After ACIP: Imperfect Paths for U.S. Vaccine Policy

How the U.S. Can Navigate a Fragmented Future and Minimize Damage in a Post-ACIP World.

I’m David Higgins, a practicing pediatrician and preventive medicine physician who cares for children and studies how to improve how we communicate about and deliver vaccines and other preventive care. This newsletter shares clear science, smart policy, and meaningful conversations, because the health of our communities depends on all three.

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Hi Community,

This week, The New England Journal of Medicine (NEJM) published a “Sounding Board” article by 17 former members of the Advisory Committee on Immunization Practices (ACIP). Titled The Path Forward for Vaccine Policy in the United States, the authors lay out a sobering reality:

The trusted system for making U.S. vaccine recommendations has been dismantled, and no single replacement can fully restore the function or credibility we’ve lost.

Since this excellent article is behind a paywall, I wanted to review their thoughtful recommendations and provide context.

This is a long one, so here’s the TL;DR: With the ACIP dismantled, the U.S. faces a fragmented vaccine future, and in the long run, only a credible, independent, legally protected “ACIP 2.0” can secure access, ensure equity, and rebuild public trust.

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How We Got Here

For over 60 years, the ACIP was the cornerstone of U.S. vaccine policy.

That system is gone.

In previous posts, I have written extensively about the history of the ACIP and the actions to dismantle it.

The old system cannot simply be resurrected. The infrastructure, data access, and federal authority that ACIP relied on have been fractured.

The goal moving forward must be to minimize damage to U.S. vaccine policy.

Proposed Paths Forward

The authors of the NEJM article outline three potential, nonexclusive models for a post-ACIP vaccine recommendation system. Each has distinct strengths but also serious limitations. Here’s a closer look at each.

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1. Coalition of Professional Societies

Under this approach, major medical and public health organizations, like the AAP, AAFP, ACP, ACOG, and others, would form a coalition to harmonize vaccine recommendations.

Pros:

• Speed and familiarity: These organizations already issue guidance for their members. A coalition could form quickly.

• Clinician trust: Pediatricians, family physicians, and many other providers already rely on their professional societies.

• Existing infrastructure: Societies like the AAP already have expert committees and policy teams that could align recommendations.

Cons:

• Risk of fragmentation: Each society has its own priorities and patient populations. Aligning on every detail could be slow or fail entirely.

• Coverage uncertainty: Insurers might not automatically honor society-based recommendations, threatening access for millions of children. It is unlikely that the VFC program will follow these recommendations over those from the CDC.

• Limited data access: Without formal federal integration, societies may lack access to real-time vaccine safety and effectiveness data that ACIP once had.

My take: This is the fastest and most realistic short-term option. These organizations already have the trust of clinicians and the infrastructure to issue evidence-based vaccine guidance. But if not harmonized, it risks producing conflicting recommendations that insurers or states could pick and choose from, deepening inequities. These efforts are already in process, but do not be fooled into thinking these recommendations can replace the ACIP.

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2. External Auditor of New ACIP

This model envisions a watchdog organization that reviews recommendations from the new politicized, handpicked ACIP and flags unscientific or dangerous decisions.

Pros:

• Quick setup: A single expert body could start monitoring immediately.

• Clear voice: Provides a single public voice for providers and states on which recommendations are credible.

• Lower resource needs: It does not require fully replicating the ACIP’s infrastructure.

Cons:

• No legal authority: Insurers and VFC would not be required to follow this auditor’s guidance.

• Dependent on credibility: Its influence would rely entirely on public trust and uptake by health systems and clinicians.

• Limited reach: A purely advisory “auditor” does not replace the coordination ACIP once provided.

My take: An external auditor could provide a clear public check on unscientific or politically motivated vaccine decisions. However, this is like a smoke alarm without a sprinkler system. And, there are many voices already sounding the alarm about vaccine decisions. This auditor may get lost in the noise without the authority to take action.

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3. Full Parallel System (“Shadow ACIP”)

The most ambitious option is to create an entirely new, independent ACIP-like body, replicating the rigorous processes of evidence review, public deliberation, and consensus-building.

