Support for immunization-related child tax credit programs: A survey of parents in the United States

Abstract

Objectives

Describe parental attitudes toward proposed tax credit policies that would promote pediatric immunization coverage in the United States.

Methods

A national survey was conducted from August–September 2025. Participants were recruited from an online panel and asked to use Likert scales to characterize support for proposed policies that would: revise the eligibility criteria of the existing federal child tax credit to include age-appropriate immunization, create a new tax credit for parents providing evidence that their children are age-appropriately immunized, or create a new tax credit for families residing in a state where at least 95% of the children are age-appropriately immunized.

Results

The data analysis included 1006 participants. 53.9% expressed support for revising the eligibility criteria of existing child tax credits to include age-appropriate immunization. 62.6% expressed support for creating a new tax credit for parents providing evidence that their children are age-appropriate immunized. 57.4% expressed support for creating a new tax credit for families residing in a state where at least 95% of the children are age-appropriately immunized. Support differed according to participant characteristics, but notably, not according to partisanship or welfare program participation.

Conclusions

Most parents in this survey supported novel tax policies that may improve immunization coverage.

Highlights

• •Most parents are willing to consider immunization-related child tax credit policies.
• •Bipartisan support exists for revising existing and creating new tax credit programs.
• •Findings may also inform the development of or revisions to state-level tax policy.

1. Introduction

Immunizations are among the most effective and cost-effective public health interventions. They have been responsible for preventing substantial amounts of morbidity and mortality, and reducing preventable health expenditures. Despite this—as well as a robust evidence base demonstrating their safety (Maglione et al., 2014; Taylor et al., 2014; Di Pietrantonj et al., 2021; Andersson et al., 2025)—public concern about the safety of childhood vaccines persists in the United States. This concern, and hesitancy toward vaccines, can result in delays in the acceptance of vaccines or the refusal of vaccination altogether (MacDonald et al., 2018). These trends are concerning, given that the public health impacts of immunization are contingent upon high levels of coverage (Doherty et al., 2016). And the harmful effects of low immunization coverage have been evidenced by recent outbreaks of vaccine-preventable diseases, such as measles and pertussis (Phadke et al., 2016; Mathis et al., 2024; Mathis et al., 2025).

Policymakers have two broad mechanisms for promoting immunization coverage: mandates and financial policies. Vaccine mandates often rely on behavioral levers that link immunization status to an individual's ability to access public goods or avoid punishments (Attwell et al., 2020). For example, in the United States, many states maintain immunization requirements for entry to public, private, parochial, and other types of schools (U.S. Centers for Disease Control and Prevention, 2022). While evidence suggests that these types of mandates may increase uptake, they can also entrench negative perceptions of vaccines, and ethical concerns remain surrounding decisions to make vaccination mandatory (Omer et al., 2019; Salmon et al., 2015; Amin et al., 2012).

Though relatively uncommon, financial policies, such as incentives and sanctions, represent other mechanisms to promote vaccine uptake (Sutherland et al., 2008; Vlaev et al., 2019). These types of government interventions often draw from concepts from the field of behavioral economics, such as nudging (Thaler and Sunstein, 2008; Dubov and Phung, 2015; Beshears and Kosowsky, 2020; Viswanadham, 2023). Nudging seeks to modify the choice architecture surrounding decision-making processes, and to alter people's behavior in a predictable way, without explicitly forbidding any choices or significantly changing economic incentives (Thaler and Sunstein, 2008). The underlying assumption behind modifying the choice architecture is that individuals make suboptimal decisions primarily because of cognitive biases and errors, not necessarily because they lack information. For example, omission bias, present bias, optimism bias, and ambiguity aversion all have implications for vaccination decisions (Dubov and Phung, 2015).

Among the more unique financial policies relating to immunization coverage is one that has been championed by the Australian government. In 1998, in the face of low pediatric immunization coverage rates, the Australian government adopted a policy requiring documented receipt of all recommended vaccines for eligibility for government family assistance payments, such as the childcare benefit and childcare rebate payments (MacDonald et al., 2018; Achat et al., 1999; Lawrence et al., 2004; Trent et al., 2019; Beard et al., 2024). Initially, medical, conscientious, and religious exemptions could be obtained via a declaration signed by a parent and medical provider; in 2016, however, the “No Jab, No Pay” legislation removed the conscientious and religious exemptions (Trent et al., 2019; Beard et al., 2024). Research suggests that these policies have increased immunization coverage and that Australians generally support the policies (Lawrence et al., 2004; Trent et al., 2019; Beard et al., 2024).

