I’m a physician, a public health professional, and a mom. Florida’s proposed repeal of vaccine mandates makes sense for some diseases. But for others, like measles, it scares me. I don’t fear a return to national endemic measles, which ended in the U.S. in 2000, thanks to high levels of vaccination. But there is a risk that this will push us from widespread but scattered outbreaks to regional endemic disease that could be devastating.
We are in a new reality, and the context matters. Under current mandates, Florida has a measles vaccination rate just under 89%, below both the 92.5% national rate and the 95% needed for herd immunity.
Government mandates linking vaccination to school eligibility have always been coercive. Families had to comply—and some otherwise healthy children did have adverse reactions. But mandates also served an important purpose: They acted as the machinery for the system. Schools required paperwork, and pediatricians tied visits to vaccine schedules.
Trust in public health officials has collapsed. The ruthless and scientifically dubious government push to force the population to submit to COVID-19 vaccinations had consequences and led to a wholesale reassessment of the schedule. Calls for rolling back mandates were driven by the breaches of trust that the pandemic’s “noble lies” and overreach epitomized.
Parents increasingly have questioned why they are required to vaccinate their children at all, even against deadly, highly communicable diseases like measles. A growing number of them have sought mandate exemptions. Policymaker reactions underscore a deep divide. Some states have responded by tightening restrictions, while others have relaxed or even rescinded mandates.
We built our community protection against infectious diseases with vaccine mandates as a blunt tool. They “worked” because most children attended school in person. Compliance relied on children as a captive audience and parents with no other options. Prolonged school closures led to the earliest cracks in the system. Our mandate-based system didn’t anticipate that some of those children wouldn’t return to the schoolhouse, and we didn’t take the additional steps necessary to develop a more tailored infrastructure. Mandates always were a flawed approach, but right now, we don’t have a backup plan.
In a post-mandate U.S., many of the kids who go un- or under-vaccinated won’t have parents who are anti-vax, but will fall through the cracks simply because of the loss of the logistical framework. Without mandates, even parents willing to vaccinate lose the default structure our current system is based on—there will be fewer well-child visits, catch-up opportunities will vanish, and inertia will set in.
Vaccine mandates are the basis for public health law and, at their core, use the police power of the state to strip people of bodily autonomy in the name of community protection. In Jacobson v. Massachusetts (1905), the Supreme Court upheld state authority to mandate adult vaccination, imposing fines for noncompliance. Zucht v. King (1922) extended this to school eligibility for children.
In 1963, the measles vaccine saw disappointing uptake in the U.S., and endemic disease continued unabated. President Carter tied federal funding to vaccination mandates, and by 1980, all 50 states had them. In 1994, President Clinton ushered in another shift, and dollars flowed based on vaccine access rather than mandates; states could drop mandates without losing federal support.
In April 2025, Idaho became the first state to pull mandates, and on September 3, Florida’s surgeon general suggested that it would follow. We are left with an increasingly Balkanized vaccine map, with some states offering strong, strict protections, others with no mandates at all, and an increasing number with what effectively are only “paper mandates”—too weakened by broad exemption policies to offer any practical benefit.
This year saw active measles cases in dozens of states. For many years, regular transmission routes had been successfully broken. Contained measles wildfires were sparked by the introduction of new cases through immigration, but these quickly burned out. More recently, pockets of particularly low vaccination rates have smoldered and, on occasion, have spontaneously flared, but have remained in place. The risk is that if general immunization rates drop much further, these isolated outbreaks will transform into endemic disease—effectively, an out-of-control blaze. If this happens, when new, unprotected children are born into the community, they will act as fuel for a fire that will be extremely difficult to extinguish.
Before the measles vaccine, 3-4 million U.S. children were infected yearly, and hundreds died. That was the pre-1963 baseline. A recent model suggests that a 10% drop in U.S. measles vaccination could lead to more than 11 million measles cases in the next 25 years. Our regional policy differences mean that such a scenario would have an uneven impact. While the West Coast would continue to have good levels of community protection, it is probable that the Southeast would not.
We can’t wish for the “good old days” of mandates. COVID-era government overreach and the expansion of the parental rights movement likely will keep them from returning, for now. Libertarians whose souls cheer Florida should consider that the return of endemic measles would inevitably trigger a draconian backlash and a return to broad mandates.
What we can do is take actions to mitigate at least some of the risk. We will need to quickly build a system that modernizes identification and engagement. Our current system was designed for an era of paper charts and rotary phones, and does little to optimize digital advances. Technology-enabled logistics—text communications and medical record interoperability—are not future states. The tech levers needed to scale personalized vaccine delivery currently exist, but immediate action will be necessary to operationalize them.
We also should acknowledge that part of the backlash to mandates is grounded in our current maximalist approach. It is the truth that babies younger than six months of age cannot be vaccinated against measles—their only protection is community coverage. But it is also true that most states treat hepatitis B and measles vaccines as if they are equal in importance. They are not, and pretending they are has eroded trust.
Vaccine mandates are blunt, coercive, and imperfect, but they have provided a structure to support community protection. Florida’s decision forces us to face the reality that if mandates are pulled without a plan for what will take their place, we may once again face endemic disease. Even if regionally contained, this would be a disaster.
It would be unrealistic to expect that mandates will return to all 50 states, at least not anytime soon. There is another path, but it means having the will and humility to be proactive and build a smarter, more precise system.
