Vaccine Coverage: $40 Co-Pays Rise as Federal Panel Remains Vacant

A $40 co-pay is the current price of entry for some patients seeking the new mRNA flu vaccine, a cost that arises because the federal advisory panel responsible for vaccine recommendations remains vacant. The gap in guidance has left insurers without a clear timeline for adding new shots to their plans, forcing individuals to pay out of pocket while the committee stays empty.

Robert F. Kennedy Jr., the secretary of the Department of Health and Human Services, has not nominated new members to the Advisory Committee on Immunization Practices, known as ACIP. A judge recently halted Kennedy's earlier attempts to replace committee experts with allies, ruling that the changes were not carried out correctly. Although the government has appealed the portion of the ruling that disbanded the committee, no new appointments have been made since the decision.

The lack of recommendations creates a delay in insurance coverage for newly approved shots. Ron Kroening, 63, sought Moderna’s mRNA flu vaccine, which the Food and Drug Administration approved in August for adults 50 and older. His insurer told him the shot was not covered because it is not listed as an ACIP vaccine, requiring him to pay the $40 fee at a pharmacy that stocked the product. Kroening, a retired public health employee, stated that any barrier to vaccination discourages people from getting shots.

Industry experts note that insurers typically have one year or more from an ACIP recommendation to add coverage to their plans. A recommendation issued in December 2026 would generally require coverage by the start of the next plan year, which is often January. However, because the committee is empty, a recommendation could be delayed until 2027 or later, pushing full coverage into 2029. Lindsay Wiley, a law professor at UCLA, said a recommendation next year would be the best-case scenario, but noted there is no reason to expect one soon.

The vacancy affects more than just flu shots, as some states require an ACIP recommendation before pharmacists can administer vaccines. Previous decisions, including a September 2025 recommendation on new RSV shots, were halted by the court order, though insurers appear to be covering those vaccines anyway. The voided vote to end the universal hepatitis B birth dose is also influencing potential state laws. Additionally, delays have been reported in Medicare coverage for the new flu shots, even though federal law requires it without a formal recommendation.

Aaron Siri, who has served as Kennedy's lawyer, wrote on Monday that the White House and the Department of Justice are making no serious attempt to revive the committee. Dorit Reiss, a vaccines expert at UC Law San Francisco, agreed that the federal government is choosing not to install a new ACIP. Reiss warned that the committee's independence has been undermined, suggesting that restoring its authority may eventually require a statute giving it legal protection.

Kroening’s insurer is part of the industry group AHIP, which has pledged to keep covering all shots recommended as of September 2025. Despite the administrative confusion, Kroening said he would choose the new vaccine again and was glad he paid for it. He described the current situation as a mess, noting that he is unhappy that his insurance did not cover the cost.