In a Nutshell: 

• Changes to federal vaccination recommendations are likely on the horizon, which would make it harder for many people to obtain certain vaccines without paying out-of-pocket. 
• Vaccination rates have been declining in recent years, but these changes could further reduce both seasonal vaccination rates for diseases like COVID-19 and childhood vaccinations rates for diseases like measles. 
• State policymakers should consider what Michigan could do to promote vaccination and ensure everyone who wants to get vaccinated is able to do so regardless of the cost. 

Vaccination rates have declined in Michigan and around the country in the wake of the pandemic, but recent and proposed federal policy changes have the potential to drive rates down even further as the changes will likely reduce the number of people whose health insurance coverage provides no-cost vaccines. 

In recent months, a number of federal policy changes around vaccination have been proposed or implemented, including the removal of COVID-19 boosters from the federal recommendation schedule for children and pregnant people. The new membership of the country’s vaccine recommendation panel has also signaled an interest in revisiting other vaccine recommendations, including the timing of established childhood vaccinations. 

In anticipation of further changes to federal vaccine recommendations, states must consider how to best ensure the public is properly informed about vaccination and preserve access to vaccines.  

Changes to Federal Vaccination Recommendations 

Typically, federal vaccination recommendations are initiated by the Advisory Committee on Immunization Practices (ACIP), a group of experts appointed by the U.S. Secretary of Health and Human Services who have clinical, scientific, and public health expertise in immunization. Following a decision by ACIP, the Centers for Disease Control and Prevention (CDC) director formally adopts federal vaccine recommendations. The ACIP process is designed to ensure that decisions regarding federal vaccine recommendations are informed by experts in the field and vetted through a public process, but ultimately the committee does not have final say over federal vaccine policy.  

This fact has come into the spotlight in recent months, as U.S. Secretary of Health and Human Services Robert F. Kennedy Jr. has taken a number of steps to alter vaccination policy in the United States by overriding and replacing members of ACIP. Secretary Kennedy is a long-time vaccine skeptic, promoting the consistently debunked idea that the MMR vaccine causes autism and urging people to resist CDC guidelines on childhood vaccination. 

In late May, without a recommendation from ACIP, he directed the CDC to remove COVID-19 boosters from the list of recommended vaccines for healthy children and  pregnant women, claiming that the “known risks associated with the use of COVID-19 vaccines in healthy U.S. children ages six months to 17 years do not outweigh the purported benefits of the vaccine” and that there is a lack of “high-quality data demonstrating safety of the mRNA vaccines during pregnancy combined with the uncertainty of the benefits of vaccination pose potential risks to the mother and the developing baby.” This action followed reporting that Secretary Kennedy’s CDC work group on COVID-19 vaccines wanted to end the recommendation that everyone receive an annual COVID-19 booster. 

In early June, Secretary Kennedy took an even more drastic step, removing every ACIP member from the committee – before their four-year terms expired – and appointing a new membership, including those who have spread baseless conspiracy theories about COVID-19 vaccines.  

When the new membership met for the first time last week, all eyes were on whether it would make further changes to recommendations for COVID-19 boosters. While no additional action was taken on COVID-19, the panel did vote to no longer recommend flu vaccines containing thimerosal, an ingredient Secretary Kennedy has wrongly argued causes autism. Many were also worried that the committee would revisit recommendations for other vaccines as well, even if those steps take more time. While the panel did not revise those recommendations last week, it announced plans at the meeting to review the timing of childhood vaccines. Given Secretary Kennedy’s actions to date, as well as his public statements and the statements of his appointees, it is reasonable for people to be concerned that federal vaccine recommendations will not be informed by the best available science going forward and vaccines that are widely accepted as best practices could be removed from the federal recommendations. 

The Importance of Federal Vaccine Recommendations  

The most straightforward role of federal vaccine recommendations is to endorse a set of health behaviors that the public should follow. The average citizen is not a medical expert and relies on experts to guide decisions about their health. The federal government outlining which vaccines a person should get carries significant weight in that decision and also helps guide the recommendations of medical professionals who work directly with patients. Changing a recommendation sends a signal to the public that a reason exists to decline the vaccine.  

While this impact is potentially problematic, other organizations exist that can inform the public on which existing vaccinations to receive, such as state and local health departments, professional organizations (America Medical Association, American Academy of Pediatrics, etc.), and non-profit organizations. These groups’ ability to persuade the public to get vaccinated may be impacted by counter messaging from the federal government, impacting vaccine uptake rates of less informed people. People who want good information about vaccination recommendations and have the ability to access relevant information will likely be able to get it even if the federal government makes changes.  

A more complicated consequence is that the disruption of the ACIP creates uncertainty about recommendations for any newly developed vaccines, as the ACIP plays a key role in balancing the costs and health benefits of vaccines. Without a single trusted federal panel to make recommendations, it is possible the state, local, and private entities that make recommendations could split on a recommendation, leaving the public somewhat unsure about the best course of action. 

