The Map That Doesn’t Match: Vaccine Exemptions and America’s Public Health Divide
Why vaccine exemptions don’t fit America’s usual divides
Everyone knows the map.
For almost every social or economic issue — poverty, anti-LGBTQ+ laws, educational access — America’s geography tells a familiar story.
The map of college education shown below mirrors patterns we’ve seen again and again: the Deep South and Mountain West trailing near the bottom, East and West coasts perched near the top.
That familiar spatial narrative isn’t just anecdotal; it’s deeply rooted in interlocking systems.
Poverty, political alignments, policy decisions—they spiral together, so much that it’s often impossible to say if poverty causes, or is caused by, political dominance or religious participation. Does voting Republican lead to poverty, or does entrenched economic hardship sway voting patterns? It’s a feedback loop, woven tight.
Except when it isn’t.
What could California, Montana, Mississippi, New York and Maine possibly have in common that would break that trend?
What could Louisiana be doing better than Washington?
Or West Virginia doing better than Massachusetts?
The one map flattens the expectations: vaccine exemption policy.
Most states offer three exits from school immunization laws — medical, religious, and philosophical. Those last two together are now referred to as “non-medical exemptions.”
As of 2025, only five states restrict exemptions to medical reasons only: California, Connecticut, Maine, New York, and West Virginia. No religious or philosophical exemptions are permitted
Let’s trace how that came to pass.
California:
California’s path toward eliminating non-medical exemptions began with a moment that shocked the nation: the 2014–2015 Disneyland measles outbreak. What should have been an ordinary family trip to “the happiest place on earth” instead became the epicenter of a disease that public health officials had once declared eliminated in the United States.
The outbreak ultimately sickened 147 people across seven states, Mexico, and Canada, with the majority of cases traced back to unvaccinated children and adults who had visited Disneyland in Anaheim during the holiday season.
Investigations revealed that in some California communities, vaccination rates had dipped as low as 50 percent, far below the 95 percent threshold needed for herd immunity. The outbreak captured national headlines and made visible the public health consequences of rising vaccine hesitancy.
In response, California lawmakers introduced Senate Bill 277. The bill eliminated both personal and religious exemptions from school vaccine requirements, leaving only medical exemptions. Governor Jerry Brown signed it into law in June 2015, despite heated protests at the State Capitol, where thousands of opponents rallied against what they saw as government overreach.
The law’s effects were immediate. According to the California Department of Public Health, kindergarten vaccination rates jumped from 90.4 percent in 2014–2015 to 95.1 percent in 2016–2017, reaching the herd immunity threshold for the first time in years. Measles cases in the state dropped sharply.
But the story didn’t end there. Some physicians — particularly in communities already skeptical of vaccines — began issuing questionable medical exemptions, sometimes for a fee. By 2018, the number of medical exemptions had more than tripled in certain counties, undermining the intent of the law.
To address this loophole, lawmakers passed SB 276 in 2019, requiring the California Department of Public Health to review medical exemptions issued by doctors who granted more than five in a year or whose schools fell below the 95 percent vaccination threshold. The bill sparked another wave of protests, with vaccine opponents again flooding the Capitol. Yet Governor Gavin Newsom signed the measure into law, cementing California’s status as one of the strictest states in the nation on vaccine policy.
California’s experience demonstrates how outbreaks can shift public opinion and policy, and how legislation itself can trigger new adaptive strategies — from both public health agencies and vaccine opponents. It also shows the precarious balance: every loophole matters when the disease in question is as contagious as measles.
Connecticut
Connecticut became the fifth state in the nation to eliminate religious exemptions to school vaccine requirements when Governor Ned Lamont signed House Bill 6423 into law on April 27, 2021.
The law immediately barred new religious exemptions for K–12 students but allowed a “grandfather clause” for children already enrolled in school at the time. Those students could continue without vaccination until they graduate high school. However, no new exemptions could be filed, meaning over time the state would fully phase out religious exemptions.
The debate in Connecticut was fierce. Lawmakers endured 20 hours of testimony, most of it from vaccine opponents. The State Capitol saw thousands of protesters rally against the bill, echoing the rhetoric that had spread nationally during the COVID-19 pandemic. Supporters, including the Connecticut Department of Public Health, argued that high vaccination rates were critical to protect vulnerable children, especially those who cannot be vaccinated for medical reasons.
Public health data showed why officials were concerned. In 2019, Connecticut reported that 134 schools and two entire school districts had kindergarten vaccination rates for measles, mumps, and rubella (MMR) below the recommended 95 percent threshold needed for herd immunity. Some schools had rates as low as 50 percent.
