Monitoring State Actions on Vaccine Coverage and Entry

There’s a complicated interaction between the federal authorities and states relating to vaccine rules, coverage, and entry. Whereas states have the first accountability for enacting and implementing legal guidelines to advertise the well being, security, and common welfare of individuals of their jurisdictions, together with, for instance, instituting vaccine mandates, the federal authorities has significant authority to affect and alter vaccine coverage via approvals and licensure, suggestions to the general public and clinicians, funding, and legislative requirements that the majority insurers cowl vaccines really useful by the Facilities for Illness Management and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP) at no-cost. Furthermore, states have usually relied on and linked their own vaccine policies to CDC/ACIP suggestions. Nonetheless, with current actions taken by Secretary of Well being and Human Companies, Robert F Kennedy, Jr., to curtail vaccine entry – together with narrowing each FDA-approval of COVID-19 vaccines and CDC’s COVID-19 vaccine suggestions for the general public, in addition to modifications to the pediatric vaccine schedule (see packing containers 1-2) — many states have moved to keep up broader entry (some states pre-emptively did so earlier than the beginning of the Trump administration).

This coverage transient offers a snapshot of this quickly altering panorama, monitoring which states have instituted modifications in response to or in anticipation of administration coverage modifications, as of September 22, 2025. It finds that, as of this date, 26 states had carried out or introduced updates to their COVID-19 vaccine and different vaccine insurance policies, offering broader entry than present federal limits. There’s a important red-blue divide in these actions–Democratic governors lead 23 of the 26 states– suggesting that entry to vaccines may more and more fluctuate and diverge by state alongside partisan traces, very like the divide in public opinion. 

Findings

We examined state actions within the following three areas (notice that faculty vaccine coverage necessities and modifications are tracked individually, here):

• 1) Pharmacy Entry: State actions to permit pharmacists to manage COVID-19 vaccines, and in some instances different vaccines, with no prescription. Most adults get vaccinated at pharmacies, together with for COVID-19, and pharmacies on the whole have grow to be an necessary entry level for vaccination throughout the US. Pharmacists’ scope of apply, together with the authority to prescribe and administer vaccines, is regulated on the state stage and is often tied in regulation or regulation to CDC/ACIP recommendations. Due to modifications on the federal stage, some states have taken motion to explicitly authorize pharmacists to manage COVID-19 vaccines, and in some instances different vaccines, with no prescription.
• 2) Insurance coverage Protection. State actions to require state-regulated well being insurers to cowl COVID-19 vaccines, and in some instances different vaccines, at no-cost. The Inexpensive Care Act and different federal legal guidelines and rules require virtually all insurers to cowl CDC/ACIP really useful vaccines for gratis. States even have the authority to manage sure plans of their state (employer plans which are absolutely insured, and particular person and small-group market plans). States can use this authority to require that these plans present protection of companies past these coated underneath federal regulation. States can’t regulate the advantages of self-insured employer plans, which cowl 57% of people with employer-sponsored well being protection.
• 3) Sources of Steering/Experience. State reliance on non-federal entities for vaccine suggestions and steerage as an alternative of or along with CDC/ACIP. States have usually relied on CDC/ACIP suggestions for figuring out state vaccine insurance policies, together with for varsity entry, pharmacist scope of apply, and insurance coverage protection, however they’ll select to depend on different standards or steerage along with or as an alternative of CDC/ACIP.

To acquire state-level knowledge, we reviewed state web sites and official documentation. We solely included actions that had been taken in anticipation of or in response to modifications in federal vaccine coverage underneath the Trump administration. We counted a state as having taken an motion if a brand new coverage, regulation, or regulation was already put in place in addition to if an government order or different government instruction had been issued requiring such an motion be taken (even when it had not but taken impact).