By comparison, in the United States, financial incentives and sanctions are not currently used to promote routine immunizations. Still, there is precedent. In 1984, researchers found that financial payments enhanced the effectiveness of other measures aimed at increasing immunization in the Midwest (Yokley and Glenwick, 1984). Other policies in the 1990s sought to determine whether withholding welfare payments could be used to improve vaccination coverage in low-income families. Studies examining these policies produced mixed results, though the focus of these policies on low-income families was criticized on ethical grounds (Minkovitz et al., 1999; Kerpelman et al., 2000; Davis and Lantos, 2000). Still, immunization coverage has stagnated or declined throughout much of the United States (U.S. Centers for Disease Control and Prevention, 2026).

Critically, the United States has government payment schemes analogous to those in Australia, including federal child tax credits. These tax credits are payments from the federal government to families that meet certain eligibility criteria, including having at least one child 17 years of age or younger, and having an annual household income of less than $200,000 (or $400,000 if filing a joint tax return). Accordingly, embracing behavioral economics and revisiting the use of financial incentives and sanctions to bolster immunization coverage in the United States may be warranted. Within this context, the objectives of this study are to explore parental attitudes toward novel tax credit policies that would seek to improve immunization coverage in the United States. Secondary objectives include examining support and opposition across subpopulations.

2. Methods

2.1. Study design and population

A survey questionnaire was developed to characterize support for tax benefit policies based on the immunization status of children. Cint Marketplace was used to recruit participants. Cint sources participants using a double-opt-in procedure whereby individuals must first opt into the Cint survey platform and then into specific surveys. Participation is incentivized using a points-based system. Eligibility criteria included: (i) residence in the United States, (ii) being 18 years of age or older, and (iii) being the parent or legal guardian of at least one child 5 years of age or younger. Surveys were administered in English, and data were collected from August 20 to September 9, 2025. Participants who failed attention checks and those who provided incomplete data were excluded from data analysis.

2.2. Measures

The instrument included questions about participants' support for three different tax policies: one modified the existing federal child tax credits by adding age-appropriate immunization, valid medical exemption, or religious exemption as an eligibility criterion; one created a new, $1000 vaccination tax credit for parents who could prove that their children are age-appropriate immunized, or have valid medical or religious exemptions; and one created a new, $1000 immunization threshold tax credit for families residing in a state where at least 95% of the children are age-appropriately immunized, or have a valid medical or religious exemption (Table 1).

Table 1.

Proposed policies that would create immunization-related child tax credit benefits in the United States.

Proposed Policy	Description
Revise Child Tax Credit (CTC)	The Child Tax Credit is a federal tax benefit designed to help families offset the cost of raising children by reducing federal income taxes. The credit is up to $2000 per qualifying child. Currently, to qualify for the Child Tax Credit, you must: (1)Have at least one child 17 years of age or younger; and (2)Your annual income must not exceed $200,000 (or $400,000 if filing a joint tax return). The federal government is considering a new policy that would require parents to prove that their children are fully vaccinated, or have a valid medical or religious exemption, to receive the federal Child Tax Credit.
Create a Vaccination Tax Credit (VTC)	The federal government is considering creating a new Vaccination Tax Credit. The Vaccination Tax Credit is a federal tax benefit that reduces federal income taxes. The credit is up to $1000 per qualifying child. To qualify for the Vaccination Tax Credit, you must: (1)Have at least one child 17 years of age or younger; (2)Your annual income must not exceed $200,000 (or $400,000 if filing a joint tax return); and (1)Provide evidence that your children are fully vaccinated or have a valid medical or religious exemption.
Create an Immunization Threshold Tax Credit (ITTC)	The federal government is considering creating a new Immunization Threshold Tax Credit. The Immunization Threshold Tax Credit is a federal tax benefit that reduces federal income taxes. The credit is up to $1000 per qualifying child. To qualify for the Immunity Tax Credit, you must: (1)Have at least one child 17 years of age or younger; (2)Your annual income must not exceed $200,000 (or $400,000 if filing a joint tax return); and (2)Reside in a state where 95% of the children are fully vaccinated or have a valid medical or religious exemption.

