Jen Fisher can do only so much to keep her son safe from the types of infections that children can encounter at school. The rest, she said, is up to other students and parents in their hometown of Franklin, Tennessee.

Fisher’s son Raleigh, 12, lives with a congenital heart condition, which has left him with a weakened immune system. For his protection, Raleigh has received all the recommended vaccines for a child his age. But even with his vaccinations, a virus that might only sideline another child could sicken him and land him in the emergency room, Fisher said.

“We want everyone to be vaccinated so that illnesses like measles and things that have basically been eradicated don’t come back,” Fisher said. “Those can certainly have a very adverse effect on Raleigh.”

For much of Raleigh’s life, Fisher could take comfort in the high childhood vaccination rate in Tennessee — a public health bright spot in a conservative state with poor health outcomes and one of the shortest life expectancies in the nation.

Mississippi and West Virginia, two similarly conservative states with poor health outcomes and short life expectancies, also have some of the highest vaccination rates for kindergartners in the nation — a seeming contradiction that stems from the fact that childhood vaccination requirements don’t always align with states’ other characteristics, said James Colgrove, a Columbia University professor who studies factors that influence public health.

“The kinds of policies that states have don’t map neatly on to ‘red’ versus ‘blue’ or one region or another,” Colgrove said.

Advocates, doctors, public health officials, and researchers worry such public health bright spots in some states are fading: Many states have recently reported an increase in people opting out of vaccines for their kids as Americans’ views shift.

During the 2023-24 school year, the percentage of kindergartners exempted from one or more vaccinations rose to 3.3%, the highest ever reported, with increases in 40 states and Washington, D.C., according to Centers for Disease Control and Prevention data. Tennessee and Mississippi were among those with increases. Nearly all exemptions nationally were for nonmedical reasons.

Vaccine proponents worry anti-vaccine messaging could accelerate a growing “health freedom” movement that has been pushed by leaders in states such as Florida. Momentum against vaccines is likely to continue to grow with the election of Donald Trump as president and his proposed nomination of anti-vaccine activist Robert F. Kennedy Jr. as secretary of the Department of Health and Human Services.

Pediatricians in states with high exemption rates, such as Florida and Georgia, say they’re concerned by what they see — declining immunization levels for kindergartners, which could lead to a resurgence in vaccine-preventable diseases such as measles. The Florida Department of Health reported nonmedical exemption rates as high as 50% for children in some areas.

“The religious exemption is huge,” said Brandon Chatani, a pediatric infectious disease doctor in Orlando. “That has allowed for an easy way for these kids to enter schools without vaccines.”

In many states, it’s easier to get a religious exemption than a medical one, which often requires signoff from a doctor.

Over the past decade, California, Connecticut, Maine, and New York have removed religious and philosophical exemptions from school vaccination requirements. West Virginia has not had them.

Idaho, Alaska, and Utah had the highest exemption rates for the 2023-24 school year, according to the CDC. Those states allow parents or legal guardians to exempt their children for religious reasons by submitting a notarized form or a signed statement.

Florida and Georgia, with some of the lowest reported minimum vaccination rates for kindergartners, allow parents to exempt their children by submitting a form with the child’s school or day care.

Both states have reported declines in uptake of the measles, mumps, and rubella vaccine, which is one of the most common childhood shots. In Georgia, MMR coverage for kindergartners dropped to 88.4% in the 2023-24 school year from 93.1% in 2019-20, according to the CDC. Florida dropped to 88.1% from 93.5% during the same period.

Andi Shane, a pediatric infectious disease specialist in Atlanta, traces Georgia’s declining rates to families who lack access to a pediatrician. State policies on exemptions are also key, she said.

“There’s lots of data to support the fact that when personal belief exemptions are not permitted, that vaccination rates are higher,” she said.

In December, Georgia public health officials put out an advisory saying the state had recorded significantly more whooping cough cases than in the prior year. According to CDC data, Georgia reported 280 cases in 2024 compared with 96 the year before.

Until 2023, Mississippi was one of the few states that allowed parents to opt out of vaccinating their kids only for medical reasons — and only with the approval of a doctor. That gave it among the highest vaccination rates in the nation as of the 2023-24 school year.

“It’s one of the few things Mississippi has done well,” said Anita Henderson, a pediatrician who has practiced in the southern part of the state for nearly 30 years. In terms of health, she said, childhood vaccination rates were the state’s one “shining star.”

But that changed in April 2023 when a federal judge ordered state officials to start allowing religious exemptions. The ruling has emboldened many families, Henderson said.

“We are seeing more and more skepticism, more and more vaccine hesitancy, and a lack of confidence because of this ruling,” she said.

State officials have granted more than 5,000 religious exemptions since the court order allowing them, according to the state health department. Daniel Edney, the state health officer, said most of the requests have come from “more affluent” residents in “pockets” of the state.

“Most people listen to the expert opinions of their pediatricians and family medicine doctors to stay on the vaccine schedule, because it’s what is best to protect their children,” he said.

West Virginia’s vaccine law — which hasn’t allowed nonmedical exemptions — also could soon change, Matthew Christiansen said in December before he resigned as the state’s health officer.

A bill that would have broadened exemptions made it through the legislature last year but was vetoed by outgoing Republican Gov. Jim Justice. The new governor, Republican Pat Morrisey, has been a vocal critic of vaccine mandates. And just a day after being inaugurated, he issued an executive order to propose provisions by Feb. 1 that could allow religious and conscientious exemptions.

