Seven US states and the nation’s largest city announced this week that they have formed the Northeast Public Health Collaborative, in an effort to strengthen the region’s health guidance as the national health landscape fractures.
As national health agencies revisit their recommendations, including high-profile restrictions on the updated Covid shots and the measles, mumps, rubella and varicella (MMRV) vaccine, the pressure is increasingly falling on states to navigate recommendations and new federal rules.
“I definitely see a future where there is considerable state-level variability on vaccine policy, much like we have seen in the abortion space,” said Katelyn Jetelina, an epidemiologist and former senior adviser for the US Centers for Disease Control and Prevention (CDC).
There were already some access issues with vaccines, especially for people who have been marginalized. “But in general, it didn’t matter where you lived,” said Jen Kates, senior vice-president at the health non-profit KFF. “Now it does.”
And while Covid shots were the first to be restricted, policies could also change on other shots – as with the MMRV restrictions proposed on Thursday.
“The area where it could really have a dramatic impact, is what might change with the kids’ [routine vaccination schedule],” Kates said.
The new alliance – among Connecticut, Maine, Massachusetts, New Jersey, New York state and New York City, Pennsylvania and Rhode Island – has been collaborating for months, including a meeting in August to discuss emergency preparedness, vaccine purchasing, lab capacity and more.
The West Coast Health Alliance, a similar organization led by the governors of Oregon, Washington, California and Hawaii, issued their first winter vaccine recommendation on Wednesday, encouraging residents to stay up to date on vaccines against Covid, flu and RSV.
In the past, the federal government funded much of the public health work done at state, local, territorial and tribal levels, and has worked as a “norm setter” by offering the best available evidence and public health practices, Kates said.
The states would then make decisions on, for instance, which vaccines are required for school attendance and whether they offer non-medical exemptions.
States also regulate pharmacists, deciding whether a pharmacist can vaccinate someone without a prescription or administer vaccinations to kids. And states regulate a subset of health insurers operating within their jurisdictions.
Several states have laws that pharmacists can administer vaccines, and that insurers must cover them, when they’re recommended by the Advisory Committee on Immunization Practices (ACIP).
Now, amid delays on recommendations and concerns that federal information may not be based on evidence or data, “they are scrambling to change their regulatory or information environments to be decoupled from the federal recommendation to the extent that they can”, Kates said.
“It’s a pretty dramatic thing. It’s happened very quickly,” Kates said. Several states have already moved to allow pharmacists to administer a Covid vaccine without a prescription and to require insurance coverage of the shots, and some have implemented broader language to potentially apply to other vaccines.
“It is going to create a very different environment, and it’s already happening.”
Other states are considering new restrictions to their vaccination policies. Florida’s surgeon general, Joseph Ladapo, promised the state would soon end vaccine mandates for school attendance, though no law has been proposed to amend those mandates.
Idaho has the highest non-medical exemption rate in the country, and the state tried to pass a law earlier this year ending mandates, though that part of the law was ultimately removed.
West Virginia’s senate passed a bill in February to expand non-medical exemptions, and Texas passed a bill making it easier to avoid vaccine mandates in May.
Some states, without changing any of their laws, might restrict access simply by “following exactly what FDA and CDC say”, Kates said.
The result is a patchwork of vaccine rules varying by location – the divided states of America.
The fractures will not be felt equally even among states. Low-income people who don’t have a strong relationship with doctors or private insurers will face more barriers to getting prescriptions and paying for shots, for example.
Medical organizations have also broken with official recommendations.
The American Academy of Pediatrics (AAP), for example, offers its own guidance on respiratory virus vaccination.
AHIP, the health insurance trade association, announced on Tuesday that members’ health plans will “continue to cover all ACIP-recommended immunizations that were recommended as of September 1, 2025”. Not every major insurer is a member of AHIP.
States can help implement the recommendations of these professional organizations and try to clear roadblocks to access, Jetelina said.
By banding together, states can also share the work of examining scientific evidence and offering recommendations, as well as sharing potential bulk orders and making other collaborative actions.
But one state’s policies can have repercussions for the entire nation.
“Infectious diseases don’t see state lines,” Jetelina said. “What happens in one state will directly impact people living in other states, especially those that cannot protect themselves because they are too young or too sick to get vaccinated.”
The changes to vaccine recommendations are “stressful”, even for people who try to stay informed, and “it contributes to this ecosystem of mistrust”, Kates said.
“And even for people who want to get a vaccine, the more obstacles that are put up – it’s going to deter everybody.”
While vaccine policy is shifting, vaccines remain overwhelmingly popular across the US.
The “vast majority of Americans” – between 80% and 90%, depending on the poll – still favor vaccination, though support has “dramatically shifted” along political lines in recent years, Jetelina said.
Even conservative parents in Florida, for example, support vaccines, according to a new KFF survey.
“They support mandates for going to school. They want their kids to be vaccinated,” Kates said.
