By Amy Killelea, Leila Sullivan, Justin Giovannelli and Sabrina Corlette
In late June, the Supreme Court upheld the Affordable Care Act’s (ACA) preventive services provision, preserving—for now—zero cost sharing access to screenings, vaccines, and other preventive care for more than 150 million people. The decision in Kennedy v. Braidwood Management Inc. foreclosed a constitutional challenge to coverage of preventive care while underscoring new risks to consumers’ access to these services: By affirming the broad authority the Secretary of the Department of Health and Human Services (HHS) has over federal advisory bodies that guide preventive service recommendations, the Court entrenched the possibility that political considerations could override scientific evidence in determining what services insurers must cover.
Section 2713 of the Affordable Care Act obligates private health plans, including individual, small group, large group, and self-insured plans to cover a defined set of preventive services without cost-sharing. These services include those that receive an “A” or “B” rating from the U.S. Preventive Services Task Force (USPSTF), all immunizations recommended by the Advisory Committee on Immunization Practices (ACIP), and women’s and children’s preventive services recommended by the Health Resources and Services Administration (HRSA). Together, these provisions extend no-cost coverage of preventive care to more than 150 million people and have consistently ranked among the most popular elements of the ACA. For over a decade, the law has relied on the work of expert advisory bodies that were designed to operate independently from politics. That insulation, however, is now under threat.
Since taking office, Secretary Kennedy has taken steps that directly undermine ACIP’s integrity and the underlying science behind vaccine recommendations. Removing scientific accountability from ACIP may also be a warning signal for how HHS will approach other federal scientific advisory bodies, including USPSTF and HRSA. Secretary Kennedy has canceled scheduled ACIP meetings, bypassed the committee to unilaterally change the COVID-19 vaccine recommendations, and in June, fired all 17 ACIP members. He has subsequently replaced them with vocal vaccine skeptics.
In late June, at ACIP’s first meeting under its new membership, updates to RSV and influenza schedules were approved, but the COVID-19 vaccine was excluded for healthy children and pregnant women—changes the Secretary had already announced in May without ACIP review. Leading medical organizations filed suit against HHS, arguing that the removal of these groups from the vaccine schedule violated federal law.
Concerns deepened when top CDC leadership were fired or resigned, many of whom cited an inability to carry out evidence-based work at a deeply politicized and hobbled CDC. Medical societies, including the American Academy of Pediatrics, have declared the reconstituted ACIP “illegitimate,” and warned that vaccine policy was drifting away from science. The newly constituted ACIP met again on September 18 and 19, where they discussed the measles, mumps, rubella, varicella (MMRV) vaccine, the hepatitis B vaccine (birth dose), and the new COVID-19COVID-19 vaccines that were recently approved (with narrower indications) by the Food and Drug Administration (FDA).
During an often chaotic and tense two days of meetings, where members often did not seem to understand what they were voting on or the parameters of the authority that ACIP has, the body made the following changes to vaccine recommendations: it voted to remove the recommendation for the combined MMRV vaccine for children under four years old (children can still get the MMR and varicella vaccines separately) and voted to move the COVID-19 vaccine recommendation to shared decision-making for anyone six months to 64 years old, with a note in the recommendation that for individuals under 65 benefits are greater for those with underlying health conditions. ACIP delayed its vote on potential removal of the recommendation of the hepatitis B birth dose amidst heavy pushback from the provider liaison groups and public commenters that there simply was not credible evidence to rollback such an important public health intervention that will help to eliminate perinatal transmission of hepatitis B. The new ACIP recommendations must be approved by the CDC Director to be finalized (in the absence of a CDC Director, the Secretary of HHS may approve, reject, or amend the recommendations).
The impact on coverage and cost-sharing protections of the ACIP changes will take some time to fully play out. Because the combined MMRV is no longer recommended, insurers are no longer required to cover it without cost sharing under the ACA, and uninsured and Medicaid/CHIP enrolled children will not be able to access the vaccine through the Vaccines for Children Program. However, ahead of the meeting and in a vote of no confidence in the credibility of ACIP, America’s Health Insurance Plans (AHIP) announced that its members would continue to cover vaccines without cost sharing that had been recommended by ACIP as of September 1, 2025 through 2026. Given this voluntary commitment, it is likely that many private insurance plans will continue to make the MMRV vaccine available at no cost sharing even in absence of a federal requirement to do so.
The impact of the COVID-19 recommendations are a little murkier. Medicare and Medicaid programs must cover vaccines recommended with shared-decision making the same way they cover other ACIP recommended vaccines, but private insurers have historically varied in whether they treat a shared decision-making designation as a full routine recommendation by ACIP that requires them to cover it without cost sharing. The voluntary AHIP announcement may indicate plans will do this voluntarily, at least for now.
