The rise of anti-vaccination legislation in two Midwestern US states: Implications for politics, policy, and society

1 Introduction

The politicization of vaccination was one of the challenges to the management of the outbreak of COVID-19 in the United States. Particularly after COVID-19 vaccines became widely available to the public, vaccination became a contentious issue between the Republican and Democratic parties. While the communication from Democratic Party leaders was mostly in line with recommendations from public health authorities, some Republican Party leaders, including former President Trump, spread inaccurate information about COVID-19 vaccination. The partisan divide over COVID-19 vaccines and vaccination policy translated into state-level politics. Republican lawmakers in state legislatures nationwide proposed bills aimed at banning COVID-19 vaccination requirements, adding barriers to vaccinations, and providing vaccination exemptions.

The COVID-19 public health emergency ended on May 11, 2023. Even though the immediate threat from COVID-19 diminished, the 3-year experience of the pandemic likely had long-term consequences on matters of public health, particularly vaccination. Scholars warned that negative attitudes toward COVID-19 vaccines people developed during the pandemic might “spill over” into attitudes toward other vaccines [1]. They also noted that the experience of the past 3 years might have breathed new life into the anti-vaccine moment [2]. It is likely that we will see a greater number of anti-vaccination initiatives compared to the years prior to the COVID-19 pandemic. Given the high number of anti-vaccination proposals in recent years, state legislatures are an area where we could observe the growing opposition to vaccines.

This commentary had two goals. First, we mapped the increase in anti-vaccination bills introduced in the South Dakota and Minnesota state legislatures since the start of the COVID-19 pandemic. Second, we discussed the potential impacts of the growth of these legislative proposals on politics, public health policy, and society in these two Midwestern states.

2 Methodology

We utilized the LegiScan database to search for bills introduced in the South Dakota and Minnesota state legislatures during the 2013–2023 period. We used the following keyword combination to search for bills: (“Vaccine” OR “Vaccination” OR “Immunization”) NOT (“Naloxone” OR “Omnibus” OR “Animal” OR “AIDS” OR “HIV” OR “Vision” OR “Abortion” OR “Mammogram” OR “Opioid” OR “Veterinarian” OR “Tribal”). Next, we excluded those bills that did not appear to be related to vaccination policy. Afterward, the three authors independently coded all bills as either anti-vaccination or not anti-vaccination. Following the extant literature, we defined anti-vaccination bills as “having the potential to decrease vaccination rates” [3,4]. Figure A1 visualizes how the anti-vaccination bills were identified.

3 The rise of anti-vaccination legislation

The initial search yielded 248 bills – 22 from South Dakota and 226 from Minnesota. After excluding bills that appeared to be unrelated to vaccination policy, we obtained 207 bills – 20 from South Dakota and 187 from Minnesota. In the end, we classified 151 bills as anti-vaccination bills – 18 from South Dakota and 133 from Minnesota. Intercoder reliability was 81.2%, which is in line with similar studies [3]. Table A1 provides a complete list of all anti-vaccination bills from South Dakota and Minnesota.

Despite the differences in the political landscapes of the two states (the South Dakota legislature has half the members of the Minnesota legislature and South Dakota’s legislative session is no longer than 40 days), there was a very similar pattern in the proposed anti-vaccination legislation. First, none of the proposed bills became law. In South Dakota, where the Republican Party holds a supermajority in both the House and Senate, 83.3% of the proposed anti-vaccination bills failed to pass the chamber of origin, and the rest failed to win support in the other chamber. In Minnesota, where the two parties split the control of House and Senate during the period we examined (the Democratic Party currently has a slight majority in both chambers), 98% of the proposed anti-vaccination bills were defeated in committee and only 2% came up for vote in the chamber (pending bills in the current session excluded). Second, anti-vaccination bills were proposed overwhelmingly by Republican lawmakers – 94.4% of anti-vaccination bills in South Dakota and 96.2% of anti-vaccination bills in Minnesota had a primary sponsor from the Republican Party. Democratic Party lawmakers rarely served as co-sponsors – only 11.1% of anti-vaccination bills in South Dakota and 13.5% of anti-vaccination bills in Minnesota were co-sponsored by a Democrat.

Third, the majority of anti-vaccination bills were proposed after COVID-19 vaccines became widely available to the public and vaccination became the main policy to stop the spread of the virus. In South Dakota, there were only three anti-vaccination bills proposed between 2013 and 2020. Since 2021, when COVID-19 vaccinations became a subject of a heated political debate, there were 15 bills proposed in total, a fivefold increase. Eight anti-vaccination bills were proposed in the 2022 legislative session, and five in the 2023 session.

Over time, the proposed anti-vaccination bills in South Dakota became broader in scope and targeted a wider range of vaccinations. In 2022, six of the eight proposed bills were specific to COVID-19 vaccination, generally seeking to prohibit vaccine mandates for COVID-19. However, in 2023, four of the five proposed anti-vaccination bills targeted vaccination more broadly, including House Joint Resolution 5003 – a proposed constitutional amendment that would grant citizens the right to refuse any vaccine or medical treatment. The most sweeping of these proposals was Senate bill 130, which sought to dilute the religious exemption from providing evidence of doctrinal teaching of a parent’s religion to a “sincerely held religious or philosophical belief” held by an individual parent or guardian.

