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When the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices met last week, confusion filled the room.
Members admitted they didn’t know what they were voting on, first rejecting a combined measles-mumps-rubella-chickenpox vaccine for young toddlers, then voting to keep it funded minutes later. The next day, they reversed themselves on the funding.
Now Jim O’Neill, the deputy health and human services secretary and the CDC’s acting director (a lawyer, not a doctor), must sign off. The panel’s recommendations matter, because insurers and federal programs rely on them, but they are not binding. States can follow the recommendations, or not.
In the West, California, Oregon, Washington, and Hawaii have joined forces in the West Coast Health Alliance. Their first move was to issue joint recommendations on Covid, flu, and RSV vaccines, going further than ACIP.
“Public health should never be a patchwork of politics,” said Sejal Hathi, Oregon’s state health director.
California’s health director, Erica Pan, described the goal as “demonstrating unity around science and values” while reducing public confusion.
The bloc is also exploring coordinated lab testing, data sharing, and even group purchasing. “Our intent is to restore trust in science and safeguard people’s freedom to protect themselves and their families without endless barriers,” Hathi said.
In the Northeast, New York and its neighbors created the Northeast Public Health Collaborative. Democratic Gov. Kathy Hochul called it a rebuke to Washington, D.C.’s retreat from science.
“Every resident will have access to the Covid vaccine, no exceptions,” she said in a statement.
The group has already gone beyond vaccines. After the CDC disbanded its infection-control advisory body, the Northeast states created their own return-to-work rules. Work groups now span vaccines, labs, emergency preparedness, and surveillance.
“Infectious diseases don’t respect borders,” said Connecticut’s health commissioner, Manisha Juthani. “We had to move in the same direction to protect our residents.”
The two blocs are in regular contact. “We communicate every day,” Hathi said.
“We can’t just sit by while federal agencies are hollowed out,” said acting New York City health commissioner Michelle Morse. “Public health is local, and we have to act like it.”
State leaders describe their coalitions as filling a vacuum left by Washington, D.C.
“You would think emerging from a pandemic, we would be embracing public health, but the federal government was heading in the opposite direction,” said James McDonald, New York state health commissioner.
Massachusetts commissioner Robbie Goldstein added: “The federal government has historically been the entity that held us all together. In January of this year, that tradition seemed to be going away.”
Boston University law professor Matt Motta summarized the dilemma: “States are taking matters into their own hands, sometimes to expand access to vaccines, sometimes to roll it back. That’s technically how the system works, but it risks inefficiency and confusion.”
Public health law has long tilted toward the states.
“If there was a public health issue, we’d say it’s for the states,” said Wendy Parmet of the Northeastern University School of Law.
States have mandated vaccines since the 1800s. Federal agencies can approve vaccines and fund programs, but they cannot force mandates except in very specific circumstances (e.g., federal employees).
UC Law-San Francisco’s Dorit Reiss agreed with Parmet: “Public health authority resides primarily with the states. Recommendations are recommendations.”
ACIP’s votes matter for coverage rules and insurance mandates, but states are free to diverge.
That divergence is already widening. Florida, led by Surgeon General Joseph Ladapo, is moving to eliminate childhood vaccine requirements altogether — a first-in-the-nation step. Georgetown Law’s Larry Gostin warned this could reopen century-old battles dating to Jacobson v. Massachusetts (1905), when the Supreme Court upheld state vaccine mandates for public safety.
Health leaders warn that competing systems risk causing confusion and costing lives. “Federal silence creates a vacuum, and states either step up together or splinter apart,” Hathi said.
Pan added that “without federal credibility, we’re left improvising.”
McDonald cautioned that partisan divides could grow sharper.
And Morse said that “blue and red states could each go their own way, leaving the public even more divided.”
Gostin put it bluntly: “That risks confusion, inefficiency, and ultimately lives.”
This state-by-state tug-of-war is not new. In the 1800s, local boards of health fought cholera with sewers and sanitation when federal authority was absent. In the 1950s, states organized mass polio clinics, with uneven uptake until federal funding smoothed disparities.
During the Covid pandemic, Trump White House response coordinator Deborah Birx saw firsthand the limits of federal power. She visited 44 states, urging governors to adopt masks, closures, and vaccines.
“I was trying to get them to tailor responses to their populations, not just follow generic federal guidance,” she later recalled.
Supreme Court Justice Louis Brandeis once said that states are “laboratories of democracy,” where leaders could test out new ideas without putting the whole country at risk. But diseases don’t follow state lines. A virus that starts in Tallahassee could spread to Times Square by the next morning.
Today, states have become laboratories of public health. Each state is experimenting — some expanding protections, others cutting them back. And those choices could, for better or worse, affect us all.
Dr. Céline Gounder is a senior fellow and editor-at-large for public health at Healthbeat’s partner, KFF Health News.