Federal vaccine recommendations also have a direct impact on vaccine access for many people, as the requirement that private insurance companies cover a particular vaccine is generally tied to the vaccine’s status as a federally-recommended vaccine. Similarly, coverage under public insurance programs such as Medicaid and Medicare is also tied to vaccines’ recommendation status. The federal Vaccines for Children program also exists to pay for vaccinations for low-income children, but that coverage is tied to ACIP recommendations. If a vaccine is removed from the list of recommended vaccines for everyone, or even a group of people, insurance companies would not be required by law to cover the cost of that vaccine, which would require people to pay for the vaccine out-of-pocket. Some nuance exists as to when the coverage requirement kicks in depending on the type of coverage provider (i.e., ACIP recommendation vs CDC director approval of the recommendation), but the overall connection between a recommendation from the federal government and the cost to the patient exists across the board. 

The combination of the federal government no longer recommending a vaccine and new out-of-pocket costs would very likely decrease the number of people who get a given vaccine. For instance, the list price of the COVID-19 booster is between $150 and $200 per dose. Some people would be able and willing to pay for that immunization, but many people would likely forgo the shot in the face of those new barriers. Other approved vaccines have prices ranging from $20 and $250 per dose. 

The Impact of Declining Vaccination Rates 

If making vaccination more costly for residents reduces the vaccination rate, the state will face a series of related problems tied to an increase in people contracting infectious diseases. The first problem is simply the harm and disruption people experience from getting sick. For some people and some diseases, this would be a minor, but preventable inconvenience. For instance, most 25-year-olds who get the flu recover quickly, but children, the elderly, and the immunocompromised could have serious complications. If the declining vaccination rate spreads to a wider range of vaccines beyond COVID-19 boosters, the consequences could be even larger. 

Higher rates of infectious diseases also further strain the health care system, taking up resources like emergency room and inpatient hospital beds, as well as provider time. Additionally, the cost of treating infectious diseases such as COVID-19, flu, and measles, is higher than the cost of vaccination, so financial resources that could be spent on other things – health care or otherwise – will be lost due to lower vaccination rates.  

Broader economic costs would also be likely from a lower vaccination rate. Illness causes lower productivity, in terms of missed workdays for those who are acutely sick or caring for someone who is, and in terms of longer-term problems like disability and death. Most people who get sick with COVID-19 or the flu will only miss a few days or work, but some could face longer impacts. If the declining vaccination rate spreads to other diseases, the impact could be larger. 

Vaccination rates have been falling in Michigan and around the country over the last five years. Previous work by the Research Council called attention to the decline in childhood vaccination rates in the wake of the pandemic, with the situation worsening further since our 2022 report. Less than 93 percent of kindergarteners nationwide had received their state-required vaccines during the 2023-24 school year, down from 95 percent in the 2019-20 school year. Nearly every state has seen a decline in childhood vaccinations, with Michigan’s vaccination rates being in the middle of the pack. State-level data shows fewer Michigan toddlers than ever have completed their recommended vaccines. 

Seasonal vaccination rates, which were on the rise prior to COVID-19, have also been falling over the last few years. Only 45 percent of adults got flu shots during the 2023-24 flu season, although Michigan residents were vaccinated at slightly higher rates. 

The State Should Try to Promote Higher Vaccination Rates 

The problems arising from lower vaccination rates should prompt state action. Reducing harm to individuals from infectious diseases, preventing strain on the state’s health care system, and limiting the economic costs of disease are all uncontroversial goals for the state.  

In the context of vaccination policy, the balancing test has traditionally been about how far the state should go in pursuing those goals in the context of restricting individual choice through vaccination mandates. The recent and proposed federal vaccine policy changes go beyond questions of individual choice and create barriers for people who want to get vaccinated from obtaining those vaccines. The barriers come in the form of less information and higher out-of-pocket costs.  

It is one thing for the state to be cautious about how far it will go to encourage people to get vaccinated, but it is another thing entirely for people who want vaccines to be hindered from getting them due to government action that curtails public information sharing and shifts costs to household budgets. 

What Can Be Done to Offset Federal Action 

As noted earlier, two categories of problems arise from the recent and proposed vaccine policy changes at the federal level. The first problem is information and the second is cost, each requiring different responses. 

Promoting Good Information 

From an informational perspective, the federal government no longer recommending a given vaccine creates the possibility that members of the public who do not follow health policy closely will believe that the shot is no longer a good idea for them, as traditionally, recommendations from the CDC have been a reliable way to obtain information about good health practices.  

The state – and for that matter, local governments and private organizations – can step in to fill the void on this front. The state and its partners can make sure reliable, official recommendations and information about which vaccines people should obtain exist.  

While the state has resources related to vaccination and it tracks data on their utilization, the state currently does not have a process analogous to the ACIP or a public facing information hub on par with what has historically come from the CDC. Traditionally, the state has made good efforts to get the message out about what shots people should get, but the actual process of making formal recommendations of a vaccine schedule is something the state is not doing. Similarly, Michigan has vaccination requirements for entering school, but these requirements all build on federal recommendations. 

With the federal government, at least temporarily, no longer being a reliable leader in this effort, the state should ensure that there is clear, authoritative messaging about what people should do to keep themselves and their communities healthy. This could include building out the messaging and information portions of the state’s immunization website, but broader initiatives could include partnerships with other states, local health departments, and universities. Pulling together or participating in an appropriate group of experts that serves the function the ACIP has traditionally served would help mitigate the information consequences of changes in federal policy. 

