Brady Collins
In the United States, the federal government has historically influenced vaccine policy through the Advisory Committee on Immunization Practices (ACIP), which develops science-based recommendations on vaccine usage. While ACIP recommendations are typically adopted by the Centers for Disease Control and Prevention (CDC), states possess varying degrees of autonomy in vaccine-related decision-making. This is particularly evident in the context of immunization requirements for immigrants, where civil surgeons follow technical instructions and HHS regulations to conduct vaccination assessments. States like Maine and Massachusetts are taking steps to empower their health departments to make independent decisions about vaccination programs and childhood immunizations, respectively. These actions reflect a shift in vaccine policy dynamics and underscore the evolving relationship between federal recommendations and state-level autonomy in the United States.
| Characteristics | Values |
|---|---|
| Federal government influence on vaccine policy | The Advisory Committee on Immunization Practices (ACIP) was formed in 1964 to develop science-based recommendations on how vaccines should be used. |
| State influence on vaccine policy | Some states are introducing legislation to protect access to vaccines and reduce reliance on ACIP recommendations. |
| Role of insurance companies | If ACIP no longer recommends certain vaccines, individuals may have to pay out-of-pocket. Insurance companies have historically covered the full cost of ACIP-recommended vaccines. |
| Immigration requirements | The CDC publishes vaccination requirements for immigrants, including refugees, seeking adjustment of status in the US. |
| Vaccine choice | There is a growing emphasis on offering individuals a choice of vaccines to reduce hesitancy and promote informed consent. |
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What You'll Learn
The Advisory Committee on Immunization Practices (ACIP)
The ACIP was established in March 1964 by the US Surgeon General to assist in preventing and controlling communicable diseases. It is a key committee responsible for shaping US vaccination policy. The committee holds three regular meetings each year, and its statements are official federal recommendations for using vaccines and immune globulins in the US. The ACIP develops written recommendations for the routine administration of vaccines to both pediatric and adult populations, along with vaccination schedules regarding appropriate timing, dosage, and contraindications.
At its meetings, the ACIP may vote to include new vaccines in the VFC program or modify existing vaccine schedules. These votes are codified as VFC resolutions. The committee's recommendations are forwarded to the CDC Director for approval and, once approved, represent the official CDC recommendations for immunizations in the US. The ACIP also provides advice and guidance to the Secretary of Health and Human Services (HHS), the Assistant Secretary for Health, and the Director of the CDC.
In June 2025, the Secretary of Health and Human Services, Robert F. Kennedy Jr., fired all 17 ACIP members, appointing replacements who were either anti-vaccine activists or lacked expertise in vaccines. Despite this, the committee continues to play a crucial role in shaping US vaccination policy.
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State-level legislation
However, recent developments have seen a shift in the decision-making process. In June 2025, Robert F. Kennedy, Jr., a prominent anti-vaccine activist and head of the Department of Health and Human Services (HHS), fired all 17 members of the ACIP, citing "persistent conflicts of interest." This move has raised concerns about the evidence-driven decision-making process being sidestepped.
In response to these changes at the federal level, several states are taking legislative action to protect vaccine access and empower their state health departments to make independent decisions. For example, Maine removed references to ACIP in a law, giving its state health department autonomy over vaccination programs. New York introduced legislation mandating health insurance coverage for the COVID-19 vaccine, and Massachusetts filed a bill to grant its public health commissioner authority over childhood immunizations without solely relying on ACIP recommendations.
These state-level efforts reflect a desire to maintain vaccine accessibility and evidence-based decision-making. They also highlight the potential challenges and opposition that may arise in politically diverse states. The insurance industry's response to changing federal guidelines remains uncertain, with major insurers yet to confirm their coverage plans for routine vaccinations.
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Immigration requirements
United States immigration law requires immigrant visa applicants to obtain certain vaccinations before their visa is issued. The Centers for Disease Control and Prevention (CDC) determines which vaccines are required for immigration purposes. The CDC publishes a list of required vaccines, and applicants must show proof of having received these vaccines. If an applicant does not have proof of vaccination, they will be administered the vaccines at the time of their medical exam.
The CDC's criteria for selecting which vaccines are required include:
- The vaccine must be age-appropriate as recommended by the Advisory Committee on Immunization Practices (ACIP) for the general US population.
- The vaccine must protect against a disease that has been eliminated or is in the process of being eliminated in the United States.
- The vaccine must protect against a disease with the potential to cause an outbreak.
