Executive Summary
Vaccines are one of the most successful and significant public health measures to reduce diseases. However, since the COVID-19 pandemic, vaccines have become more politicized, especially in state legislatures where lawmakers decide state vaccination policies such as school-entry vaccine requirements.
This report reviews the voting records on vaccine-related bills of state legislators with health backgrounds in four states: Texas, Louisiana, Oklahoma, and Arkansas. The findings demonstrate that while several of these legislators sponsored or authored anti-vaccine bills, many consistently supported legislation that limited vaccine requirements and other public health measures.
Vaccines and Public Hesitancy
Vaccines are a public health tool used to prevent the spread of infectious diseases and are estimated to save more than 4 million lives each year.[1] However, as widespread vaccine use has significantly reduced the prevalence of vaccine-preventable diseases, concerns about vaccine safety and necessity have also emerged. Those who are wary of vaccines often share their views through social media, where myths and misinformation can spread widely. The strong and persistent messaging of vaccine opponents can also contribute to a societal perception that vaccines carry risks, influencing some people to question or avoid vaccinations.[2] While the World Health Organization (WHO) named vaccines one of the top ten health innovations of the 20th century, it also listed vaccine hesitancy as one of the major threats to public health.[3]
Vaccine hesitancy is defined as reluctance or refusal to vaccinate despite the availability of vaccines.[4] However, not all vaccine-hesitant individuals decide against immunizing themselves or their families. Some choose to skip specific vaccines, immunize on a schedule different from that recommended, or simply have concerns and questions they want addressed before proceeding with vaccination. Hesitancy can often be a result of misinformation about vaccines and/or concerns about the potential side effects of immunization. Many who are hesitant about vaccines also question the role of government and the pharmaceutical industry and are likely to prioritize personal freedoms, medical autonomy, and limited government.[5]
The coronavirus pandemic intensified debates over vaccine safety and the need for vaccination requirements.[6] Rapid development of COVID-19 vaccines, conflicting information from authorities, and misinformation on social media contributed to increased vaccine hesitancy. Furthermore, COVID-19 vaccine requirements for work and travel increased the politicization of vaccines.[7] The end result was a reduction in immunization rates.[8]
State Legislature Politics
While many look to the federal government to implement public policy, immunization policies are predominately determined at the state level, including school-entry vaccine requirements. This makes state legislatures the key battlegrounds for debates on vaccine policy.
Vaccines were not always politically charged. From 2009 to 2019, Texas — a conservative state — frequently passed mostly bipartisan immunization bills that supported improved vaccine access.[9] However, after the 2015 Disneyland measles outbreak, California eliminated personal belief exemptions for school-entry vaccinations, which sparked a movement against vaccine requirements in Texas and other states.[10] The COVID-19 pandemic intensified the debate over vaccines along with other public health measures such as stay-at-home orders and masking.[11]
During the past five years, vaccines have become more politicized. Activists have mobilized to promote the removal of all vaccination requirements — many of which have been in effect for more than half a century — and make it easier to obtain vaccine exemptions.[12] Vaccines are now considered a wedge issue, that politicians use to intentionally divide and polarize voters for political advantage.[13] The politicization of vaccines has significant implications for public health, hindering efforts to achieve high vaccination coverage and control outbreaks of vaccine-preventable diseases.
Focus of This Study
This report focuses on state vaccine policies in Texas and three neighboring states: Louisiana, Arkansas, and Oklahoma. The political landscape in these states is characterized by a strong conservative presence, holding in the governor’s office and Republican majorities in both legislative houses. In addition, conservative lawmakers and advocacy groups in these states have challenged public health requirements, including vaccines.
The goal of this report is to look at the voting records of lawmakers with backgrounds in medicine or biology on vaccine legislation during the period when vaccines were becoming politicized. There are several reasons for this approach. It is often assumed that legislators with health backgrounds support positive public health measures. Vaccine advocates may believe these lawmakers will explain the importance of vaccines and other public health measures to their legislative peers. These legislators could bring valuable expertise to policy discussions and influence legislative outcomes by advocating for evidence-based practices. As vaccine hesitancy continues to pose a threat to public health, examining the voting behavior of legislators with health backgrounds can provide insights into how professional expertise influences policy decisions.
