COVID-19 Vaccine Access

Following federal policy changes, governors and lawmakers in many states introduced new or expanded policies to preserve access to COVID-19 vaccines. 

In August, the U.S. Food and Drug Administration (FDA) approved the COVID-19 vaccine for people over age 65 and those considered at “high risk” due to certain medical conditions. Then in September, the Advisory Committee on Immunization Practices (ACIP) voted to recommend COVID-19 vaccines to anyone six months or older under “shared clinical decision-making”.  

Because existing state laws typically mandate that guidelines and vaccine administration protocols align with federal advisory bodies’ formal recommendations, lawmakers worried the changes could result in access issues, like prescription requirements, insurance copays, and more. As a result, numerous policy solutions were recently implemented to minimize anticipated barriers.   

According to KFF’s tracker, 26 states now allow pharmacists to administer COVID-19 vaccines without a prescription, while 13 states require health insurers to cover the vaccine at no cost. State policymakers or regulators made these changes possible through a variety of mechanisms, including executive orders (CO), state pharmacy board actions (PA), and standing orders (NC), to name a few examples. Collectively, these policy actions expanded pharmacists’ scope of practice, regulated insurance coverage, or untethered state law from reliance on federal entities to make vaccine recommendations.  

Health Insurance Coverage

The U.S. federal government shutdown that began on October 1 is, in part, a byproduct of the debate on enhanced premium tax credits (ePTCs). The American Rescue Plan Act of 2021 included ePTCs that effectively lowered the cost of premiums by providing additional subsidies to insurance carriers and more than doubled enrollment across marketplace-based health care plans—from 11.4 million people in 2020 to 24.3 million people in 2025. However, the subsidies will expire at the end of 2025 without Congressional action, which means more expensive premiums. Even if Congress acts by December 31, the open enrollment period for marketplace plans will already be underway by November 1. 

To preemptively mitigate costs, some state lawmakers codified short-term solutions to provide state-subsidized premium reductions. In Colorado, for example, policymakers passed HB25B-1006 during a special session, which authorizes the state to sell tax credits to finance up to $100 million for the health insurance affordability cash fund if PTCs are not extended before December 31, 2025. Similarly in New Mexico, Governor Michelle Lujan Grisham (D) signed HB1 into law on October 3, which includes $17 million to reduce premium costs for plans on the state’s exchange, BeWell.   

Earlier this year, lawmakers in other states anticipated ePTCs ending and passed legislation accordingly. In Maryland, for example, HB1082, which was signed into law by Governor Wes Moore (D) in May, replaces the state’s existing additional premium subsidies for young adults aged 18-37 by broadening the funding’s coverage scope to include a wider range of enrollees if ePTCs expire.  

Although these measures are expected to reduce premium costs during Open Enrollment, the absence of sustained funding for subsequent periods suggests that discussions around policy solutions will persist among future state policy trends and in upcoming legislative sessions.  

HIV Prevention Medications

California lawmakers passed legislation that would solidify protections for insurance coverage of HIV pre-exposure prophylaxis medications, or HIV PrEP.  AB554, which was presented to Governor Gavin Newsom (D) for signature on Sept 22, prohibits insurance carriers from imposing cost-sharing or prior authorizations on all PrEP drugs approved by the FDA, unless there is a therapeutically equivalent drug available. Similarly, insurance carriers cannot require utilization management techniques such as step therapy, which requires a patient to try a less expensive drug before a costlier one, or impose out-of-pocket costs for non-formulary PrEP drugs (unless a therapeutically equivalent is on the plan’s formulary).  

The language may particularly aid patients seeking long-acting injectable PrEP medications, for which there are no generic options. Such PrEP drugs are a newer modality and often face coverage barriers despite both state law and federal requirements from the U.S. Preventive Services Taskforce (USPSTF) requiring carriers to cover at least three PrEP formulations.  

Assemblymember Mark Gonzelz (D – Los Angeles), the bill’s sponsor, along with community advocates argued these changes will further increase access to HIV prevention strategies. However, Governor Newsom vetoed the legislation on Oct 13, arguing it would exceed cost-sharing provisions under the Affordable Care Act and increase premiums while duplicating existing USPSTF requirements already baked into state law. The governor made similar arguments in 2023 when vetoing AB1645, which would have expanded zero cost-sharing protections for STI testing and treatment.