“I want to send a message that if you have a religious belief, then we’re going to have an exception,” he said at a Jan. 14 press conference. “We’re not going to be the outlier.”

People asserting their personal freedoms to decline vaccines for their kids can ultimately curtail the ability of others to live full lives, Christiansen said. “Kids getting measles and mumps and polio and being paralyzed for their whole life is an impediment on personal freedom and autonomy for those kids,” he said.

Since the covid pandemic, anti-vaccine sentiment has been growing in Tennessee. One organization, Stand for Health Freedom, drafted a letter for constituents to send to their state lawmakers calling for the resignation of the medical director of Tennessee’s Vaccine-Preventable Diseases and Immunization Program. The group said she demonstrated a “lack of respect for the informed consent rights” of the people.

“They feel emboldened by the idea that this presidential administration seems to feel very strongly that a lot of these issues should be taken back to the states,” said Emily Delikat, director of Tennessee Families for Vaccines, a pro-vaccine group.

Ultimately, like many effective public health interventions, vaccines are a victim of their own success, said Henderson, the Mississippi pediatrician. Most people haven’t seen outbreaks of measles or polio, so they forget how dangerous the diseases are, she said.

“It may unfortunately take a resurgence of those diseases to raise awareness to the fact that these are dangerous, these are deadly, these are preventable,” she said. “I hope it doesn’t come to that.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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When KFF Health News published an article in August about the “prior authorization hell” Sally Nix said she went through to secure approval from her insurance company for the expensive monthly infusions she needs, we thought her story had a happy ending.

That’s because, after KFF Health News sent questions to Nix’s insurance company, Blue Cross Blue Shield of Illinois, it retroactively approved $36,000 worth of treatments she thought she owed. Even better, she also learned she would qualify for the infusions moving forward.

Good news all around — except it didn’t last for long. After all, this is the U.S. health care system, where even patients with good insurance aren’t guaranteed affordable care.

To recap: For more than a decade, Nix, of Statesville, North Carolina, has suffered from autoimmune diseases, chronic pain, and fatigue, as well as a condition called trigeminal neuralgia, which is marked by bouts of electric shock-like pain that’s so intense it’s commonly known as the “suicide disease.”

“It is a pain that sends me to my knees,” Nix said in October. “My entire family’s life is controlled by the betrayal of my body. We haven’t lived normally in 10 years.”

Late in 2022, Nix started receiving intravenous immunoglobulin infusions to treat her diseases. She started walking two miles a day with her service dog. She could picture herself celebrating, free from pain, at her daughter’s summer 2024 wedding.

“I was so hopeful,” she said.

But a few months after starting those infusions, she found out that her insurance company wouldn’t cover their cost anymore. That’s when she started “raising Cain about it” on Instagram and Facebook.

You probably know someone like Sally Nix — someone with a chronic or life-threatening illness whose doctor says they need a drug, procedure, or scan, and whose insurance company has replied: No.

Prior authorization was conceived decades ago to rein in health care costs by eliminating duplicative and ineffective treatment. Not only does overtreatment waste billions of dollars every year, but doctors acknowledge it also potentially harms patients.

However, critics worry that prior authorization has now become a way for health insurance companies to save money, sometimes at the expense of patients’ lives. KFF Health News has heard from hundreds of people in the past year relating their prior authorization horror stories.

When we first met Nix, she was battling her insurance company to regain authorization for her infusions. She’d been forced to pause her treatments, unable to afford $13,000 out-of-pocket for each infusion.

Finally, it seemed like months of her hard work had paid off. In July, Nix was told by staff at both her doctor’s office and her hospital that Blue Cross Blue Shield of Illinois would allow her to restart treatment. Her balance was marked “paid” and disappeared from the insurer’s online portal.

But the day after the KFF Health News story was published, Nix said, she learned the message had changed. After restarting treatment, she received a letter from the insurer saying her diagnoses didn’t actually qualify her for the infusions. It felt like health insurance whiplash.

“They’re robbing me of my life,” she said. “They’re robbing me of so much, all because of profit.”

Dave Van de Walle, a spokesperson for Blue Cross Blue Shield of Illinois, said the company would not discuss individual patients’ cases.

“Prior authorization is often a requirement for certain treatments,” Van de Walle said in a written statement, “and BCBSIL administers benefits according to medical policy and the employer’s benefit.”

But Nix is a Southern woman of the “Steel Magnolia” variety. In other words, she’s not going down without a fight.

In September, she called out her insurance company’s tactics in a http://change.org/ campaign that has garnered more than 21,000 signatures. She has also filed complaints against her insurance company with the U.S. Department of Health and Human Services, U.S. Department of Labor, Illinois Department of Insurance, and Illinois attorney general.

Even so, Nix said, she feels defeated.

Not only is she still waiting for prior authorization to restart her immunoglobulin infusions, but her insurance company recently required Nix to secure preapproval for another treatment — routine numbing injections she has received for nearly 10 years to treat the nerve pain caused by trigeminal neuralgia.

“It is reprehensible what they’re doing. But they’re not only doing it to me,” said Nix, who is now reluctantly taking prescription opioids to ease her pain. “They’re doing it to other patients. And it’s got to stop.”

Do you have an experience with prior authorization you’d like to share? Click here to tell your story.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.