Holding the Line: Primary Care’s Response to Fragmented Immunization Guidance 

Abstract 

The federal Advisory Committee on Immunization Practices, reconstituted in June 2025, narrowed its childhood and adult immunization recommendations, and these changes have coincided with a measles outbreak of historic proportions. This issue brief reports findings from Series 7 of the Larry A. Green Center Flash Survey, a rapid-cycle national survey of 632 primary care clinicians conducted March 5-12, 2026. According to the survey, 56% of clinicians report that adult patients are questioning vaccines they previously accepted, and among clinicians who care for children, 43% report that parents are generally less interested in childhood vaccines. Sixty-seven percent of clinicians with pediatric patients have shifted to following the American Academy of Pediatrics vaccination schedule, which they find more credible. Clinicians report spending considerably more time on vaccine counseling (53%), yet this work remains unfunded in fee-for-service settings. Nearly half of practices (43%) report lacking capacity to manage their practices in a vaccine-preventable disease outbreak. Most strikingly, 52% of surveyed clinicians report high levels of moral injury or burnout, with clinicians experiencing more vaccine-related practice disruptions reporting higher moral injury. These findings reveal a primary care workforce on the frontline of population health that is absorbing the time and cost of vaccine counseling in the absence of the federal guidance that primary care practices have historically relied on to deliver a key part of preventive care.

Introduction 

In June 2025, the Secretary of Health and Human Services removed all 17 sitting members of the Advisory Committee on Immunization Practices (ACIP), the expert panel that informs the Centers for Disease Control and Prevention (CDC) immunization schedule commonly used by primary care practices across the country.¹ Between June 2025 and early 2026, the new members of ACIP narrowed recommendations for some childhood vaccines, including the hepatitis B vaccine, to certain high-risk groups, and moved others, such as vaccines for rotavirus and influenza, from routine recommendation status to shared clinical decision-making.² ACIP also changed the status of COVID vaccines for adults from routine recommendation to shared clinical decision-making. For the first time since 1995, the immunization schedules of the CDC and the professional medical societies no longer align.³ The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) have stated that they do not endorse these changes to the federal schedule and have published their own schedules, which are identical to the previous ACIP recommendations for children.^{4, 5} 

These changes in federal guidance have coincided with a disruptive moment in US population health. The United States recorded 2,289 confirmed cases of measles in 2025,⁶ its highest annual total since 1991, across 48 reported outbreaks. These outbreaks led to three deaths — the first US measles deaths in a decade. In November 2025, the Pan American Health Organization announced that the Americas had lost their measles elimination status, and the United States, with 2,777 cases this year as of August 25,⁶ is highly likely to lose its country-specific elimination status in 2026.⁷  

This issue brief draws on Series 7 of the Larry A. Green Center’s Flash Survey, a rapid-cycle national survey of frontline primary care clinicians fielded March 5-12, 2026.⁸ Series 7 reports the responses of 632 clinicians from 49 states and the District of Columbia, pairing the survey’s structured data with clinician voices, drawn from 267 open-text comments. This is a convenience sample and is not statistically representative of US primary care clinicians. The range of specialties, ownership arrangements, practice settings, and geographies represented does, however, support the transferability of these findings to comparable practice settings. (For more detail, see the “About This Study” section of this issue brief.) Through these data, primary care clinicians state clearly that they continue to hold the line for population health amid changes in federal policy; that they are mission-driven to steward the health of the nation; and that doing so at a time of federal and epidemiological disruption comes at great personal cost. That cost can be mitigated with appropriate policy action to help sustain one of the key workforces safeguarding the country from the next pandemic.  

Survey Findings 

Patients Are Questioning Vaccines They Once Accepted 

The most consistent signal in the survey data is erosion of previous norms. Vaccine decisions, once a routine part of already overburdened clinical encounters, now require time to discuss advice supported by decades of evidence. One respondent from North Carolina wrote: “We have an active measles outbreak, which is having a significant impact on our clinic, staffing, and workflows. Counseling on the MMR [measles, mumps, and rubella] vaccine is taking a lot of time and people are still not accepting it.” (See Figure 1.) Fifty-three percent of clinicians report that conversations about vaccines now take considerably more time than they used to, and 39% report that patients increasingly reference political figures or social media content when discussing vaccines. Nearly two in five (37%) clinicians noted that there is new tension with patients who are confused about changing recommendations.  