Support for the proposed policies was measured using a 5-point Likert scale. If an individual indicated that they would not support a policy, they were presented with a list of reasons for opposition that included a free-response option for other reasons. The survey also queried on whether the proposed policies would cause people to reconsider vaccinating their children if they had previously objected or hesitated. Other collected data included participant sex, age, race, ethnicity, educational attainment, annual household income, health insurance status, participation in the federal government's Supplemental Nutrition Assistance Program (SNAP), partisanship, vaccine hesitancy, and state of residence. The survey instrument also included a validated tool for characterizing vaccine hesitancy (Larson et al., 2015). This tool posed a series of 10 statements about vaccines, and participants were asked to quantify their agreement with the statements using 5-point Likert scales, where lower scores corresponded to lower levels of vaccine hesitancy. Survey questions are available in an appendix (Supplementary File 1).

Raw survey data were obtained and processed to facilitate data analyses. A vaccine hesitancy index score (VHIS) was calculated by calculating the average score across the 10 vaccine hesitancy questions. Participants were then categorized as being either hesitant (VHIS≥3.0) or not hesitant (VHIS<3.00). This threshold was selected to dichotomize vaccine hesitancy at the point where participants were, on average, more hesitant than neutral or not hesitant. Partisanship was condensed by collapsing Democrat and Strong Democrat into a single group (i.e., Democrat), and Republican and Strong Republican (i.e., Republican) into a single group. Support was also dichotomized for certain analyses by collapsing support and strongly support into a single group (i.e., Support), and neither support nor oppose, oppose, and strongly oppose into a single group (i.e., Oppose).

2.3. Statistical analysis

Chi-squared tests to compare differences in dichotomized support between those of different partisan preferences and participation in SNAP. The threshold for statistical significance was set at p < .05. Adjusted odds ratios (aORs) and 95% confidence intervals (95%CI) for supporting proposed policies were calculated using a hierarchical logistic regression analysis. The dependent variable for these analyses was dichotomized support for a proposed policy. Participant characteristics were controlled for by progressively adding blocks of covariates to multiple logistic regression models. The first model included demographic characteristics, the second model included demographic and socioeconomic characteristics, and the third model included all collected participant characteristics. Multicollinearity was assessed prior to regression modeling, and Akaike Information Criterion and Bayesian Information Criterion were used to assess model fit. All analyses were performed using StataSE/v19.

2.4. Ethical review

Study materials were submitted to the Texas A&M University Institutional Review Board prior to initiating recruitment and data collection. The study was declared exempt (STUDY2025–0819).

3. Results

3.1. Study population demographics

A total of 1006 participants were included in the analysis. Participants most often reported being female (55.0%), 25–34 years old (38.9%), white (63.0%), non-Hispanic (80.9%), having obtained a high school diploma or less (29.4%), an annual household income of $50,000–$99,999 (32.4%), having health insurance (96.2%), not participating in SNAP (61.1%), Democrat partisanship (42.6%), not being vaccine hesitant (90.6%), and residence in a southern state (38.9%) (Table 2). Participants also most often reported having heard of the federal child tax credits (75.2%), being eligible for the tax credit (79.3%), receiving the tax credit (47.7%), and the federal child tax credits making a difference to their family finances (50.5%) (Table S1).

Table 2.

Sociodemographic characteristics of the parents or legal guardians of children five years of age or younger in the study population, United States (2025).

