US State Actions Related to COVID-19 Vaccination Infrastructure and Access Amid Federal Shifts

Abstract

This study analyzes US state actions taken in 2025 that strengthened or weakened COVID-19 vaccination infrastructure and access.

Immunization programs have historically relied on aligned federal and state policy.¹ The US Food and Drug Administration (FDA), Advisory Committee on Immunization Practices (ACIP), and Centers for Disease Control and Prevention (CDC) release vaccine regulatory decisions and recommendations, which states often reference in laws and regulations to govern clinician authority, insurance coverage, and, ultimately, vaccine access. Delays and the absence of updated ACIP recommendations early in the 2025-2026 viral respiratory season introduced uncertainty for states whose regulations explicitly reference federal guidance.² These developments prompted varied state-level actions, both executive and legislative, affecting COVID-19 vaccination access, with long-term implications for future vaccine policy.³ This study analyzed state actions taken in 2025 that strengthened or weakened COVID-19 vaccination infrastructure and access.

Methods

We systematically reviewed public documentation of state actions from April 1 to December 31, 2025, during the period leading into the 2025-2026 respiratory season across 50 US states. Inclusion criteria were any official statewide measures that affected the infrastructure for and access to COVID-19 vaccination, including standing orders, insurance directives, executive and regulatory directives, legislation, and state-issued clinical guidance, as well as state participation in public health collaboratives in response to shifting federal policy. Finally, actions were categorized as strengthening if they expanded or supported COVID-19 vaccination infrastructure or access and weakening if they modified or constrained policy mechanisms supporting vaccination infrastructure or access. This study was reviewed by the University of North Carolina at Chapel Hill Office of Human Research Ethics and determined to be exempt from institutional review board oversight. Informed consent was waived. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Results

From April to December 2025, 31 states (62%) took actions to strengthen COVID-19 vaccine infrastructure, while 13 states (26%) enacted policies that weakened COVID-19 vaccine infrastructure. Five states enacted both strengthening and weakening policies. Eleven states did not enact policies related to COVID-19 vaccine infrastructure (Figure).⁴

Figure. Map of State Actions That Impacted COVID-19 Vaccine Infrastructure or Access, April to December 2025.

Actions including standing orders, insurance directives, executive and regulatory directives, legislation, and clinical guidance from April 1 to December 31, 2025. Based on 2025 US Census Bureau estimates, states taking strengthening actions represent 57.9% of the US population (197.6 million); weakening actions, 25.0% (85.2 million); both, 6.9% (23.7 million); and no captured action, 10.1% (34.6 million).⁴ S indicates strengthened and W, weakened.

Policy mechanisms used to strengthen vaccine infrastructure or access included standing orders (n = 18), insurance directives and coverage policies (n = 15), executive or regulatory directives (n = 18), and legislation (n = 8) (Table). Thirty states enacted at least 1 strengthening action affecting pharmacist scope of practice authority, with individual states often using multiple policy mechanisms. Fifteen states issued statewide clinical guidance through release of their own COVID-19 vaccine recommendations. Across strengthening state actions, the professional medical society guidance referenced most often included that of the American Academy of Pediatrics (n = 21), the American College of Obstetricians and Gynecologists (n = 20), and the American Academy of Family Physicians (n = 20). Fourteen states joined the Governors Public Health Alliance and/or regional collaboratives (ie, the Northeast Public Health Collaborative or the West Coast Health Alliance), which coordinated vaccine policy responses.⁵

Table. State Actions Strengthening and Weakening COVID-19 Vaccine Infrastructure or Access, April to December 2025.

