Tracking State Actions on Vaccine Policy and Access

There is a complex interplay between the federal government and states regarding vaccine regulations, policy, and access. While states have the primary responsibility for enacting and enforcing laws to promote the health, safety, and general welfare of people in their jurisdictions, including, for example, instituting vaccine mandates, the federal government has significant authority to influence and alter vaccine policy through approvals and licensure, recommendations to the public and clinicians, funding, and legislative requirements that most insurers cover vaccines recommended by the Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP) at no-cost. Moreover, states have generally relied on and linked their own vaccine policies to CDC/ACIP recommendations. However, with recent actions taken by Secretary of Health and Human Services, Robert F Kennedy, Jr., to curtail vaccine access – including narrowing both FDA-approval of COVID-19 vaccines and CDC’s COVID-19 vaccine recommendations for the public, as well as changes to the pediatric vaccine schedule (see boxes 1-2) — many states have moved to maintain broader access (some states pre-emptively did so before the start of the Trump administration).

This policy brief provides a snapshot of this rapidly changing landscape, tracking which states have instituted changes in response to or in anticipation of administration policy changes, as of September 22, 2025. It finds that, as of this date, 26 states had implemented or announced updates to their COVID-19 vaccine and other vaccine policies, providing broader access than current federal limits. There is a significant red-blue divide in these actions–Democratic governors lead 23 of the 26 states– suggesting that access to vaccines could increasingly vary and diverge by state along partisan lines, much like the divide in public opinion. 

Findings

We examined state actions in the following three areas (note that school vaccine policy requirements and changes are tracked separately, here):

• 1) Pharmacy Access: State actions to allow pharmacists to administer COVID-19 vaccines, and in some cases other vaccines, without a prescription. Most adults get vaccinated at pharmacies, including for COVID-19, and pharmacies in general have become an important access point for vaccination across the United States. Pharmacists’ scope of practice, including the authority to prescribe and administer vaccines, is regulated at the state level and is typically tied in law or regulation to CDC/ACIP recommendations. Because of changes at the federal level, some states have taken action to explicitly authorize pharmacists to administer COVID-19 vaccines, and in some cases other vaccines, without a prescription.
• 2) Insurance Coverage. State actions to require state-regulated health insurers to cover COVID-19 vaccines, and in some cases other vaccines, at no-cost. The Affordable Care Act and other federal laws and regulations require almost all insurers to cover CDC/ACIP recommended vaccines at no cost. States also have the authority to regulate certain plans in their state (employer plans that are fully insured, and individual and small-group marketplace plans). States can use this authority to require that these plans provide coverage of services beyond those covered under federal law. States cannot regulate the benefits of self-insured employer plans, which cover 57% of people with employer-sponsored health coverage.
• 3) Sources of Guidance/Expertise. State reliance on non-federal entities for vaccine recommendations and guidance instead of or in addition to CDC/ACIP. States have generally relied on CDC/ACIP recommendations for determining state vaccine policies, including for school entry, pharmacist scope of practice, and insurance coverage, but they can choose to rely on other criteria or guidance in addition to or instead of CDC/ACIP.

To obtain state-level data, we reviewed state websites and official documentation. We only included actions that were taken in anticipation of or in response to changes in federal vaccine policy under the Trump administration. We counted a state as having taken an action if a new policy, law, or regulation was already put in place as well as if an executive order or other executive instruction had been issued requiring such an action be taken (even if it had not yet taken effect).

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

• Twenty-six states have moved to allow pharmacists to administer COVID-19 vaccines without a prescription in an effort to maintain access as federal guidelines narrow. Four states and DC have moved to do so beyond COVID-19 and include other vaccines, which could include those that may no longer be recommended by CDC/ACIP. Most of these states indicate that they are taking these actions to ensure COVID-19 vaccines remain widely available to all amid concerns about the narrowing of federal guidelines. Two states – North Carolina and Virginia – clarify that COVID-19 vaccines are available at pharmacies without a prescription (and allow individuals under the age of 65 to self-attest that they have an underlying condition in order to get vaccinated at a pharmacy without a prescription). Hawaii has joined a coalition of western states that has issued its own COVID-19 guidelines recommending universal vaccination for all those 6 months and older; it already authorizes pharmacists to administer vaccines to those ages 3 and older but has not issued an updated standing order for the COVID-19 vaccine.  Among the remaining twenty-five states, while some may have general policies allowing pharmacists to administer recommended vaccines without a prescription, they have not made clear if this would permit them to do so for COVID-19 vaccines beyond federal limits.
• Thirteen states have moved to require state-regulated health insurers to cover COVID-19 vaccines at no cost, including four that have done so for all vaccines recommended by the state. In these states, regardless of changes to CDC/ACIP recommendations, which govern insurance coverage requirements for most insurers, state-regulated insurers will still need to cover these vaccines for free. In states that have not taken steps to require continued coverage of COVID-19 and other vaccines at no cost, if CDC adopts recent ACIP recommendations, individuals will no longer be guaranteed access to vaccines previously recommended by ACIP (though AHIP, the trade association for commercial insurers and other plans, has announced that member insurers will continue to cover the vaccines with no cost sharing voluntarily, at least through 2026).
• Twenty-two states specifically identify non-federal entities as sources for their vaccine recommendations, either in addition to or instead of CDC/ACIP. In over half (13) of these states, the recommendations only apply to COVID-19 vaccines, while in nine states, the recommendations apply to all vaccines. Several states indicate that they will follow the recommendations of independent medical associations and professional groups (most commonly, AAP, AAFP, and ACOG) while others have established or are setting up their own state-led advisory bodies to develop vaccine recommendations. In addition, two inter-state alliances have formed to develop shared recommendations and other resources, including the Northeast Public Health Collaborative and the West Coast Health Alliance, which together represent fourteen states (see Box 3). The West Coast Health Alliance recently issued its own vaccine recommendations for COVID-19, influenza and RSV for the 2025–26 respiratory virus season, which do not rely on ACIP.
• There is a significant red-blue divide, with almost all states that have moved to maintain vaccine access despite federal changes having Democratic governors. Twenty-three of the twenty-six states that allow pharmacy access for COVID-19 vaccines without a prescription have Democratic governors. Of these, North Carolina is the only one that hasn’t explicitly recommended COVID-19 vaccines beyond federal guidelines but allows those ages 65 and older and those under the age of 65 who have an underlying health condition to get vaccinated in a pharmacy (and those under the age of 65 can self-attest that they meet the criteria). Among the three states with Republican governors – Nevada, Vermont, and Virginia – Nevada and Vermont allow individuals to access COVID-19 vaccines at pharmacies without a prescription and not necessarily linked to CDC/ACIP guidelines, while Virigina allows for self-attestation at pharmacies without a prescription.  All of the thirteen states that have moved to require ongoing insurance coverage of COVID-19 vaccines have Democratic governors.

The recent moves by many states to de-couple their vaccine policy determinations from federal recommendations to ensure continued access as the federal government takes steps that narrow access is unprecedented, and will likely continue as the federal government pursues further changes to vaccine recommendations. This divergence between federal policy and the states and among states ultimately means that vaccine coverage and access could increasingly vary according to where one lives. More limited access in some states could, in turn, lead to decreased vaccine coverage, increased incidence of vaccine preventable diseases, as already has been seen with the recent measles outbreak, and declining vaccine coverage among school-aged children. Confusion and mistrust on the part of the public overall, and parents specifically, could exacerbate these trends.