The Long-Term Consequences of Ending Vaccine Mandates in Florida

Earlier this month, Florida Surgeon General Dr. Joseph Ladapo declared that Florida would be the first state to abolish all vaccine mandates, marking a rejection of traditional public health strategies and an unprecedented change in vaccine policies across the U.S.

Although the exact process for reversing the state’s mandates remains uncertain, Dr. Ladapo and Governor DeSantis have announced the creation of a Florida “Make America Healthy Again” (MAHA) commission, which is likely to further weaken vaccine confidence and participation in the state.

While Florida’s surgeon general said he had not considered the costs—such as infections, hospitalizations, or deaths—of ending vaccine mandates in his state, scientists who have made those calculations say those costs could be significant, Brenda Goodman and Deidre McPhillips reported for CNN on September 9.

Healthcare Innovation recently spoke with Dr. Amy Bucher, Chief Behavioral Officer of Tennessee-based Lirio, about the potential impact of Florida’s decision to eliminate vaccine mandates. Bucher is also a researcher who conducted a recent study on vaccination behaviors in the U.S.

Could you provide a little background?

I have my Ph.D. in Psychology from the University of Michigan. I've spent the last 20 years working in the digital health space, focused on applying behavioral science to the way that we design tools that help patients start and then sustain behavior changes toward better health. Lirio is the second startup that I've worked for earlier in my career. We are a startup that uses artificial intelligence (AI) and behavioral science to personalize how we talk to people about their health, with the goal of empowering them and supporting them across their entire health journey.

Can you provide insights into the vaccine hesitancy you're seeing and how these views have developed?

Lirio has been nudging about vaccination for the past four years on behalf of both health systems and then, more recently, a national retail pharmacy. We have had the opportunity to develop these nudging programs which are based on research around people's vaccine attitudes. As we've put them out into the world, we've had the chance to learn about people's reactions to them. We do a lot of text message-based nudging, and people reply to those text messages. We have had the opportunity to analyze hundreds of thousands of text message replies, look at the themes, look at the things that people are responding to, and get an additional sense of what their vaccine attitudes are like.

One of the first things to know about vaccine hesitancy that's really important is that it's non-binary. It's really a range of attitudes. And you may find that there are individuals who are anti a particular vaccine, but very open to other vaccines. There are also people who may have different vaccination attitudes at different points in time. I think we've seen that quite a bit with COVID, where when the vaccines were first introduced, they were positioned as a return to normalcy, people were more accepting of them than you see in some pockets today, after a few years have passed. People have had an opportunity to see the impact of those and adjust their attitudes.

There are a lot of factors that go into people's vaccination attitudes. One of the things that we've really looked at is factors in the form of capability, or people's ability to make decisions and take action. Opportunity, which is about the environment where decisions are made, and sometimes that even means, do I live near a pharmacy where a vaccine is convenient and available? If not, I may not be as excited about getting vaccinated, because it's a higher effort behavior for me. And then motivation, which is, am I interested and willing to do this, but also mentally. Does this make sense to me? Is this something that I can see supports other goals that I have for myself? And if so, I may be more likely to take the step of vaccination. But if I'm having a hard time linking vaccination to things that I care about, then it's going to drop down my priority list.

We've researched nationwide and conducted some of this research in Canada as well, finding fairly similar results between the U.S. and Canada.

What do you see as the consequences so far when it comes to vaccine hesitancy?

The first and most obvious consequence of hesitancy is that we are seeing lower vaccination rates. The uptake of vaccines at this point in the year seems to be lower. It is still a little bit early for flu vaccination. The optimal time to receive the flu vaccine is later in September or in October. We will have a clearer idea in a week or two of how significant the drop is, but we're certainly seeing that drop year over year in COVID-19 vaccination. What I anticipate seeing, although the national data is no longer presented as easily and clearly, is that we would subsequently also see an uptick in infections and the negative consequences of those infections.

We work with a national pharmacy chain, and we've been able to compare the vaccination uptake of their patients against national trends. This is because the CDC had a vaccination dashboard that showed how many people were receiving each of the major vaccines on a weekly basis. That dashboard no longer exists this year, so we're relying solely on market share data and not on national trends, which is unfortunate, because it's really hard to gauge the relative performance of what's happening here.

What has the response been from both the public and healthcare providers to the announcement by the Florida Surgeon General?

I live in a corner of the world where most of my professional contacts are very vaccine supportive. The reactions that I've seen have been primarily critical of this decision in Florida. The behavioral scientist community of which I am a part generally thinks about things like decision making and how to help people. How do we create the environment in which people can make healthier choices when you have a state public health official, and in this case, somebody who is trained as a physician at some of the most highly regarded academic institutions in the nation, come out and make statements that cast doubt on the efficacy and necessity of vaccines? That creates confusion for people who are looking to authorities to help guide good decision-making. From a behavioral science perspective, a really negative dynamic has developed.

