A Look at Recent Changes to State Vaccine Requirements for School Children

Routine vaccination rates for kindergarten children have declined since the COVID-19 pandemic began, while exemptions from school vaccination requirements, particularly non-medical exemptions, have increased. These trends coincide with shifting attitudes toward childhood vaccination likely fueled in part by vaccine misinformation. The past few years have seen more skepticism and confusion among the public about the safety and effectiveness of vaccines, a decline in trust of health authorities, and a growing partisan divide. Shifts in vaccine attitudes are reflected in recent state-level policy changes, with state lawmakers introducing more than 2,500 vaccine-related bills since 2021, with almost half targeting vaccine requirements. In addition, Florida officials recently announced plans to eliminate all school vaccination requirements. Despite these changes, recent KFF polling found that public confidence in the safety of routine vaccines like MMR remains high and about eight in ten (81%) parents overall as well as large majorities of parents who identify as Democrats, independents, and Republicans support current state vaccine requirements, saying students should be required to be vaccinated against measles and polio to attend public schools with some exceptions. This policy watch examines recent state policy changes to school vaccine requirements and the extent to which they may impact vaccination trends.

States and local jurisdictions, not the federal government, set vaccine requirements for daycare and school entry. The federal government does, however, have a long-standing, evidence-based system for approving and recommending vaccines for the public, including the childhood vaccination schedule. The childhood vaccination schedule is set by the Centers for Disease Control and Prevention (CDC) based on recommendations from the Advisory Committee on Immunization Practices (ACIP). ACIP’s recommendations are used by many states to develop school vaccine requirements. HHS Secretary Robert F. Kennedy Jr. (RFK Jr.), who has a long record of opposing immunizations and spreading vaccine misinformation, has led recent efforts to re-examine the federal childhood vaccine schedule, replace members of ACIP, and restrict COVID-19 vaccines and mRNA vaccine research. In addition, the Trump administration recently released a report that calls for a new vaccine framework that includes reevaluating the childhood vaccine schedule and addressing vaccine injuries.

All states currently require children to be vaccinated against certain diseases in order to attend public schools. School vaccination requirements are an important tool for reducing the spread of diseases and increasing vaccination coverage rates. Required vaccinations across every state and D.C. include MMR, DTaP, polio, and varicella; some states also require hepatitis A, hepatitis B, meningococcal, and/or HPV vaccines. At this time, no states require the COVID-19 vaccine for school entry. While it has yet to be enacted, Florida’s plan to eliminate all school vaccination requirements would make them the first and only state to do so. However, as the divide between red and blue states on health policy grows, more states may consider moving this direction.

All states allow exemptions from school vaccination requirements for medical reasons and almost all states (47 including D.C.) allow exemptions for religious and/or personal beliefs (Figure 1). This leaves four states (California, Connecticut, Maine, and New York) that only allow medical exemptions. Studies have shown that higher exemption rates from school vaccination requirements are associated with lower vaccination coverage rates and increased risk for disease outbreaks. In the 2024-2025 school year, the share of children claiming an exemption from vaccination requirements from one or more vaccinations rose to 3.6%, the highest national exemption rate to date, up from 2.5% in 2019-2020. Increases in non-medical exemptions accounted for the recent increases, with non-medical exemptions increasing from 2.2% to 3.4% over the period. Vaccination rates and exemption rates vary significantly by state, with the share of children claiming an exemption from one or more vaccinations during the 2024-2025 school year ranging from 0.1% in California to 15.4% in Idaho.

At least 10 states so far this year have enacted or issued changes related to routine vaccine requirements for children (Table 1). In the years following the pandemic, states saw an increase in vaccine-related policy proposals. The pandemic spurred increased state legislative activity initially focused on state-level authority to require COVID-19 vaccines. However, over time, as the response to COVID-19 became more politicized, states began limiting COVID-19 vaccine mandates as well as focusing more broadly on routine vaccination requirements (and exemptions to those requirements) in schools. Notably, most of the vaccine-related bills introduced by legislators since the pandemic began have not passed, but ten states in the past year have enacted or issued policy changes related to school or child care vaccination requirements.

Almost all states (nine out of 10 states with recent changes) made changes that could result in more students claiming a non-medical exemption, which could reduce vaccination rates. Many of the recent changes (described in Table 1) will make it easier for families with children in childcare settings or school to obtain a non-medical vaccine exemption. Notably, the governor of West Virginia signed an executive order allowing religious and personal belief exemptions in January 2025, though litigation is ongoing. Prior to 2025, West Virginia was one of five states (now four states) that only allowed medical exemptions and had the highest vaccination rates and lowest exemption rates in the country during the 2023-2024 school year (the latest available data for the state). In addition, Idaho, the state with the lowest vaccination rates and highest exemption rates during the 2024-2025 school year, transferred control of required vaccines to the legislature and restricted medical mandates (likely weakening school vaccine requirement enforcement). These changes, in addition to broader state efforts to scale back immunization outreach and promotion, changes to vaccine recommendations at the federal level, and reduced support from the federal government for state and local health departments, could further increase the number of exemptions requested and drive down vaccination rates among children. Florida’s plan to eliminate all school vaccination requirements goes beyond expanding exemptions and would mark a major shift in state vaccination requirements, though the issue will have to be taken up by the state legislature.

At the same time, one state has made a change that could maintain or increase children’s routine vaccination rates. Colorado recently passed a law allowing the consideration of vaccine recommendations from outside groups like the American Academy of Pediatrics (AAP), not only ACIP, when developing school vaccine requirements. More states may move in this direction depending on the outcome of ACIP’s upcoming meeting on vaccine recommendations and potential further changes by RFK Jr. to the ACIP panel. In addition, the AAP also recently reaffirmed their support for eliminating non-medical exemptions amid rising exemption rates, and some states, such as Massachusetts and Hawaii, are proposing eliminating non-medical exemptions, though these changes have not been enacted. While the appointment of RFK Jr. in early 2025 likely spurred additional efforts to loosen vaccine requirements in many states this year, other states are working to ensure vaccine access amid changes at the federal level.