It's been a tempestuous 2025 for the nation's healthcare infrastructure. I think the worst is yet to come, given cutbacks to Medicaid eligibility and coverage and the devolving recommendations by government healthcare agencies. Concern is also arising that third-party payers (Medicaid, Medicare, and private insurance) and Vaccines for Children may not cover some scientifically proven vaccines or some parts of scientifically based schedules.
Vaccination rates and public trust in vaccines had been dropping since the pandemic, and only 69% of families trusted CDC vaccine recommendations in January 2025, even before recent shakeups in CDC committees. Declining postpandemic national vaccine rates now hover just above thresholds for losing herd immunity (Figure 1) also in part because of increasing vaccine exemptions (Figure 2).
However, some local rates have dipped below thresholds in what I call "vaccine deserts," those geographic pockets where vaccine deniers comprise larger parts of the population -- the measles outbreak being the poster child for this. In addition, discussions are emerging about limiting or removing school vaccine requirements or expanding exemptions.
Other factors that imperil herd immunity have always reduced vaccine uptake, even in families that want to vaccinate their children: time and resource limitations for working parents, language barriers, limited or no medical care coverage, limited transportation, rural or inner-city residence, and uncovered vaccines.
Some may say, "So what?" We still have more than 90% uptake for most vaccines. Evidence suggests that even with relatively high uptake, vaccine-preventable disease still occurs in subpopulations, including vulnerable children. For example, a Boston group recently reported that, even before the drop in vaccination rates over the past 5 years, vulnerable children were more likely have more invasive pneumococcal disease (IPD). So, cracks in the proverbial dam existed in populations (those with comorbidities or lower socioeconomic status) even pre-pandemic and before current cutbacks.
Massachusetts IPD data (ie, Optum Clinformatics DataMart and Merative MarketScan Medicaid Multi-State Database) from a time of Medicaid expansion (January 2015 through December 2019) were analyzed by insurance type and comorbidities.
As expected, children younger than 2 years and particularly those younger than 1 year had the highest IPD rates regardless of insurance status, but children with Medicaid had higher IPD rates than commercially insured children. Of concern, these differences occurred despite statewide pneumococcal conjugate vaccine vaccination rates reported previously as being fairly high (92% with three or more doses by 2 years of age). Relative IPD rates for children with Medicaid vs those with commercial insurance were higher in infants (1.3, 95% CI, 0.9-1.9) and adolescents (3.4, 95% CI, 1.5-7.1).
Among children with comorbidities, the IPD rate was about four times higher in infants and 10 times higher in 6- to 10-year-olds, regardless of insurance type. The authors cite three prior studies showing lower vaccine uptake in Medicaid recipients, suggesting that, among factors affecting Medicaid patients' IPD burden, lower vaccine uptake likely has a role.
It seems logical that these prepandemic, pre-cutback data foreshadow darker times ahead due to a combination of increasing postpandemic public distrust, vaccine fatigue, and cutback-era policies. Not only is vaccine confidence still dropping and Medicaid becoming more restrictive at the federal level, but states may change Medicaid coverage when more costs are reassigned to them.
The bottom line is that vaccine availability and access will likely decrease, even in non-economically vulnerable children. So, all children could be exposed to increased types of circulating infectious disease -- resulting in increased IPD, particularly in vulnerable children. And here we are only considering one among many vaccine-preventable diseases.
As pediatric providers, can we close the anticipated vaccine gaps as vulnerable families deal with healthcare cutbacks and likely become more economically vulnerable? One way is to rededicate ourselves to getting as many children as possible vaccinated (eg, reminder texts, emails, phone calls before vaccine due dates) according to schedules recommended by organizations that are politically independent and science-driven, such as the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Obstetricians and Gynecologists. It's not a time for "business as usual."
We need to proactively confirm our belief in scientifically based vaccine schedules to the families of our patients. While I strongly believe in patient medical homes, there may be room for flexibility if vaccines become available from alternative sources that are economically helpful to families. We can hope charitable organizations, foundations, and some altruistic individuals will ramp up funding to fill the evolving voids. The answers are not simple nor are potential fixes easy. Yet, pediatric providers have always answered the call when children are in jeopardy. Let's keep as many children safe as possible.