No. of states	Policy mechanism and definition	States
Actions strengthening COVID-19 vaccine infrastructure or access
18	Executive and regulatory directive: executive orders, emergency or public health proclamations, or directives from regulatory bodies (eg, boards of pharmacy) that modify clinician authority, clarify permissible clinical practices, or remove operational barriers but do not serve as standing clinical orders	Arizona, Colorado, Connecticut, Hawaiʻi, Illinois, Kentucky, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, South Carolina, Utah, Wisconsin
18	Standing order: clinical orders issued by a state health officer or designated physician that acts as a prescription, allowing pharmacists and other nonprescribing clinicians to administer COVID-19 vaccines without patient-specific prescriptions	Alabama, Arizona, Colorado, Delaware, Illinois, Indiana, Maine, Maryland, Massachusetts, Minnesota, New Jersey, New York, North Carolina, Rhode Island, Vermont, Virginia, Washington, Wisconsin
15	Insurance directive: directives from insurance departments or Medicaid agencies requiring or affirming coverage of COVID-19 vaccination, including zero cost sharing	Colorado, Connecticut, Hawaiʻi, Illinois, Maine, Massachusetts, Michigan, New Jersey, New Mexico, New York, Oregon, Pennsylvania, Rhode Island, Vermont, Wisconsin
15	State-issued clinical guidance: stand-alone, statewide advisories issued by state health departments that articulate clinical recommendations or patient eligibility criteria for COVID-19 vaccination, independent of Centers for Disease Control and Prevention or Advisory Committee on Immunization Practices schedules; these documents do not themselves confer legal authority to administer vaccines and may reference professional society guidance (eg, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American Academy of Family Physicians)	California, Connecticut, Hawaiʻi, Illinois, Iowa, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, Pennsylvania, Rhode Island, Vermont
8	Legislation: statutory changes enacted that alter vaccination authority, insurance coverage mandates, or related regulatory requirements	California, Colorado, Illinois, Maine, Maryland, Massachusetts, Nevada, New Mexico
Actions weakening COVID-19 vaccine infrastructure or access
10	Patient requirements, consent, and cost: measures that prohibit COVID-19 vaccine requirements or impose additional COVID-19–specific access, disclosure, or consent requirements on individuals	Arizona, Florida, Idaho, Iowa, Kansas, Louisiana, Montana, New Hampshire, Tennessee, Texas
4	Clinician practice and liability frameworks: policies that rescind or limit clinician authority to administer COVID-19 vaccines, modify liability protections, or require COVID-19–specific informed consent disclosures	Minnesota, Ohio, South Carolina, Texas
3	Public health authority limitations: state actions that constrain health official or health department authority over COVID-19 vaccine regulation, emergency use authorization products, or related public health communications	Louisiana, South Carolina, Tennessee

State actions that weakened vaccine infrastructure or limited access (Table) included alterations to COVID-19 vaccine requirements, informed consent process, and out-of-pocket cost (n = 10; eg, expanding exemptions from or prohibiting requirements, increasing vaccine fees). States also altered clinician practice and liability frameworks (n = 4), including scope-of-practice restrictions for COVID-19 vaccination and vaccine informed consent or liability modifications. Three states limited public health authority, reducing state health department regulatory or communication authority related to COVID-19 vaccines.

Discussion

During a period of federal uncertainty as the FDA narrowed the COVID-19 vaccine label and ACIP recommendations were delayed in fall 2025, 62% of US states enacted policies to strengthen COVID-19 vaccine infrastructure or access, while 26% took actions that weakened vaccine infrastructure or access. Because many states encode federal recommendations into their statutes and rules governing clinician scope of practice and vaccine coverage requirements, delays in federal action prompted state-level intervention for vaccine access.⁶ Actions to maintain or expand pharmacist authority were the most common action, a critical step as pharmacists administer more than two-thirds of adult COVID-19 vaccinations annually.⁷ States frequently relied on evidence-based clinical guidance from national medical societies in the absence of updated ACIP recommendations.⁸ With further changes to the broader US Department of Health and Human Services childhood immunization schedule, 28 states as of January 2026 had announced they no longer solely rely on the CDC for vaccine recommendations.⁹

The most common actions that weakened vaccine infrastructure or access for COVID-19 vaccines were expanded exemptions or limitations on vaccine requirements, signaling a shift in priority from population-level immunization coverage to individualized risk-benefit assessment. In the 5 states that enacted both strengthening and weakening measures, executive and/or administrative actions were most often targeted at preserving pharmacy vaccine access amid delayed updates to federal COVID-19 vaccination guidance, while legislative actions expanded exemptions or constrained public health authority.

Although state actions were systematically searched and reviewed with national partners, publicly available documentation may not capture all legislative or executive activity. Local or health system–level actions were not included, nor were the reasons for state inaction.

State actions in 2025 demonstrate how state authority can impact vaccinations in a shifting federal landscape. Overall, more states preserved vaccine infrastructure and access for COVID-19 than weakened it. Sustained divergence in state policy may increasingly determine how and where vaccines are accessed. A stable, evidence-based national recommendation and regulatory framework remains critical to maintaining coherence in the US immunization system.¹⁰

Supplement.

Data Sharing Statement