Any cost-benefit analysis has two columns. President Trump’s August 10 executive order on vaccines considers neither. If put into action, it would impose a burden on families in the form of additional medical visits, yet it carries no estimate of the impact. It asserts that the proposed schedule is an improvement over the prior CDC schedule, yet offers no figures to support the proposed changes. Nowhere does it quantify a harm of multiple injections at a time, or analyze what changing that is worth.
The order recommends that childhood vaccines be given at separate visits. The president was explicit at the signing: “at 1 year, you should have five separate visits for vaccines rather than getting them all in the same day.” It also says the measles, mumps, and rubella (MMR) vaccine should be split into separate shots for each disease, even though no such versions are licensed in the U.S. Merck stopped making the standalone shots in 2008 and declined to resume, based on input from organizations such as the American Academy of Pediatrics, whose infectious-disease committee advised that splitting it up would delay protection. The order also reduces the number of universally recommended childhood vaccines, placing hepatitis A and B vaccines, meningococcal B and ACWY vaccines into the high-risk only category, and moving flu and COVID shots to shared decision-making.
I work at the far end of the pediatric vaccine schedule: the intensive care unit (ICU) is where an unvaccinated child or adult is eventually admitted, either in childhood or decades later in adulthood, by which time no one connects the two. I intimately understand the life-or-death consequences of this schedule. A closer look at the costs and benefits of any proposed changes is warranted.
The Cost Column
This is arithmetic any of us can run — and a calculation the government should have run. Based on the existing schedule, U.S. children need roughly 25 injections by age 6 (not including annual flu shots), delivered today across seven visits or so. One at a time, they would need 25 individual visits. That would mean nearly four times the time spent traveling to and enduring doctor’s visits; four times the co-pays that too many families already can’t afford; four times the complaints from the child who fears needles. More visits would mean more missed visits.
Nearly 3 million American families with children under 6 live below 125% of the poverty line; of these families, nearly 2 million are single-parent households. These parents are responsible for both childcare and earning an income to sustain the family. Meanwhile, among the lowest-paid tenth of private-sector workers, fewer than half (41%) have paid sick days. Hours for each visit — between travel, time in the pediatric waiting room, and the visit itself — are hours of pay that would not appear in a parent’s paycheck. Families would be forced to choose: take the child to the doctor for yet another preventive care visit or earn enough to put dinner on the table.
None of this appears in the order. Sections 1 through 5 say nothing about cost, Medicaid, or resources, and the supplementary White House fact sheet is similarly silent. The January HHS assessment of proposed changes to the vaccine schedule praises Denmark for administering combined vaccines at separate visits, yet never asks what a visit costs a Danish parent versus an American one. Regulatory impact analysis attaches to agency rulemaking, while presidential orders never have to check this box. A federal judge already stayed the revised vaccine schedule issued by HHS in January, likely making these new proposed changes arbitrary and capricious. This is the second attempt at an overhaul, with seemingly less analysis than the first.
If the schedule is changed, the costs will be measured over time. Today in the form of more sick kids with measles. Two decades out in the form of meningococcal meningitis in a college freshman who wasn’t “high-risk” until the dorm outbreak. Three decades out in the form of congenital rubella in the pregnancy of a woman whose split MMR doses were started but never finished. Forty years out in the child born in 2027 who never received the hepatitis B birth dose and reaches my ICU around 2066 with a failing liver tied to a chronic infection acquired at birth.
What Benefit Column?
The second column of a cost-benefit (cost-outcome) analysis holds space for the potential benefits. Trump tries to claim one: fewer antigens in one sitting, suggesting that the number or timing of vaccines could play a role in rising rates of autism spectrum disorder. This is the only stated “benefit,” yet he offers no evidence behind it.
Giving all age-appropriate vaccines at a single visit is the standing recommendation because it works, and the 2013 Institute of Medicine review of the schedule found no evidence of major safety concerns. The benefit column for the proposed changes is therefore empty.
We know the government knows how to conduct a detailed analysis. In August 2024, CDC published an economic analysis of routine childhood vaccination among kids born 1994-2023: every dollar spent returned about $3 in direct savings and $11 to society, with 1,129,000 deaths prevented. This time around, the administration produced only an order.
What Gets Recorded
What the order would do over decades, if put into action, has to do with more than pathogens. It has to do with what it teaches: that the schedule was a scheme, that we were in on it, that it took a president to protect children from us. That lesson outlasts an administration.
In Annenberg surveys, the share of Americans who consider MMR safe has already fallen from 88% in 2022 to 83% by late 2024. This drop in trust is real, and when there is another pandemic, it will arrive with its own vaccine recommendations. These recommendations will reach parents who were told by their own government that the last schedule was a scheme.
We will absorb what follows at the front desk, in the fee waiver nobody asks for, in the fourth appointment that does not happen, and for me, in the ICU. None of it will be recorded as a policy failure. It will be recorded as pertussis in an infant too young to be vaccinated, and no one in that room will think to ask about the appointment.