Among the 463 clinicians who see pediatric patients, 43% report that parents are generally less interested in vaccines for their children, and 42% report parents delaying or refusing childhood immunizations they had previously accepted. At the same time, 33% of clinicians report parents asking for their children to receive the MMR vaccine ahead of schedule. While prior population-level studies have shown that less than 1% of children receive the MMR vaccine ahead of schedule,⁹ our results are consistent with previous findings during active measles outbreaks. For instance, the proportion of children in Texas receiving the MMR vaccine ahead of schedule increased from 0.7% prior to an outbreak in February 2025 to 20.1% following this outbreak.¹⁰  

Figure 1: Clinicians Share Concerns Among Patients and Parents

“Hesitant parents are confused and/or worried about vaccination in ways they have never been before. They no longer ask specific focused questions about vaccines but allude to a fear of vaccination in general. They have a hard time absorbing fact-based information and increasingly trust their fears over the facts. Parents who are devoted to vaccination are also fearful about access to shots and exposure to disease — they have a lot of specific focused questions about these topics. I am devoting a significantly larger portion of my time to counseling about vaccines.” — Rhode Island clinician
 
“Some parents have been more outspoken about WANTING to vaccinate their children.” — West Virginia clinician
 
“Families that previously declined vaccines are now more interested in getting vaccines, specifically measles.” — North Carolina clinician
 
“It is so very disheartening having otherwise intelligent, caring, loving parents not want to vaccinate their children because of all the disinformation out there. Bad for my morale and my staff’s morale.” —Virginia clinician  

Some clinician respondents note that distrust of health care is long-standing and multifactorial. One family physician from Pennsylvania wrote: “Nothing in the last three months has changed vaccine reluctance. The COVID pandemic, and the concerns with some COVID vaccines, is what really reduced acceptance and created difficult conversations with parents regarding childhood vaccines.” According to respondents, the recent changes to federal recommendations appear to have fueled concerns regarding vaccines by giving them the stamp of authority. 

Primary Care Is Pulling Away from Federal Guidance 

Primary care clinicians are choosing their professional societies and boards’ recommendations over the current federal guidelines, which they find less credible. Among clinicians who see children, 67% report that their practice now follows the AAP immunization schedule, while only 4% report following the current CDC schedule.  

Differences in guidelines seed confusion among staff. Some clinicians report that their staff remain uncertain about which immunization schedule to follow (12%), while others report anxiety about the implications for payer coverage. One clinician from Virginia noted, “Until AAFP endorsed [the] AAP immunizations schedule, there was confusion about which schedule to follow. We are monitoring insurer decisions about coverage and following AAP preferentially.” AHIP, the trade organization that includes most major US insurers, has said its members’ plans will continue to cover all vaccines recommended by ACIP as of September 1, 2025, through the end of 2027.¹¹  

A small number of respondents welcomed the federal changes. According to one clinician, “Yesterday, two families for well-child checks expressed relief with the changes of the vaccine schedule. The mother of a 2-month-old was happy that she did not have to get HepB [hepatitis B] vaccine for her baby, especially since she has always tested negative for HepB and is not at risk.” Another respondent cautioned against framing the survey’s findings in a unilaterally negative way, for similar reasons. Some clinicians differentiated between support of use of childhood vaccines — which they strongly endorsed — and use of vaccines among healthy adults, which they did not. As with patients, the shift in federal guidance appears to have given new institutional cover to a minority of clinicians who are also vaccine hesitant.  

Many Clinicians Report Practices Are Not Ready for What’s Coming Next 

Clinicians see a rising risk for the rapid spread of infectious disease in absence of an adequately vaccinated population, and they do not feel equipped to address it (Figure 2). Most clinicians surveyed, especially those who see children, fear the public health implications of dropping vaccination rates (Table 1).  