Since HB 6423’s passage, the state has reported steady improvements in overall compliance, though opponents have filed lawsuits claiming the law violates religious freedom. Federal courts have consistently dismissed those challenges, citing Jacobson v. Massachusetts (1905) as precedent for the state’s authority to protect public health.
This makes Connecticut a kind of bridge case: unlike California and Maine, which passed sweeping bans in the wake of outbreaks, Connecticut acted in a moment where anti-vaccine activism was at its peak nationally. It shows that even in that climate, legislatures could still move toward stricter laws — though only by phasing them in gradually and under intense public scrutiny.
New York
New York’s move to eliminate religious vaccine exemptions came amid the largest measles outbreak in the United States in more than 25 years. From September 2018 to June 2019, the state recorded over 900 cases, mostly concentrated in Brooklyn and Rockland County, where vaccination rates had dropped well below herd immunity levels. Nationally, the CDC reported 1,282 measles cases in 2019 — the highest since 1992 — and over 75 percent of them were in New York.
The outbreak was heavily concentrated in Orthodox Jewish communities, where misinformation campaigns had circulated through pamphlets, hotlines, and community groups, discouraging parents from vaccinating. Public health officials documented that some schools had MMR vaccination rates below 80 percent, creating fertile ground for transmission.
In June 2019, amid growing pressure from health experts, Governor Andrew Cuomo signed legislation passed by the Democratic-controlled state legislature that repealed the religious exemption for all school-required vaccines. New York already did not allow philosophical exemptions, making the repeal particularly significant: it left only medical exemptions available.
The debate was intense. Lawmakers reported that they had received death threats and were met by thousands of protesters at the Capitol in Albany. Anti-vaccine activists claimed the law violated religious liberty, while supporters argued it was a necessary step to protect children and communities from preventable disease.
The impact was swift. According to the New York State Department of Health, compliance with school vaccination requirements rose in the 2019–2020 school year. The law helped quickly curb the outbreak — by September 2019, New York declared the measles outbreak over.
Opponents filed multiple lawsuits, but state and federal courts upheld the law, citing the precedent set by Jacobson v. Massachusetts (1905) and noting that religious freedom does not extend to practices that endanger public health.
New York’s situation underscores the tension between religious liberty and public health, but also shows how crises can catalyze decisive action. New York’s outbreak was preventable, and its aftermath reshaped vaccine policy nationwide — strengthening the argument for medical-only exemptions in the states that would follow.
Maine
Maine’s path to stricter vaccine laws began in 2019, when the state legislature passed LD 798, a bill eliminating both religious and philosophical exemptions to school immunization requirements.
At the time, Maine had one of the highest rates of non-medical exemptions in the country. In the 2018–2019 school year, nearly 5.6 percent of kindergartners entered school with a religious or philosophical exemption — more than double the national average of 2.6 percent. In some schools, exemption rates exceeded 20 percent, raising alarms among public health officials about the risk of outbreaks.
The move to repeal exemptions came after repeated warnings from the Maine Center for Disease Control and Prevention, which documented falling vaccination coverage and increasing vulnerability to preventable diseases like measles and pertussis. Lawmakers pushed LD 798 through the legislature, and Governor Janet Mills signed it into law in May 2019.
The backlash was immediate. Vaccine opponents mobilized quickly, gathering more than 90,000 signatures to force a “people’s veto” referendum — Question 1 on the March 2020 ballot.
The campaign became one of the most heated public health battles in Maine’s history.
Opponents framed the law as an infringement on parental rights and religious freedom, while supporters argued that protecting community health outweighed individual objections.
The campaign drew in major players: the Maine Medical Association, American Academy of Pediatrics, and Maine CDC all endorsed a “Yes on 1” vote to uphold the law. Governor Mills also publicly defended the repeal, stating that “vaccines save lives” and that high community immunization levels were essential to protecting children.
On March 3, 2020, voters delivered a decisive verdict: Nearly 73 percent voted to uphold the law and terminate religious exemptions.
The margin was one of the largest ever seen in a Maine referendum. It was also one of the rare times in U.S. history that the public directly affirmed stricter vaccine requirements at the ballot box.
Since then, Maine’s immunization rates have improved. By the 2021–2022 school year, kindergarten coverage for the MMR vaccine rose to 97 percent, placing the state among the highest in the country and well above the herd immunity threshold.
The Post-COVID Backslide
Only four states (Connecticut, Vermont, Colorado, and Washington) have decreased the number of non-medical exemptions since the anti-vaccine movement was mainstreamed by conspiracy theorists and republican lawmakers in 2020.