Characteristic		No. (%)
Sex
	Female	553 (55.0)
	Male	453 (45.0)
Age
	18–24 years	100 (9.9)
	25–34 years	391 (38.9)
	35–44 years	359 (35.7)
	45–54 years	105 (10.4)
	55–64 years	33 (3.3)
	65 years or older	18 (1.8)
Race
	Asian	102 (10.1)
	Black	167 (16.6)
	White	634 (63.0)
	Other	103 (10.2)
Hispanic ethnicity
	Yes	192 (19.1)
	No	814 (80.9)
Education
	High school or less	296 (29.4)
	Some college, no degree	139 (13.8)
	Technical certificate or associate's degree	141 (14.0)
	Bachelor's degree	229 (22.8)
	Graduate degree	201 (20.0)
Annual household income
	$49,999 or less	322 (32.0)
	$50,000–$99,999	326 (32.4)
	$100,000–$149,999	176 (17.5)
	$150,000–$199,999	107 (10.6)
	$200,000 or more	75 (7.5)
Health insurance status
	Insured	968 (96.2)
	Uninsured	38 (3.8)
Receiving SNAP benefits
	Yes	371 (36.9)
	No	615 (61.1)
	Unsure	20 (2.0)
Partisanship
	Democrat	429 (42.6)
	Independent	172 (17.1)
	Republican	405 (40.3)
Vaccine hesitancy
	Vaccine-hesitant	95 (9.4)
	Not vaccine-hesitant	911 (90.6)
Geographic region
	Midwest	208 (20.7)
	Northeast	176 (17.5)
	South	391 (38.9)
	West	231 (23.0)

Notes: n = 1006.

3.2. Support and opposition for proposed tax credit policies

A majority of participants expressed support for all three policies (Table 3). Regarding the revision of the existing federal child tax credit, 542 participants (53.9%) reported that they would support or strongly support revising the policy to include age-appropriate immunization, valid medical or religious exemptions as an eligibility criterion. Of the 464 participants who would not support revising the policy, concerns about vaccine safety and/or efficacy (32.8%), concerns about accessing the vaccines and/or healthcare system (31.0%), and concerns about insurance and paying for vaccines (25.9%) were the most common reasons for opposition. Participants most often reported that they believed others would reconsider vaccinating their children if they had previously objected or hesitated toward it and the federal child tax credit eligibility criteria were revised (64.3%). More specifically, 458 participants (45.5%) reported that they believed others would probably reconsider, and 189 participants (18.8%) reported that they believed others would definitely reconsider (Fig. 1).

Table 3.

Responses from parents or legal guardians of children five years of age or younger regarding support for proposed immunization-related child tax credit policies and potential reasons for opposition, United States (2025).

Support or Opposition		Proposed Tax Credit Policy
		Revise CTC	Create VTC	Create ITTC
Support for proposed policy		n = 1006 (%)	n = 1006 (%)	n = 1006 (%)
	Strongly Support	218 (21.7)	254 (25.2)	222 (22.1)
	Support	324 (32.2)	376 (37.4)	355 (35.3)
	Neither support nor oppose	219 (21.8)	221 (22.0)	247 (24.5)
	Oppose	118 (11.7)	67 (6.7)	99 (9.8)
	Strongly oppose	127 (12.6)	88 (8.7)	83 (8.2)
Reasons for opposition		n = 464 (%)	n = 367 (%)	n = 429 (%)
	Concerns about accessing vaccines and/or healthcare system	144 (31.0)	99 (26.3)	110 (25.6)
	Concerns about vaccine safety and/or efficacy	152 (32.8)	208 (55.3)	215 (50.1)
	Concerns about insurance and paying for vaccines	120 (25.9)	150 (39.9)	163 (38.0)
	Concerns about tax credit eligibility criteria	67 (14.4)	129 (34.3)	143 (33.3)
	Concerns about tax credit benefit amount	87 (18.7)	159 (42.3)	178 (41.5)
	Morally opposed to vaccines	79 (17.0)	168 (44.7)	178 (41.5)
	Does not believe that childhood vaccines are necessary	45 (9.7)	132 (35.1)	141 (32.9)
	Concerns about immunization threshold	–	–	91 (21.2)
	Other	64 (13.8)	39 (10.4)	41 (9.6)

Notes: CTC – Child tax credit; VTC – Vaccination tax credit; ITTC – Immunization threshold tax credit.

Fig. 1.

Survey responses from parents or legal guardians of children under five years of age or younger as to whether the proposed immunization-related child tax credit policies would make others reconsider vaccinating their children if they previously objected or hesitated toward it, United States (2025). Notes: n = 1006; CTC – Child tax credit; VTC – Vaccination tax credit; ITTC – Immunization threshold tax credit.