Health Legislators and Their Vaccine Positions
To understand how state legislators with health-related backgrounds in Texas, Louisiana, Arkansas, and Oklahoma approach vaccine-related policies, a review of their voting records on relevant vaccine bills was conducted. The analysis focused on bills that received floor votes in both chambers during legislative sessions held between January 2021 and June 2024. During this time, Texas met in 2021 and 2023, while Louisiana, Oklahoma, and Arkansas had legislative sessions every year.
Health-related legislators were ascertained through state legislature websites based on their qualifications, which required a bachelor’s or graduate degree in a health or biology-related field, including veterinary, medical, nursing, pharmacy, paramedic, or optometry. Bills were identified from state legislative websites, searching “vaccine” or “immunization.” Those bills that did not receive votes from both chambers were excluded. Vaccine-related bills were categorized as “pro” or “anti” based on their potential impact on immunization rates. Those deemed neutral were excluded from the analysis.
Legislators
Only a small number of legislators had a health-related background (Table 1). Of the 609 state legislators in total, only 33 were identified as health legislators (5.25% of the total). Each state had between four to 13 health-related legislators.
As previously noted, all four states have Republican-controlled legislatures, ranging from 58% Republican members in Texas to 82% in Arkansas (Figure 1). The majority of the health legislators were also Republicans (75%, 24 members). With the exception of Arkansas (where only half of the health legislators were Republican), the percentage of Republican health legislators was higher than the overall percentage of Republicans in the legislature.
Table 1 — State Legislators and State Health Legislators
Note: †Members in both chambers.
Figure 1 — Legislators vs. Health Legislators, by Party Affiliation and State
Vaccine Bills
During legislative sessions, thousands of bills are filed, but few actually advance through the legislative process. Even fewer receive votes on both floors and become law. While dozens of vaccine-related bills were filed from January 2021 to June 2024, only 27 bills received floor votes in both chambers in the four states (Table 2). More than half of these bills (18) were enacted. Only three bills were voted on in Oklahoma, but there were seven in Arkansas, seven in Texas, and ten in Louisiana.
Table 2 — Vaccine-Related Bills That Received Floor Votes, 2021–24
Note: S = special session; S3 = third special session.
Of the 27 bills that went to a floor vote, seven bills were pro-vaccine. Five of these bills focused on permitting pharmacists (or pharmacy technicians) to administer a vaccine without a prescription. Three became law: Arkansas HB 1134, Arkansas HB 1135, and Oklahoma SB 398. The Texas and Louisiana bills passed in both chambers of their respective legislatures, but in neither state did the two chambers agree on a final version of the bill, so no laws resulted. Texas enacted the two other pro-bills. Texas SB 239, which requires the distribution of immunization education materials to community organizations during a disaster, and Texas SB 1353, which requires the collection of immunization data by age, race and location during disasters.
A total of 20 anti-bills were brought to a floor vote, with 13 of them enacted. Between 2021 and 2023, six anti-vaccine bills were passed by the legislature but vetoed by the Democratic Governor John Edwards. In 2024, Jeff Landry, a Republican, became the governor. During that session, three anti-vaccine bills were passed, including two that were previously vetoed in 2023.
There were three major types of anti-vaccine legislation: COVID-19 vaccines, vaccine discrimination, and vaccine information. Twelve COVID-19 bills were voted on, and nine were enacted. These bills banned either COVID-19 vaccine requirements (school, government, or business) or vaccine passports. The remaining three, all from Louisiana, were vetoed by the governor. Five anti-vaccine bills were framed as anti-discrimination bills, with two becoming law. Louisiana’s HB 908 prohibits discrimination against students based on their vaccination status, while Texas HB 44 prohibits Medicaid providers from discriminating against individuals based on immunization status. Three bills were brought to the floor that focused on the inclusion of vaccine exemption information. Louisiana HB 47 and Oklahoma SB 658 both passed in their respective legislatures.
Vaccine Score
After identifying health legislators and vaccine-related bills, those legislators’ voting records were reviewed. Each health legislator was assigned a vaccine score based on their sponsorship and voting records on vaccine-related bills (Figure 2).
- A point was awarded for voting for a pro-vaccine bill or against an anti-vaccine bill, and two points for sponsoring a pro-vaccine bill.