For decades, Mississippi and West Virginia were the outliers on the vaccine exemption map, permitting only medical exemptions after their state courts ruled in the 1970s and 1980s that religious exemptions violated their constitutions.
Judges in both states argued that the right to practice religion stopped where it endangered public health. As a result, their schools maintained some of the highest vaccination rates in the country, even as neighboring states allowed parents to opt out on non-medical grounds.
But the COVID-19 pandemic scrambled that balance. Vaccine skepticism — once a fringe movement — was carried into the mainstream by conspiracy theorists, political influencers, and Republican lawmakers who cynically framed mandates as an assault on liberty. The result has been a wave of policy reversals in places once considered the strictest.
Mississippi resisted at first, standing almost alone against the tide. That changed in April 2023, when a federal judge ordered the state to create a process for religious exemptions. By July 15, 2023, Mississippi parents could claim such exemptions for their children, though the process required counseling at county health departments.
Even with that safeguard, the effect was immediate: in less than two years, more than 5,800 exemptions were filed. Despite the surge, Mississippi still has the lowest proportion of non-medical exemptions among states that allow them.
West Virginia followed a similar path, though by executive order rather than judicial decree. In January 2025, the state’s new Republican governor signed an order permitting religious exemptions. Yet as of mid-2025, the Board of Education had neither enforced nor codified the order into law, leaving the state in legal limbo. On paper, West Virginia remains one of the five medical-only states — in practice, its exemption status is unsettled.
Elsewhere, the retreat has been more dramatic.
Wyoming and Illinois — states that once restricted exemptions to medical reasons only — now allow religious exemptions, citing pressure from parents’ rights groups galvanized during COVID.
Idaho went even further.
In 2024, its legislature passed Senate Bill 1210, removing most childhood immunization requirements, including those for K–12 students. While not technically an “exemption law,” it effectively dismantled the enforcement of vaccine mandates. Families can now opt out entirely, reshaping Idaho into one of the most permissive states in the nation.
And then there’s Florida, where DeSantis and Surgeon General Joseph Ladapo have made dismantling vaccine mandates a political rallying cry. Their proposals include ending requirements for long-standing childhood immunizations against diseases like measles and polio.
For now, the legislature has balked — with even some Republicans signaling they’re unwilling to go that far — but the threat remains.
This shift tells a larger story: even as some states have tightened vaccine requirements in response to outbreaks, others have undone decades of precedent, rolling back safeguards that once kept children and communities safe.
The map of vaccine exemptions does not fit neatly into the well-worn patterns of poverty, politics, or culture that so often define America’s divides.
Instead, it reveals something deeper — the way moments of crisis, court rulings, and political will collide to shape public health policy.
California’s Disneyland measles outbreak in 2015 forced lawmakers to act where complacency had festered.
New York’s devastating 2019 outbreak showed how misinformation and falling vaccination rates could turn a preventable disease into an emergency, and how legislation could halt it.
Maine tested the question of whether the public itself, at the ballot box, would stand against a mobilized anti-vaccine movement — and the overwhelming answer was yes.
Connecticut demonstrated that even at the height of pandemic-fueled conspiracy theories, lawmakers could phase out non-medical exemptions with data and public health on their side.
But the story doesn’t only bend toward stronger safeguards.
Mississippi and West Virginia, once bastions of medical-only policies, have been forced or pressured into retreat. Idaho has gone further still, dismantling much of its childhood vaccine infrastructure altogether. And in Florida, powerful officials have made rolling back mandates a political rallying cry, even as legislators hesitate.
The lines of the map are shifting — not just between red and blue states, but between states that prioritize collective responsibility and those that privilege personal objection, even at the expense of public health.
What remains constant is the precedent set in 1905, when the Supreme Court ruled in Jacobson v. Massachusetts that the state has both the power and the duty to protect public health.
Whether states still choose to wield that power is another matter. In some, the mandate to protect the vulnerable has been upheld, strengthened, and defended even against organized opposition. In others, the hard-earned lessons of past outbreaks are being undone, replaced by a dangerous experiment in leaving disease prevention to chance.
The vaccine exemption map is no longer just a curiosity that defies the usual patterns — it is a test of whether we will learn from history or allow it to repeat itself, with children’s health hanging in the balance.
Additional map sources:
The Atlantic, The Geography of Hate.
American Enterprise Institute, Measuring Social Capital: Can We Tell If Some Places Are Richer in Social Capital Than Others?
Center for Disease Control, Homicide Mortality per 100,000 people*
Center for Disease Control, Underlying Cause of Death, 2018-2023, Guns
RAND Corporation. Percent of households with guns in 2016.