Regarding the vaccination tax credit, 630 participants (62.6%) reported that they would support or strongly support the creation of a new tax credit for parents who could prove that their children are age-appropriately immunized or have valid medical or religious exemptions. Of the 367 participants who would not support creating a new tax credit, concerns about vaccine safety and/or efficacy (55.3%), moral opposition to vaccines (44.7%), and concerns about the tax credit benefit amount (42.3%) were the most common reasons for opposition. Participants most often reported that they believed the creation of a vaccination tax credit would cause others to reconsider vaccinating their children if they had previously objected or hesitated toward it (67.6%). More specifically, 460 participants (45.7%) reported that they believed others would probably reconsider, and 220 (21.9%) reported that they believed others would definitely reconsider.

Regarding the immunization threshold tax credit, 577 participants (57.4%) reported that they would support or strongly support the creation of a new tax credit for families residing in a state where at least 95% of the children are age-appropriately immunized or have valid medical or religious exemptions. Of the 429 participants who would not support creating a new tax credit, concerns about vaccine safety and/or efficacy (50.1%), concerns about immunization threshold (42.0%), concerns about tax credit benefit amount (41.5%), and moral opposition to vaccines (41.5%) were the most common reasons for opposition. For those who indicated concern about the 95% immunization threshold, a threshold of below 70% was the preferred alternative (Table S2). Participants most often reported that they believed the creation of an immunization threshold tax credit would cause others to reconsider vaccinating their children if they had previously objected or hesitated toward it (65.2%). More specifically, 458 participants (45.5%) reported that they believed others would probably reconsider, and 198 (19.7%) reported that they believed others would definitely reconsider.

3.3. Differences in support for proposed policies

Democrats most often reported support for revising the federal child tax credit eligibility criteria to include age-appropriate immunization, valid medical exemption or religious exemptions as an eligibility criterion (56.2%), the creation of a new vaccination tax credit (64.1%), and the creation of a new immunization threshold tax credit (59.4%) (Fig. 2). Independents most often reported opposition to revising the federal child tax credit (61.6%) and creating a new immunization threshold tax credit (44.2%), but most often reported support for the creation of a new vaccination tax credit (54.6%). Republicans most often reported support for revising the existing federal child tax credit (58.0%), the creation of a new vaccination tax credit (64.4%), and the creation of a new immunization threshold tax credit (60.7%). Support differed between political groups for revising the federal child tax credit (X² (2, 1006) = 20.35, p = .000) and creating a new immunization threshold tax credit (X² (2, 1006) = 14.86, p = .001). A majority supported the proposed policies irrespective of receiving SNAP benefits, and there were no meaningful differences between those who were and were not receiving SNAP benefits.

Fig. 2.

Support for proposed immunization-related child tax credit policies among parents or legal guardians of children five years of age or younger by (A) partisanship and (B) SNAP participation, United States (2025). Notes: n = 1006; CTC – Child tax credit; VTC – Vaccination tax credit; ITTC – Immunization threshold tax credit.

Regression analyses confirmed these findings (Table 4; Table S3-S6). Fully adjusted multiple logistic regression models suggested that, compared to their respective reference groups, the odds of expressing support for revising eligibility criteria of the existing child tax credit were higher for those with a graduate degree, those with an annual household income of $150,000 or greater; in contrast, the odds were lower for females, Hispanics, Independents, and vaccine-hesitant individuals. Compared to their respective referent groups, the odds of expressing support for creating a new vaccination tax credit were higher for those with a graduate degree and those with health insurance; the odds were lower for Black or African American individuals and vaccine-hesitant individuals. Compared to their respective referent groups, the odds of expressing support for creating a new immunization threshold tax credit were higher for females, Independents, and vaccine-hesitant individuals.

Table 4.

Associations between characteristics of parents or legal guardians of children five years of age or younger and expressed support for proposed immunization-related child tax credit policies, United States (2025).