As of September 22, 2025 (additionally see Table 1):

• Twenty-six states have moved to permit pharmacists to manage COVID-19 vaccines with no prescription in an effort to keep up entry as federal tips slender. 4 states and DC have moved to take action past COVID-19 and embrace different vaccines, which may embrace people who might now not be really useful by CDC/ACIP. Most of those states point out that they’re taking these actions to make sure COVID-19 vaccines stay extensively out there to all amid issues in regards to the narrowing of federal tips. Two states – North Carolina and Virginia – make clear that COVID-19 vaccines can be found at pharmacies with no prescription (and permit people underneath the age of 65 to self-attest that they’ve an underlying situation as a way to get vaccinated at a pharmacy with no prescription). Hawaii has joined a coalition of western states that has issued its personal COVID-19 tips recommending common vaccination for all these 6 months and older; it already authorizes pharmacists to manage vaccines to these ages 3 and older however has not issued an up to date standing order for the COVID-19 vaccine.  Among the many remaining twenty-five states, whereas some might have common insurance policies permitting pharmacists to manage really useful vaccines with no prescription, they haven’t made clear if this may allow them to take action for COVID-19 vaccines past federal limits.
• 13 states have moved to require state-regulated well being insurers to cowl COVID-19 vaccines for gratis, together with 4 which have executed so for all vaccines really useful by the state. In these states, no matter modifications to CDC/ACIP suggestions, which govern insurance coverage protection necessities for many insurers, state-regulated insurers will nonetheless have to cowl these vaccines without spending a dime. In states that haven’t taken steps to require continued protection of COVID-19 and different vaccines for gratis, if CDC adopts current ACIP suggestions, people will now not be assured entry to vaccines beforehand really useful by ACIP (although AHIP, the commerce affiliation for industrial insurers and different plans, has introduced that member insurers will proceed to cowl the vaccines with no value sharing voluntarily, at the least via 2026).
• Twenty-two states particularly establish non-federal entities as sources for his or her vaccine suggestions, both along with or as an alternative of CDC/ACIP. In over half (13) of those states, the suggestions solely apply to COVID-19 vaccines, whereas in 9 states, the suggestions apply to all vaccines. A number of states point out that they are going to observe the suggestions of impartial medical associations {and professional} teams (mostly, AAP, AAFP, and ACOG) whereas others have established or are organising their very own state-led advisory our bodies to develop vaccine suggestions. As well as, two inter-state alliances have fashioned to develop shared suggestions and different sources, together with the Northeast Public Well being Collaborative and the West Coast Well being Alliance, which collectively symbolize fourteen states (see Field 3). The West Coast Well being Alliance not too long ago issued its personal vaccine suggestions for COVID-19, influenza and RSV for the 2025–26 respiratory virus season, which don’t depend on ACIP.
• There’s a important red-blue divide, with virtually all states which have moved to keep up vaccine entry regardless of federal modifications having Democratic governors. Twenty-three of the twenty-six states that enable pharmacy entry for COVID-19 vaccines with no prescription have Democratic governors. Of those, North Carolina is the one one which hasn’t explicitly really useful COVID-19 vaccines past federal tips however permits these ages 65 and older and people underneath the age of 65 who’ve an underlying well being situation to get vaccinated in a pharmacy (and people underneath the age of 65 can self-attest that they meet the standards). Among the many three states with Republican governors – Nevada, Vermont, and Virginia – Nevada and Vermont enable people to entry COVID-19 vaccines at pharmacies with no prescription and never essentially linked to CDC/ACIP tips, whereas Virigina permits for self-attestation at pharmacies with no prescription.  The entire 13 states which have moved to require ongoing insurance coverage protection of COVID-19 vaccines have Democratic governors.

The current strikes by many states to de-couple their vaccine coverage determinations from federal suggestions to make sure continued entry because the federal authorities takes steps that slender entry is unprecedented, and can doubtless proceed because the federal authorities pursues additional modifications to vaccine suggestions. This divergence between federal coverage and the states and amongst states in the end signifies that vaccine protection and entry may more and more fluctuate in accordance with the place one lives. Extra restricted entry in some states may, in flip, result in decreased vaccine protection, elevated incidence of vaccine preventable ailments, as already has been seen with the current measles outbreak, and declining vaccine protection amongst school-aged youngsters. Confusion and distrust on the a part of the public overall, and parents particularly, may exacerbate these tendencies.