Medically, the consensus is that vaccines are safe, effective, and one of the most important tools we have for public health. This decision is very disappointing, from that standpoint.

I am very surprised, looking at the background of the Surgeon General of Florida, that this is where he arrived. It seems like this is something that kind of emerged from him in 2020, at the beginning of the COVID pandemic, when he started publicly speaking out against masking and vaccination. The cynical part of me wonders if it was a calculated attempt to gain some political power.

What is the potential impact of eliminating these mandates?

I'm particularly concerned about eliminating the mandates for school children because children are a very vulnerable population. There's a reason why there has been more attention on vaccination for children than you necessarily see with adults. Many adults aren't even aware that some of the routine vaccines that are recommended for us. I was surprised when traveling to India about 15 years ago and learned that one is supposed to get a polio vaccine. As an adult, there's a booster. But as an adult, I'm also fully grown, and I'm better able to recover from, and ward off, some of these infectious diseases.

I am very concerned. Not only will some of these diseases re-emerge and become more prominent, but the lingering health effects of them will be more serious on a young population than they would be on adults who already have developed some immunity through their decades of living. I also anticipate that we will see the effects of this ripple beyond Florida. Infectious diseases don't respect state boundaries. People travel. Florida is a tourist destination. It has some of the major theme parks, it has beautiful weather. I think we will see some national disease trends that are affected by what's going to happen in Florida.

How do you anticipate this will unfold in the long term?

The natural conclusion of this might be that we see infectious diseases reemerge. There are certain infectious diseases that we really haven't seen in any significant quantity in decades. We’re already seeing in Texas that Measles is occurring far more than we have seen anywhere else in the United States in my lifetime, or at least that I've been aware of. I think that as those things surge, hopefully, people will realize that vaccines were playing a really important positive role. I will say psychologically, it's very hard to measure a negative if you're taking something that prevents you from catching a condition or prevents you from getting worse. It's really hard to know what would have happened in the alternative timeline if you hadn't done that. My hope is that people realize that and they decide to course correct before it goes too far.

There's the hopeful part of me that hopes people will realize that there are negative trends in people's health and well-being, and that there are easy, inexpensive ways to address them, and…that we re-embrace vaccination. There's a more cynical part of me, and especially the part of me that is trained in understanding how people use information, how emotions can polarize people, that worries that we really will break into two increasingly distinct camps of people around…vaccination attitudes. People who are pro-vaccine in this sort of polarized environment are becoming more pro-vaccine, because we have a natural tendency to cling to our ideals when we're in this sort of challenge.

Do you have any advice for healthcare leaders?

In our research, we have found that those factors I mentioned, capability, opportunity, and motivation, are modifiable factors. Those are things that we can affect through our behaviors, through adjusting the environment. I think it's worth still paying attention to what we can do to help people feel empowered to choose vaccinations. Whether that's providing them with education and information, helping them bust through myths or false information about vaccination, helping them feel supported, helping them get to a pharmacy if there are transportation issues; all of those things do matter.

The other thing that matters a lot is the personal connection. There is an idea of a credible source in behavioral science. The physician remains a credible source for most people, even as they're divided around whether the CDC is credible, whether the World Health Organization is credible. It's very uncomfortable to have personal conversations with somebody who is against the thing that you're promoting. I think it's incredibly worthwhile if you are a provider…I put myself out there, saying: This is something that I believe is healthy. The more you can have that personal connection with somebody, the more you can help put them in a place where they can be receptive to the good information when they receive it.

It's not about finding the magic bullet, the one set of right words that breaks through somebody's vaccine hesitancy. We have to think of it as a long game, really helping people get comfortable, helping them overcome, in some cases, multiple barriers to vaccine acceptance. They may feel uncomfortable for multiple reasons, and there won't be that single conversation that gets them all the way to comfort. But if we take it as a journey, if we're willing to engage with people each step of the way, I think that we can make progress in depolarizing some of these issues.

We do text message nudging to people, and they reply to us. One of the things that I have noticed in reviewing the more recent vaccine replies, they seemed very polarized with some significant negativity in 2021 when the COVID vaccine was first introduced, that seems to have waned a little bit in the years since. There are still pockets of really strong negative replies, but they just seem a little bit less pervasive in 2023 and 2024. This year, they seem to be back, and they're very negative.  I think there is an environment that is giving permission to expressing and spreading some of these negative ideas, whether or not people sincerely believe them. I think that in this social media world, too; people have learned that if you want to get engagement online, you say something that's really strong, whether or not it's exactly right. In fact, sometimes having something be slightly wrong is a great way to get people to engage with you, which will then boost your profile. I think we have a whole dynamic in the environment that permits negativity. Some people are leaning into that negativity because it gets them attention. These online platforms are very popular, and that's a difficult dynamic to break into.