Characteristic		Proposed Tax Credit Policy
		Revise CTC aOR [95%CI]	Create VTC aOR [95%CI]	Create ITTC aOR [95%CI]
Sex
	Male	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Female	0.64 [0.48, 0.86]	0.82 [0.60, 1.10]	0.72 [0.54, 0.97]
Age
	18–24 years	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	25–34 years	0.99 [0.61, 1.61]	1.10 [0.67, 1.81]	0.95 [0.58, 1.55]
	35–44 years	0.95 [0.58, 1.57]	1.17 [0.70, 1.94]	0.93 [0.56, 1.53]
	45–54 years	0.92 [0.50, 1.68]	1.10 [0.59, 2.05]	0.86 [0.47, 1.57]
	55–64 years	0.59 [0.24, 1.41]	0.61 [0.25, 1.45]	0.76 [0.32, 1.80]
	65 years or older	0.68 [0.24, 1.99]	0.99 [0.33, 3.00]	0.49 [0.17, 1.43]
Race
	White	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Asian	0.84 [0.53, 1.14]	0.94 [0.55, 1.60]	0.60 [0.37, 1.00]
	Black	0.78 [0.51, 1.39]	0.66 [0.45, 0.98]	0.68 [0.46, 1.00]
	Other	1.19 [0.71, 1.99]	1.01 [0.59, 1.72]	1.02 [0.61, 1.72]
Hispanic ethnicity
	Non-Hispanic	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Hispanic	0.64 [0.43, 0.94]	0.88 [0.59, 1.32]	1.07 [0.73, 1.58]
Education
	High school or less	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Some college, no degree	0.75 [0.49, 1.17]	0.96 [0.62, 1.50]	0.86 [0.55, 1.33]
	Technical certificate or associate's degree	0.71 [0.45, 1.12]	1.09 [0.69, 1.72]	1.04 [0.66, 1.64]
	Bachelor's degree	1.29 [0.85, 1.97]	1.51 [0.98, 2.35]	1.42 [0.93, 2.18]
	Graduate degree	1.65 [1.01, 2.68]	2.34 [1.38, 3.96]	1.42 [0.88, 2.30]
Annual household income
	$49,999 or less	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	$50,000–$99,999	1.15 [0.80, 1.65]	1.00 [0.69, 1.45]	1.01 [0.70, 1.45]
	$100,000–$149,999	1.10 [0.69, 1.76]	0.90 [0.55, 1.46]	1.05 [0.65, 1.68]
	$150,000–$199,999	1.90 [1.06, 3.38]	1.53 [0.82, 2.84]	1.41 [0.79, 2.51]
	$200,000 or more	2.13 [1.14, 3.98]	1.93 [0.96, 3.88]	1.58 [0.85, 2.96]
Health insurance status
	Uninsured	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Insured	1.87 [0.87, 4.02]	2.28 [1.09, 4.75]	1.83 [0.88, 3.82]
Receiving SNAP benefits
	No	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Yes	1.33 [0.98, 1.80]	1.14 [0.83, 1.57]	1.37 [1.01, 1.85]
	Unsure	0.85 [0.31, 2.32]	0.67 [0.24, 1.88]	0.73 [0.27, 1.96]
Partisanship
	Democrat	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Independent	0.59 [0.40, 0.88]	0.87 [0.58, 1.30]	0.63 [0.43, 0.94]
	Republican	1.08 [0.77, 1.50]	1.02 [0.72, 1.44]	1.03 [0.74, 1.44]
Vaccine hesitancy
	Not vaccine-hesitant	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Vaccine-hesitant	0.15 [0.08, 0.26]	0.08 [0.05, 0.15]	0.11 [0.06, 0.20]
Geographic region
	Northeast	1.00 (Ref.)	1.00 (Ref.)	1.00 (Ref.)
	Midwest	0.82 [0.53, 1.28]	0.78 [0.49, 1.24]	0.82 [0.63, 1.27]
	South	0.98 [0.66, 1.46]	0.99 [0.65, 1.49]	1.14 [0.77, 1.69]
	West	1.13 [0.72, 1.77]	1.03 [0.64, 1.66]	1.29 [0.82, 2.02]

Notes: CTC – Child tax credit; VTC – Vaccination tax credit; ITTC – Immunization threshold tax credit; n = 1006.

4. Discussion

This study sought to characterize parental support for the creation of immunization-related child tax credit benefits in the United States. Results suggest that parents in this survey were largely receptive to the idea, and would support the modification of existing tax credit programs to include immunization criteria or the creation of new immunization-related tax credit programs. Support differed according to several characteristics, such as sex, race, education, income, health insurance status, partisanship, and vaccine hesitancy. Still, support for proposed policies did not differ between major political parties (i.e., Democrat and Republican) or according to participation in SNAP. Parents in this study also believed that pursuing these policies could convince parents to vaccinate their children if they previously objected or hesitated.