The specific vaccines required for immigration have changed over time. For example, from August 1, 2008, to December 13, 2009, the human papillomavirus (HPV) vaccine was required for female applicants aged 11 to 26 years. This requirement was eliminated on December 14, 2009. From August 1, 2008, to December 13, 2009, the zoster vaccine was required for applicants aged 60 years or older unless they had received the varicella vaccine. The zoster vaccine no longer meets the CDC's criteria and is not required for the immigrant medical exam.
As of January 22, 2025, the COVID-19 vaccination is no longer required for immigration medical exams. However, some vaccines are still expressly required by statute, including the Hepatitis B and meningococcal vaccines. Additionally, applicants must receive any other vaccinations recommended by the ACIP if they are age-appropriate and medically appropriate. If an applicant does not have the required vaccinations and they are deemed medically appropriate, they are considered inadmissible.
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Vaccine hesitancy
In the context of the COVID-19 pandemic, vaccine hesitancy became a pressing issue in the United States, with large numbers of people expressing reluctance to receive the vaccine. Vaccine hesitancy refers to the reluctance or refusal to vaccinate, often due to misconceptions about vaccine safety and effectiveness. This issue is not new, but the COVID-19 pandemic brought it into sharp focus, as it was one of the fastest vaccine development and approval processes in history.
National surveys conducted in the US between January and May 2021 shed light on the prevalence and factors associated with vaccine hesitancy. Overall, 23.5% of respondents reported vaccine hesitancy, with rates varying across different states. Louisiana had the highest hesitancy rate at 40.2%, while Rhode Island had the lowest at 11.7%.
Demographics, geography, beliefs, and behaviours all influenced vaccine hesitancy. Younger adults, females, and those with a lower education level and income were more likely to be hesitant. Additionally, people living in rural areas, in Republican-leaning states, and in the Southern US were also more likely to express hesitancy.
The reasons for vaccine hesitancy are complex and varied. Common concerns included fear of side effects, distrust in the vaccine and the government, not feeling the need for the vaccine, and preferring to wait and see if it is safe. Other factors included past experiences with COVID-19 infection, risk perception, and personal beliefs about the severity of the disease and the effectiveness of vaccines.
Addressing vaccine hesitancy requires understanding the specific concerns and contexts of different communities. State-specific data and understanding factors contributing to hesitancy can help inform public health planning, programs, and policies to increase vaccine confidence and uptake.
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Insurance coverage
In the United States, most private health plans are required by law to cover the cost of recommended vaccines without charging their members. This includes vaccines for Covid-19, measles, and the flu. However, this requirement only comes into effect after the Advisory Committee on Immunization Practices (ACIP) has made its recommendations and they have been adopted by the CDC director.
The Advisory Committee on Immunization Practices advises the CDC on which people should receive vaccines and at what intervals after they are approved by the FDA. ACIP has provided vaccine guidance to the CDC for 60 years. However, in 2025, Robert F. Kennedy Jr., a longtime anti-vaccine activist, was appointed to head the US Department of Health and Human Services (HHS). Kennedy replaced the entire ACIP committee with his own appointees, including anti-vaccine activists. This has caused uncertainty around insurance coverage for vaccines, as it is unclear whether insurers will continue to cover vaccines if the government stops recommending them.
Some states, such as Colorado and Massachusetts, have amended their laws to include vaccine recommendations from major medical societies in addition to ACIP when setting policies for immunizing schoolchildren. Insurers have stated that they would be more likely to cover uniform vaccine recommendations, and some health professionals have expressed concern that the push for alternative standards will increase confusion among providers and patients.
Regarding Covid-19 vaccines specifically, there is no clear answer as to whether insurance plans will cover them in the fall of 2025. While some experts believe that employer plans will likely cover the vaccines, others note that insurance coverage rules are becoming more restrictive. It is recommended that individuals check with their employer or insurer about coverage policies before getting vaccinated.
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Frequently asked questions
No, vaccinations are not mandatory in the US. However, certain vaccinations are required for immigration purposes.
Yes, some applicants who have previously completed an immigration medical examination abroad, including refugees applying for adjustment of status, may be exempt from repeating the entire examination.
The ACIP is a committee that provides science-based recommendations on how vaccines should be used. Their recommendations are typically adopted by the Centers for Disease Control and Prevention (CDC) and influence insurance coverage for vaccines.
In voluntary vaccination programs, offering a choice of vaccines may reduce hesitancy and show respect for individual decision-making. However, during the early stages of the COVID-19 vaccination distribution, the ACIP argued against offering choices due to limited vaccine supply.