Keeping Costs Down for Patients 

Even in a world where the public remains adequately informed on the best vaccination options, federal policy changes around vaccines are likely to impact their cost to patients, which will likely decrease their utilization. If a vaccine is not recommended by the CDC, insurers will not be required to cover it under federal law, creating the possibility that many insurers would drop coverage for any impacted vaccines. In the immediate future, COVID-19 boosters are likely to be affected, but there is certainly a possibility that childhood vaccinations could be impacted. The state has a couple of broad options to respond to this dynamic. 

State-Level Insurer Mandate: One option for Michigan is to enact a state law mandating coverage for certain vaccines even if those vaccines are not covered by the federal process. While seemingly straightforward to swap in a state mandate for a disappearing federal one, the state would need to establish an official process for determining which vaccines fall into this category and may not be able to apply the mandate to every private plan that operates in the state. If those hurdles could be overcome, the cost would be spread across the premiums charged to the entire enrollee base. Effectively, this approach would maintain the status quo arrangement as if the federal changes did not occur. Additionally, this approach would create a level playing field for all insurers who would not have to grapple with the decision to maintain coverage for certain vaccines.  

While insurers are generally in favor of covering low-cost care that reduces total costs, such as vaccines, the indirect nature of infectious disease spread and associated costs may lead to an individual insurance company not offering coverage because they may not be able to tie their direct investment in vaccine coverage to their direct savings. 

The state could also support coverage through the insurance system with a subsidy or tax-incentive to insurance companies that stops short of a mandate. If the state can shift the economics so that insurers are not incentivized to drop coverage, the status quo would be maintained for patients and providers. Figuring out how to design this subsidy or incentive could be challenging, however, and is not guaranteed to work the same way a mandate would. 

State-Funded Vaccine Clinics: The state could also inject money into vaccine clinics which provide certain shots at little or no cost to the patient. Many clinics exist around the state through local health departments and other organizations, many of which provide vaccines through a combination of insurance coverage, assistance programs, and general funds. Providing direct state funding to these kinds of programs for the purpose of providing specific vaccines for no cost (or a nominal cost) could make sense.   

In the case of COVID-19 boosters, for instance, some people will likely want to get vaccinated but will not be able to pay out of pocket for the $150 to $200 shot. Giving that population an option to find the shot for free will increase the uptake for the shot compared to doing nothing, even if it does make obtaining the shot harder than an insurance mandate approach. If federal policy turns against more traditional childhood vaccines, the demand for this option would likely grow and parents would be scrambling for opportunities to find lower cost options. 

Solving this kind of problem solely through state-funded vaccine clinics may be challenging, but at least creating some availability with this approach may make sense if an insurer mandate is not feasible. The benefit of this option is that it can be scaled to the amount of funding that the state can spare for this purpose and that local governments and private organizations can contribute as much as they are able as well. For example, finding $50 million for shots and deploying it through this network might not have the same impact as $1 billion, but it would help a portion of the population obtain vaccinations. The geographic variation in availability, however, could further exacerbate health disparities. This option is also more flexible than a mandate because the process for determining which shots are funded through this avenue can be less formalized, as it would not be establishing a mandate on a private company in the same way as an insurer mandate. Reports in other states suggest terminated federal grants are jeopardizing clinic capacity, so state support may be necessary if vaccine clinics are going to be part of the solution. 

While a state response may not seem urgent at the moment, given that the only official changes to federal vaccine recommendations are around COVID-19 boosters for children and pregnant women, the implications will be significant if childhood vaccines that have traditionally been required to attend school in the state are implicated. In the event that recommendations around the childhood vaccination schedule shift, the state will need to be ready to find a way to ensure continuity of vaccination coverage or alter the required vaccinations. Either path is costly for the state, but taking no action will not be an option, so policymakers should consider their options ahead of time. 

All of these policy options presume that the federal government only alters vaccine recommendations. In the event that the U.S. Food and Drug Administration looks to remove vaccinations from the market entirely, the state will not be able to do anything to address that situation and would have to focus on being ready to respond to higher infectious disease rates. 

Conclusion 

Recent changes to federal vaccination policy, driven by Secretary Kennedy’s dismissal of ACIP members and unilateral decisions about COVID-19 booster recommendations, mark a significant departure from the evidence-based, expert-led process that has traditionally guided national immunization guidance. It is likely these changes will lead to confusion about vaccination best practices and impact the ability of people who want to obtain vaccinations to afford them. 

Michigan policymakers are likely to face decisions in the near future about how to replace CDC messaging infrastructure, establish its own advisory processes akin to ACIP, and pursue policy solutions to ensure cost does not become a barrier to immunization for those who want to get vaccinated. Options such as insurer mandates, state-funded vaccine clinics, or subsidies to maintain vaccine coverage all offer avenues to mitigate the fallout from federal actions, although none of them are easy solutions. Given the stakes of declining vaccination rates, the time to deliberate of the path forward is now.