Concerns about vaccine safety and/or efficacy were among the most common reasons for not supporting all three proposed policies. Interestingly, this finding came from a study population that was found to be predominantly not vaccine hesitant. Still, recognizing the vaccine-hesitant sentiments that persist in the United States, as well as the confusion felt by parents amidst shifting vaccine policy (KFF, 2025), this result is, perhaps, unsurprising. Moral opposition was also commonly listed as a reason for opposing the vaccination tax credit and the immunization threshold tax credit. This finding may be expected given that the proposed policies specified that only medical and religious exemptions would be allowed. Concerns about the tax credit benefit amount were also common to the vaccination tax credit and the immunization threshold tax credit. Acknowledging that these proposed policies would create new tax credit programs, future research should seek to identify the amount of financial compensation that would be acceptable to both parents and policymakers.

Concerns about the immunization threshold were also commonly listed as a reason for not supporting the immunization threshold tax credit. The 95% threshold was selected because it is the estimate thought to be required to confer population-level immunity against measles (De Serres et al., 2000; Plans-Rubió, 2012). While other childhood diseases have lower thresholds required for herd immunity, results from this survey suggest that the most preferred alternative threshold was below 70%, which would be insufficient to provide herd immunity. Still, future survey experiments may also wish to examine how support for immunization threshold tax credit policies varies based on coverage thresholds.

Additional reasons for not supporting revising the existing federal child tax credit included concerns about accessing vaccines and/or the healthcare system, and concerns about insurance and paying for vaccination. These concerns relate to issues of convenience, as opposed to complacency or confidence (MacDonald et al., 2018). Notable is that these concerns were voiced by a population in which greater than 95% of the individuals reported having health insurance—emphasizing persistent and pervasive apprehensions about access-related challenges. Critically, these types of issues are more amenable to policy solutions than issues of complacency or confidence. Should any of the proposed policies be pursued, it will be imperative to ensure that individuals are able to access and pay for vaccines without excessive financial burden.

It is also worth noting that while this survey queried about federal tax credits, 17 states and the District of Columbia also have child tax credit programs (National Conference of State Legislatures, 2025). Accordingly, while these results are most applicable to federal tax credit programs, they may also inform the development of policy at the state level in geographies that maintain child tax credit programs.

Limitations associated with these results include those common to online surveys, including the use of online data collection processes and self-reported data. Data collection processes may have resulted in a biased sample due to self-selection into the panel and this particular survey. However, the lack of comparative demographic benchmarks for parents with children five years of age or younger in the United States limits opportunities for weighting. Self-reported data also presents the risk of social desirability bias. Further, these results reflect views of broad, hypothetical policies, and public opinion is likely to change depending on specific details of any policies that are developed and adopted in the future. For example, in the absence of federal immunization requirements, definitions for age-appropriate immunization are ambiguous and likely to vary between states. It is difficult to predict how support for proposed policies may vary according to immunization requirements.

5. Conclusions

In the face of persistent vaccine hesitancy and stagnating or declining immunization coverage rates, parents in the United States appear to be open to considering the addition of immunization requirements to existing child tax credit programs, as well as developing new immunization-related child tax credit programs. While the creation of new child tax credit programs appears to be the favored policy option among parents, amidst a federal government budget deficit, revising the existing tax credit program may represent the most practical policy option. Future research should validate these results with broader populations and larger sample sizes to better determine the viability of proposed policies. Future work may also wish to explore the use of child tax credit programs as a means of promoting progress toward other public health challenges.

CRediT authorship contribution statement

Matthew R. Boyce: Writing – review & editing, Writing – original draft, Visualization, Validation, Project administration, Methodology, Investigation, Formal analysis, Data curation, Conceptualization.

Ethical statement

All procedures were performed in compliance with relevant laws and institutional guidelines and have been approved by the Texas A&M University Institutional Review Board (STUDY2025–0819).

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

Supplementary material 1

Survey Questions.

Supplementary material 2

Supplementary Tables.

Data availability

Data will be made available on request.