We uncovered a similar pattern among the anti-vaccination bills proposed in the Minnesota legislature. Between 2013 and 2020, there were 25 anti-vaccination bills proposed. Since 2021, when COVID-19 vaccines became widely available, 108 bills were proposed, more than a fourfold increase. The scope of these proposals became increasingly broad and went beyond COVID-19 vaccines. During the most recent legislative session, there have been 32 bills proposed, with only two being COVID-19 specific. One example is House bill 680, which established a “vaccine recipient bill of rights” with the right “to determine what is in the individual’s own best medical interest” in regard to vaccination.

Overall, we found an increase in anti-vaccination bills introduced since the start of the COVID-19 pandemic. There was a clear uptick in legislative activity on weakening well-established vaccination mandates for diseases beyond COVID-19. While COVID-19 vaccination was likely the catalyst for this flurry of legislative activity, the reach of the proposed legislation was far beyond COVID-19 vaccination policy into a policy sphere where we have traditionally seen bipartisan consensus. The remainder of this commentary discussed the broader implications of these developments.

4 Implications for politics

Although none of the proposed anti-vaccination measures has been enacted in law, the mere presence of a large number of such proposals already affected both states. Politics represents one area where we have already seen a significant impact. During the COVID-19 pandemic, anti-vaccination attitudes, which used to occupy the fringes, moved into mainstream politics. Vaccination policy became one of the main political cleavages between the Republican and Democratic parties.

Given the current political climate, politicians particularly at the local and state levels might now have more incentive to continue proposing laws that restrict access to vaccination or provide vaccination exemptions. As vaccination policy is becoming a major issue, lawmakers have an incentive to introduce legislative proposals even when they know that they have little chance of success. Such proposals might increasingly become part of a strategy to draw attention or raise funds. For example, Dr. Scott Jensen, a former Minnesota state senator, managed to secure the Republican Party nomination for the 2022 gubernatorial election after his anti-vaccination rhetoric brought him to national prominence [5].

It is likely that similar anti-vaccination bills will be proposed in future legislative sessions beyond South Dakota and Minnesota. Anti-vaccination legislature might over time become routinized. Given the overlap between anti-vaccination and general anti-science attitudes, there is a possibility that bills targeting other domains of health and health policy will be proposed in the near future.

5 Implications for public health officials and healthcare workers

The growth of anti-vaccination legislation during COVID-19 added to the challenges facing public health officials and healthcare providers. Some public health officials and healthcare providers already faced pressure and were targets of hate speech and online campaigns due to their involvement in promoting COVID-19 vaccination. The proposition of such anti-vaccination legislation created additional challenges in communicating to the public the benefits of vaccination.

The growth in increasingly broader anti-vaccination proposals creates challenges for public health officials as they prepare for future health emergencies. The creation, implementation, and evaluation of strategies to increase vaccination confidence will be challenging given the shifting legislative landscape. Reinforcing trust in the medical community, which was undermined due to the spread of misinformation during the COVID-19 pandemic, will be even more challenging in the context of the growing volume of anti-vaccination legislation.

6 Implications for society

The increase in anti-vaccination legislative proposals could negatively affect people’s confidence in vaccines. Given the fast pace of COVID-19 vaccine development and the perceived novelty of the mRNA technology, an understandable degree of concern already existed regarding their safety and effectiveness. The anti-vaccination proposals were covered extensively by the state and local media in both states [6,7], which could undermine people’s trust in vaccines, science, public health authorities, and healthcare workers. Scholars already documented a growth in anti-vaccine discourse on the social network X (formerly known as Twitter), targeting not only COVID-19 but also influenza vaccines [8]. Such developments are cause for concern, as research linked low trust in government and low trust in medical doctors to vaccine hesitancy [9].

Since the start of the COVID-19 pandemic, diphtheria, tetanus, pertussis (DTaP), polio, and measles, mumps, and rubella (MMR) vaccination rates among kindergarten-aged children have declined in South Dakota in the recent years. In addition, Minnesota recorded 22 cases of measles in 2022, which was the third-highest annual figure since 2000 [10]. The growing number of increasingly broader anti-vaccination legislative proposals could likely lead to a further decline in vaccination rates among vulnerable populations.

7 Conclusion

This brief commentary documented the rise of anti-vaccination legislation in South Dakota and Minnesota since the start of the COVID-19 pandemic. Anti-vaccination sentiment has always been present in society; however, it becomes particularly dangerous when it becomes part of mainstream politics. COVID-19 vaccination quickly became a contested issue between Republican and Democratic politicians, and we saw bills against mandatory COVID-19 vaccination and expanding exemptions. The legislative proposals became broader in scope and targeted multiple vaccines. We discussed the implications of the rise of anti-vaccination legislation for society, public health officials, and politics. Given the momentum that anti-vaccination activists and ideas gained in our study, the “anti-vaccination moment” is likely to remain in the coming future.