Table 1: Clinician-Reported Experiences and Perceptions of Recent Vaccine Changes 

The 2025 measles vaccination data for the United States appear to validate the anxiety expressed by surveyed clinicians. National two-dose MMR coverage has fallen among kindergartners to 92.5%,¹² below the 95% threshold generally cited for herd immunity. Only 10 states report coverage at or above that threshold. The clinicians in this survey are describing, at a micro level, the same trajectory that epidemiologists are seeing in the population at large. 

Figure 2: Clinicians on Managing Their Practices in Community Measles Outbreaks

The Cost of Disruption 

These survey findings also show an undercurrent of exhaustion, moral injury, and burnout, which has been seen in Green Center survey series since March 2020. Over the same period, there has been an increase in the population’s health burden along with reductions in access to care and primary care capacity.¹³  

In the March 2026 survey, 52% of all clinicians surveyed report high levels of moral injury or burnout. When we sorted clinicians by the number of vaccine-related disruptions they reported, the share reporting high moral injury or burnout rose steadily with the burden they carried (Figure 3). This is a cross-sectional association and not a causal finding.  

Figure 3: Vaccine-Related Disruption and Moral Injury 

Moral injury, as distinct from ordinary burnout, is the distress that arises when clinicians are prevented from doing what they believe is right for their patients. The comments in this survey are, in many cases, textbook descriptions of moral injury. Clinicians reporting high moral injury share that they know what the evidence supports, they are watching a preventable disease return, and they feel the shifting ground of shared institutional truth during what used to be brief and easy conversations about immunizations. The work of maintaining trust with patients is being absorbed, unfunded and largely unrecognized, into the clinical relationship. At a time when mistrust in public institutions and medical professionals is rising, 38% of primary care clinicians surveyed report that their patients trust their personal clinical recommendations more than those of government agencies. This is a clinician-reported measure of relative trust versus government agencies, not a measure of absolute patient trust in doctors, which national polling puts at 86% expressing at least “a fair amount” of trust.¹⁴

Implications for Policy and Practice 

Together, these findings describe a primary care workforce caring for people faced with new health concerns, from the COVID-19 pandemic and its aftermath to the current measles outbreaks. Clinicians are expending greater resources (both time and money) to address previously straightforward vaccine delivery. The one resource they had previously been able to rely on has been withdrawn: a single authoritative federal source of evidence-based immunization guidance. This one change has shifted and expanded the resources required, and clinicians are absorbing the difference in unreimbursed time and in practice capital committed to an inventory they can no longer efficiently forecast. They are choosing to follow the vaccine and immunization schedules that they trust, spending time they do not have, and bracing for outbreaks they do not feel ready to meet. A small but powerful set of policy actions could prove effective in mitigating these burdens and improving primary care’s ability to steward the health of the population. 

1. Restore a coherent, trustworthy source of vaccine guidance. 

The single most repeated theme in the survey’s open-text sections was loss of a federal source of evidence-based vaccination information, which drains clinicians’ time and their patients’ trust. Rebuilding an authoritative, evidence-based, and transparent federal advisory process, harmonized once again with the professional societies wherever the evidence allows, would relieve a burden that is currently being borne by clinicians and patients. 

2. Ensure stability of vaccine coverage and supply to allow clinicians to follow best scientific guidance with limited risk. 

Two-thirds of surveyed clinicians who see children have chosen to follow AAP guidance, but that choice leaves them financially exposed to changes in insurer decisions, and 22% are already uncertain how much vaccine to buy. Commercial payers should anchor coverage decisions to the recommendations of the major professional societies in writing before practices place seasonal orders, so that patients are not exposed to unexpected cost-sharing and practices are not exposed to unpaid claims.  

