Q&A - September 29, 2025
This week’s questions:
State public health officials are having to make difficult decisions about whether to follow CDC guidance on vaccines and other topics. Could there be a similar erosion of trust by states regarding FDA guidance?
Anti-vaccine policies poll poorly and Republicans are worried that Secretary Kennedy’s approach could hurt them in the 2026 election. What do you think?
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Q: State public health officials are having to make difficult decisions about whether to follow CDC guidance on vaccines and other topics. Could there be a similar erosion of trust by states regarding FDA guidance?
A: Possibly. Not yet. Hopefully never.
It also depends upon which function of FDA is being addressed. Here is a way to look at it:
The federal government and states run parallel integrated public health programs (CDC public health guidance and surveillance, FDA food safety programs, and FEMA for disaster relief). To some extent, every state has a mini-CDC agency — generally less well-funded and less well-staffed. But most are quite capable.
Devolving responsibilities to the states — either by intention or by creating a vacuum at the federal level — would be inefficient and, in the aggregate, quite costly. Most states and regional compacts have access to sufficient information and expertise to develop reasonably sound policy and guidance. However, decisionmaking would likely not be as good or as authoritative without national expertise, networks, and information collection. Uniformity is a critical benefit.
Of course, devolution makes no sense in other ways. Each of the fifty states crunching surveillance data or employing multiple experts in Listeria is inefficient and expensive. Importantly, state borders don’t constrain the pathogens that cause communicable diseases and unsafe food. [note: this same logic would apply to FEMA, which is also under attack].
Vaccine production is a separate and specific case. The federal government taking the lead is essential for supply purposes, equity among the states, and the funding of innovation.
At least as far back as Operation Warp Speed, there has been tension between the CDC role (public health guidance on vaccine schedules) and the FDA role (labeling for use of approved vaccine products).
Adding fifty states with an unlimited number of variations seems confusing, unwise, and a serious impediment for manufacturers. Were this to occur, it would be detrimental to public health, disease prevention, and the development of new vaccines. Large-market states would receive significantly more attention than small states, creating a serious equity problem.
States can more readily take up the CDC guidance role than the FDA product labeling role. Neither is desirable.
The FDA’s approval of medical products has no obvious parallel at the state level. No other organization has the capacity, expertise, or authority to approve medical products that will be involved in interstate commerce, which is effectively “everything.” However, this is not without its challenges. For example, Montana is trying to create a haven for doctors to treat patients with unapproved and experimental drugs (https://bit.ly/45TrXS8; https://bit.ly/4m8HWl2).
In summary, the first scenario (states deciding public health policy in the absence of CDC) is unwise. The second (states disrupting the national market for vaccines) is truly awful. The third (states trying to bypass the Food Drug and Cosmetics Act and making decisions on the use of medical products) is a disaster.
Q: I heard that anti-vaccine policies poll poorly and Republicans are worried that Secretary Kennedy’s approach could hurt them in the 2026 election. What do you think?
A: I am not surprised that current vaccine policies poll poorly. Assuming that’s the case, then the Republican National Committee (RNC) is likely to be concerned.
However, I don’t see that mattering much, if at all. “Hot-button” issues thirteen months before an election are a poor predictor of what will motivate voters to show up and vote a particular way on election day.
Furthermore, I don’t see public opinion translating into enough angst for Republican Senators and Representatives to risk offending the President by calling for the ouster (or restraint) of a cabinet member, especially one who is perceived by the White House as having contributed to Trump’s 2024 electoral success.
Regarding the durability of Robert F. Kennedy, Jr. as Secretary of HHS, I last addressed this three weeks ago in a prior Q&A on Monday (here). My focus then was that Kennedy’s appearance before the Senate Finance Committee on September 4 was great “political theatre” and probably viewed quite favorably by President Trump.
My updated view: Secretary Kennedy’s stock at the White House is undiminished and anti-vaccine policies will continue unabated.
The argument that Kennedy threatens President Trump’s legacy by undercutting Warp Speed... rests on the assumption that either Trump or Kennedy is troubled by the inconsistency. I see no evidence that it does. At the September 4th hearing, one of the questions was whether Warp Speed was a crowning achievement of Trump’s first term. Kennedy agreed it was, but then went right back to bad-mouthing the safety, efficacy, and need for COVID vaccines.
Kennedy’s temperament is probably more like Trump's than that of any of Trump's other cabinet members or close advisors. I sense that Trump is delighted by Kennedy’s shenanigans and sees himself benefiting from Kennedy’s energetic, iconoclastic, pugnacious, and norm-breaking approach. He probably wishes he had more Kennedy’s in his cabinet.
[1] Weekend announcements receive less attention, especially in this case, being sandwiched between the ACIP vaccine meeting and the Charlie Kirk funeral. Kudos to the Washington Post for covering it. CORRECTION: I have been told that the WSJ first broke the story, not WP. I am glad both publications saw the announcement as newsworthy.