Finally, ACIP also voted to encourage CDC to update the Vaccine Information Statements, which must be provided to every patient seeking a vaccine, with information spelling out the risks of each vaccine. Statements that are no longer tethered to rigorous scientific assessment of risks and benefits may undermine public trust in vaccines and cause individuals and families to choose not to vaccinate, regardless of whether the vaccine is covered by insurance.
Meanwhile, HHS has canceled the next USPSTF meeting, raising fears that it too may face the same politicization as ACIP.
The ACIP changes are causing consumer and provider confusion for people trying to obtain a COVID-19 vaccine, primarily because of variable pharmacy scope of practice laws that limit the vaccines pharmacies can administer to ones recommended by ACIP. Major insurers appear to be continuing to cover the vaccine without cost sharing for now and AHIP’s commitment may help support continuity in coverage for now, but if ACIP continues to remove recommendations or change them to shared decision-making, there could be variability in how insurers approach coverage. Prior to the passage of the ACA, patients faced significant barriers accessing preventive services, including vaccines, due to cost-sharing and inconsistent coverage. Even when vaccines were covered in commercial health plans, patients often had to pay copays or meet deductibles. Evidence shows that even modest costs can deter people from getting vaccinated, particularly those with lower incomes, and could worsen existing health disparities.
Coverage decisions could also vary across markets and plan types, especially as states step in to regulate the fully insured market. Plans in the employer market may approach vaccines differently than insurers in the individual market. Some employers might want to save money by dropping or imposing cost-sharing for immunizations that are no longer federally required. Others may view them as a worthy investment in workforce health and reduced absenteeism. In the individual market, where consumers often transition in and out of coverage and shop for plans largely based on price, insurers may be more inclined to reduce vaccine coverage to lower costs.
Vaccines protect communities by limiting the spread of infectious diseases, but the level of vaccination needed to maintain population-level protection varies; measles requires about 94% of the population to be immunized, while polio requires about 80%. If coverage and costs begin to vary significantly across states, this patchwork could leave many people unvaccinated, undermining herd immunity and increasing risks for the broader public, particularly for immunocompromised individuals
Anticipating risks from the Braidwood case, more than a dozen states codified ACA preventive service protections into law. Critically, however, state efforts to protect against an adverse decision in Braidwood weren’t designed to counter threats to the integrity of the recommending bodies themselves and generally are inadequate for that purpose. In recent months, several states have amended their codes to point state coverage and access standards away from federal recommending bodies. Colorado, for example, enacted SB 25-196, which gives its insurance commissioner authority to adopt guidance from a state clinical advisory task force if federal standards are rolled back. Maine has taken a different approach, empowering its health department to determine vaccine policy independently of ACIP. Massachusetts is considering legislation that would allow its public health commissioner to define routine immunizations without relying solely on federal recommendations, and its Department of Insurance has already acted under executive authority to require state-regulated plans to cover all vaccines recommended by the state’s Department of Public Health without cost-sharing.
Other states are moving in similar directions, with Pennsylvania developing proposals modeled on Colorado’s approach. In both the Northeast and the West, a consortium of states have announced a regional framework for vaccine guidance and procurement to preserve access based on science.These types of regional collaboratives could enable these states to band together to purchase the MMRV vaccine that was just removed from the VFC pediatric vaccine schedule to preserve access for uninsured and Medicaid/CHIP enrollees. Florida, in contrast, has announced plans to ban all vaccine mandates within the state.
And even as states create a process for making their own recommendations, the prospect of 50 state approaches to clinical recommendations for preventive services and vaccines could sow provider and consumer confusion and further erode trust in public health. In an effort to support a national approach to vaccine recommendations, a non-profit led by clinicians and public health experts is working to develop a single set of vaccine recommendations that states, providers, and consumers can rely on, but it is still in its nascent stage.
Although these state actions reflect growing urgency to preserve access, their impact is inherently limited when it comes to mandated insurance coverage. States cannot regulate self-funded employer health plans, which cover the majority of working adults, leaving millions without protection if federal standards collapse. Moreover, a patchwork of varying state policies could fuel consumer confusion, heighten vaccine skepticism, and create administrative burdens for providers and insurers.
The Supreme Court preserved the ACA’s preventive services benefit, but federal actions have destabilized the evidence-based framework it relies on. With ACIP politicized and USPSTF potentially next, coverage that was once uniform nationwide may soon vary dramatically by state and insurer.
Some states are stepping in to safeguard access, but their efforts are an incomplete patchwork. Ultimately, the erosion of federal science-based standards threatens to drive down vaccination rates, widen inequities, and put public health at risk.
Support for this work was provided by the Commonwealth Fund and the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect their views.