Separately, the up-front cost of private vaccine stock should not fall on small and independent practices that cannot afford it. The federal Vaccines for Children (VFC) program, which covers recommended vaccines for children who do not have private insurance that fully covers their costs, provides free doses for enrolled practices. The VFC formulary has not changed, so the burden for practices there is administrative: segregated inventory and demand forecasting. The cash risk is associated with practices’ private stock for other patients, which they purchase weeks to months ahead of administration and absorb when demand shifts or doses expire. Consignment or pay-on-administration terms from manufacturers and distributors, guaranteed credit for unopened doses returned before expiration, and expansion of state universal vaccine purchase programs would each move that risk to a party better able to absorb it. Several states already operate universal purchase programs, and several others have begun decoupling school-entry requirements from ACIP, offering a template. 

3. Invest in frontline outbreak readiness, especially for small and rural practices. 

Forty-three percent of practices surveyed report lacking capacity to manage patients during an outbreak, and readiness is lowest exactly where the buffer is thinnest, in small and rural settings. Supports — including isolation-capable space and personal protective equipment, standing measles screening protocols, and integration with local public health departments — would help convert clinician concerns into clinical capacity before the next outbreak occurs. These supports, funded through the Health Resources and Services Administration and state health departments and coordinated through the CDC’s Public Health Emergency Preparedness cooperative agreements with local health departments, would boost practices’ capacity to handle outbreaks. 

4. Financially support vaccine counseling for the clinical work it now is. 

The survey documents a large, unfunded increase in the time required to support and personalize vaccination decisions. This time investment was first documented in Green Center surveys during the pandemic and continues to be a concern. More than half of clinicians surveyed report that these conversations are taking considerably longer, yet the still dominant fee-for-service system does not recognize this work, a gap clinicians named repeatedly in survey comments. Public and private payers should ensure that vaccine counseling, including counseling that does not end in a vaccination, is a reimbursable clinical service. Several clinicians noted the new ICD-10 code for immunization safety counseling (Z71.85) but described it as inadequately valued. The code documents medical necessity of the visit but carries no payment of its own. Reimbursement depends on the office visit or counseling CPT code billed alongside it, and that code often does not capture the time vaccine counseling actually takes. Appropriately valued billing codes, including time-based codes, not just diagnosis codes, must be part of the solution.

Conclusion 

The strength of primary care has always been its relational, whole-person, locally adaptive character; its ability to meet people where they are; and its trustworthiness. Primary care is now doing double duty, standing in for federal institutions that have stepped back from evidence-based vaccination recommendations, and primary care clinicians report that they are facing an overwhelming number of challenges. Whether the line against preventable infectious disease holds will depend less on the clinicians and more on whether the systems around them decide to help carry the weight. 

About This Study 

The Larry A. Green Center Flash Survey series is anonymous and voluntary, is conducted four to eight times a year, and takes less than five minutes to complete.¹⁵ Survey findings report on a national cross-sectional convenience sample that uses a dual recruitment strategy: sharing of survey invitations through email distribution lists of professional organizations and networks, and sharing of survey invitations with a standing panel of frontline primary care clinicians who have agreed to regularly receive them. Alphanumeric tokens embedded in survey links enable the center to track longitudinal survey recipients while maintaining their confidentiality. Each survey includes structured questions, open-ended questions, demographic questions, and core questions.  

Seventy percent of all survey items are designed based on requests made by previous survey participants; thus, the questions shift in response to clinician perceptions of the policy and practice environment. Core questions include seven items that remain stable over time and ask about clinician, practice, and patient well-being. Surveys are fielded for one week. On closing, structured data are most often analyzed using descriptive statistics and chi-square tests. Open-text entries are coded by a multidisciplinary team using an approach that combines reflexivity and reflexive thematic analysis.^16,17 Survey item design and analysis are informed by conversation with a multi-sector and multidisciplinary national advisory committee.  

Survey items on outbreak capacity asked clinicians about their capacity to manage their own practices during an outbreak, not about community-level outbreak containment, which is a public health function. Several items asked participants to select all responses that apply, so a percentage reports the share of respondents who endorsed that item and should not be read as implying that the remainder endorsed the opposite. Participant characteristics of the Series 7 survey, fielded March 5-12, 2026, are shown in Table 2. 

Table 2: Participant Characteristics (N = 632) 

Acknowledgments 

The Larry A. Green Center’s Flash Surveys are funded by the Healing Works Foundation. 

Notes