- A point was deducted for voting against a pro-vaccine bill or in favor of an anti-vaccine bill, and two points for sponsoring an anti-vaccine bill.
- No points were added or deducted when people were absent votes, non-voting, or were listed as “present” without voting on bills.
Figure 2 — State Health Legislators’ Score on Vaccine Bills
Legislators’ scores were based on their voting records, with each legislator represented by a dot colored by party: Republicans (red) and Democrats (blue). Points were awarded for supporting vaccines (+1) and deducted for opposing them (-1). For anti-vaccine bills, points were given for voting against them (+1) and subtracted for voting in favor (-1). Points were earned for sponsoring pro-vaccine bills (+2) and lost for sponsoring anti-vaccine bills (-2).
Of the 33 health legislators identified, only nine had a positive vaccine score. The majority of those were Democrats (seven), with two Republicans from Oklahoma and Louisiana. Two legislators had neutral scores, a Texas Democrat and a Republican from Oklahoma. Three legislators served only one term, so this may have affected their results.
The overall average vaccine score for health legislators was negative (-1.4). The highest score was a Democrat from Texas (+7) who sponsored and voted for a pro-bill (HB 1105), voted for the other pro-bill (SB 1353), and voted against all but one of the anti-bills. The lowest score (-10) went to a Republican from Louisiana who voted for all the anti-vaccine bills and against all the pro-vaccine bills.
Texas was the only state where health legislators authored or sponsored anti-vaccine bills (nine legislators). Two pro-vaccine bills were sponsored by health legislators, the high-scoring Democrat in Texas and a Republican in Louisiana. However, the latter received a negative score (-4) due to supporting eight anti-vaccine bills.
Alongside examining scores by state, health legislators were sorted into four groups by specialty: 1) veterinarians and those with animal science degrees, 2) doctors, 3) nurses, and 4) others (pharmacists, optometrists, dentists, chiropractors, licensed paramedics, and those with biology degrees). Veterinarians had the lowest average vaccine score by a large margin (-4.3). Only one veterinarian had a positive score, a Republican from Texas (+1). The field also contained the three lowest scores (-10, -9, and -8). Doctors and others also had negative average vaccine scores, -1.4 and -0.9, respectively. Only one doctor had a positive score, while four others had positive scores. In contrast to the above, nurses had positive scores (+1.5).
Figure 3 — Health Legislator Vaccine Scores, by Occupation
What Does This Mean for Public Health Policy?
Our study identified a small number of legislators with health backgrounds, predominately as medical doctors, veterinarians, and nurses. There were a few pharmacists, as well as an optometrist, a dentist, a chiropractor, and a licensed paramedic. Others held degrees in biology and human development. Most of these health legislators were Republicans, which aligns with the Republican control of all four states. Interestingly, however, the proportion of health legislators who were Republican was a higher rate than the overall Republican percentage in the legislatures.
Given their health-related backgrounds, one might expect these legislators would recognize the importance of vaccines to public health. However, veterinarians and medical doctors almost all had negative vaccine scores, often supporting bills that would weaken immunization programs and increase the risk for vaccine-preventable diseases.
In addition, Republican health legislators often voted for anti-vaccine bills, a position due to party politics and not based on their background in biology, medicine, or health. In fact, several health legislators in Texas promoted anti-vaccine legislation by authoring and/or sponsoring these bills.
Previously, there has been a common presumption that a legislator with a health-related background would use their biology and science knowledge and experience to inform colleagues about how vaccines work, why vaccines are important, and why policies should promote vaccination for the public good. However, as vaccines become more of a wedge issue, legislators are voting along party lines. Republican legislators often argue for looser immunization policies such as broad vaccine exemptions or prohibiting vaccination requirements, especially related to the COVID-19 vaccine.
Although the sample was small, it revealed that elected medical doctors are less often primary care or infectious disease experts who understand the role of vaccines and see the effects of vaccine-preventable disease. Instead, they are more often specialists, such as surgeons and anesthesiologists. As such, they may have limited patient interactions. In contrast, nurses typically have more frequent contact with patients and their families and are often responsible for administering vaccines. This may help explain why nurses were more likely to support vaccine-related legislation.