Pros:

• Maximum credibility: Mirrors the proven system that providers and the public trusted.

• Comprehensive expertise: Could analyze safety, effectiveness, feasibility, and cost-effectiveness, just like the old ACIP.

• Clear guidance: Offers a unified schedule that could prevent the state-by-state fragmentation we are sliding into.

Cons:

• Expensive and logistically difficult: The authors estimate $2–3 million per year, plus the need for staffing, data access, and administrative support.

• No automatic legal authority: Without new legislation, insurers and the VFC program would not be obligated to follow its recommendations.

• Heavy lift: Recruiting experts, administering this program, and restoring public trust would take time.

My take: This is the most credible long-term solution, but the hardest to implement. However, without legislative changes, it would operate as a parallel “shadow ACIP” rather than a fully empowered authority. This approach may become unavoidable. The longer the current situation goes on, the greater the need for an independent, credible, and legally empowered body to review vaccine evidence, incorporate diverse perspectives, and analyze safety, effectiveness, feasibility, and cost-effectiveness.

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A Long-Term Solution: “ACIP 2.0”

The three options outlined by the NEJM authors are important to consider in the months ahead. And, in the long run, the U.S. needs a solution that not only rebuilds what remains of the ACIP but also shields it from the kind of reckless dismantling we have just witnessed.

The overnight collapse of the ACIP has exposed a core weakness in U.S. public health: our national vaccine recommendations rely on a committee that exists entirely at the discretion of the administration in power.

Unlike some peer nations, the U.S. has no legally protected, statutory body for immunization policy. The Secretary of HHS has broad discretionary authority over the ACIP. As we have seen, one politically-appointed individual in an administration can dismiss all members, bypass the evidence-based process, and inject politics into decisions that should rest on science. To learn more, this Health Affairs article is an excellent overview of the legal questions surrounding these actions.

While not without flaws, several countries have established National Immunization Technical Advisory Groups (NITAGs) with legal foundations and statutory independence, helping shield vaccine policy from political pressure. Examples include the United Kingdom’s Joint Committee on Vaccination and Immunisation (JCVI), created under the National Health Service Act 2006, and Germany’s Standing Committee on Vaccination (STIKO), established in the Infection Protection Act.

The U.S. could create a statutory, independent vaccine advisory body with the following features:

1. Created and protected by law, not administrative charter, so it cannot be dismantled without Congressional action.

2. Independent membership selection, with clear, legislated conflict-of-interest rules and fixed terms.

3. Statutory requirement for federal consultation before changes to vaccine recommendations.

4. Formal linkage to insurance and VFC coverage, so evidence-based recommendations automatically protect access.

Such a body could ensure that vaccine recommendations and access are driven by evidence and public health, not political winds.

The biggest hurdle? Congress would have to act. After you finish rolling on the floor laughing, I invite the brilliant readers of this newsletter—many with more experience and insight than I have—to weigh in: Is this a viable path, even if it takes years to materialize?

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The Risks of Doing Nothing

If no trusted, coordinated system emerges:

• Insurance coverage will fracture, leaving major gaps for both children and adults.

• Vaccine access will become unequal, with rural and low-income children suffering the most.

• Public trust will erode further, as providers and families see confusing or contradictory messages from states, societies, and federal agencies.

• Disease outbreaks will follow. As I have said before, you can ignore science, but sooner or later, you will encounter an infectious disease that doesn’t. The ultimate outcome will be more outbreaks, more suffering, and more death—inevitable and entirely preventable tragedies.

The real question is: How long can the United States afford to operate without a trusted, evidence-based system with the authority to guide vaccine policy?

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Thank you to the “ACIP 17” authors on the NEJM article this post is based on, who were unjustly dismissed in June after their dedicated public service on this vital committee. They close their article with a simple, urgent reminder:

“Families are counting on us.”

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Thanks, as always, for being part of this community.

-David

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Community Immunity is a newsletter dedicated to vaccines, policy, and public health, offering clear science and meaningful conversations for health professionals, science communicators, policymakers, and anyone who wants to stay informed. This newsletter is free for everyone, and I want it to be a conversation, not just a broadcast. And if you find this valuable, please help spread the word!