’s what scares Philip.

PL: We’re going to see more Texarkanas, so long as there are other states where large numbers of children are unvaccinated, those states represent a threat. More children are going to get measles, more children are going to get rubella, some children could get polio. All of that can be prevented. 

DG: Thank you so much for your reporting on this, Melanie. 

ME: You’re welcome. 

DG: I’m Dan Gorenstein, this is Tradeoffs.