This analysis was limited to four states and a small number of health-related legislators, so it does not allow for broad conclusions about how a legislator’s specialization might influence voting behavior. Expanding future research to include more states and a wider range of public health issues could provide a more detailed picture and a clearer understanding of sponsorship and voting patterns of legislators.
Conclusion
Legislators with a health background are frequently called upon for their perspectives on health-related topics and are often seen as health experts by their legislative peers and constituents. Their influence can positively affect public health policies, but it can also have negative consequences. It should not be assumed that lawmakers with health backgrounds will vote to support vaccines or positive public health measures. As a result, voters are encouraged to learn more about who represents them, discover their specific positions and values on health and vaccine-related issues, and pay attention to their voting patterns. Political identity plays a significant role in shaping a legislator’s vote and decisions. Public health issues are not an exception to this rule, even when legislators have a background in biology or health.
Notes
[1] “Immunization,” World Health Organization (WHO), https://www.who.int/news-room/facts-in-pictures/detail/immunization.
[2] Neil F. Johnson et al., “The Online Competition Between Pro- And Anti-vaccination Views,” Nature 582 (May 2020): 230–3. https://doi.org/10.1038/s41586-020-2281-1; Gregory A. and Robert M. Jacobson, “Understanding Those Who Do Not Understand: A Brief Review of the Anti-Vaccine Movement,” Vaccine 19, nos. 17–19 (March 2001): 2440–5. https://doi.org/10.1016/S0264-410X(00)00469-2.
[3] WHO, “Vaccine Hesitancy: A Growing Challenge for Immunization Programmes,” news release, August 18, 2015, https://www.who.int/news/item/18-08-2015-vaccine-hesitancy-a-growing-challenge-for-immunization-programmes; WHO, “Ten Threats to Global Health,” WHO Newsroom, 2019, https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019.
[4] WHO, “Ten Threats to Global Health.”
[5] Kirstin R.W. Matthews et al., “Personal Rights over Public Health: Anti-vaccine Rhetoric in the Texas Legislature,” Vaccine: X 18, art.100468 (June 2024), https://doi.org/10.1016/j.jvacx.2024.100468.
[6] Andrew J. Dolman, et al. 2023. “Opposing Views: Associations of Opposing Views: Associations of Political Polarization, Political Party Affiliation, and Social Trust with COVID-19 Vaccination Intent and Receipt,” Journal of Public Health 45, no. 1 (March 2023): 36–9, https://doi.org/10.1093/pubmed/fdab401; Matthews.
[7] Dolman; Matthews.
[8] Shannon Kolman and Claudia Meyer, “Routine Child Vaccination Rates Lower Than Pre-Pandemic Levels,” National Conference of State Legislatures (NCSL), February 29, 2024, https://www.ncsl.org/state-legislatures-news/details/routine-child-vaccination-rates-lower-than-pre-pandemic-levels; Ranee Seither et al., “Coverage with Selected Vaccine and Exemption from School Vaccine Requirements Among Children in Kindergarten — United States, 2022–23 School Year,” MMWR Morbidity and Mortality Weekly Report 72, no. 45 (November 10, 2023): 1217–24, http://dx.doi.org/10.15585/mmwr.mm7245a2.
[9] Sarah Lasater et al., “Vaccine Legislation in Texas and the Rise of the State Anti-Vaccine Movement,” Rice University’s Baker Institute for Public Policy, November 30, 2020, https://doi.org/10.25613/316v-r631.
[10] Neal A. Halsey and Daniel A. Salmon, “Measles at Disneyland, a Problem for All Ages,” Annals of Internal Medicine 62, no. 9 (May 2015): 655–6. https://doi.org/10.7326/M15-0447.
[11] Halsey and Salmon.
[12] Matthews.
[13] Fredel M. Wiant, “Exploiting Factional Discourse: Wedge Issues in Contemporary American Political Campaigns,” Southern Communication Journal 67, no. 3 (April 2009): 276–89, https://doi.org/10.1080/10417940209373236.
This material may be quoted or reproduced without prior permission, provided appropriate credit is given to the author and Rice University’s Baker Institute for Public Policy. The views expressed herein are those of the individual author(s), and do not necessarily represent the views of Rice University’s Baker Institute for Public Policy.
