On Jan. 5, the U.S. Centers for Disease Control and Prevention (CDC) changed the childhood immunization schedule after President Donald Trump ordered a review of how U.S. vaccinations compared to those of other similar nations.

The unprecedented shift creates more confusion than clarity for doctors and families: Why did the U.S. change which vaccines are recommended for all children? Will these vaccines still be covered by insurance?

Here’s what you need to know about how American children will now be vaccinated.

What prompted the changes?

“There has been no change in the evidence on vaccine [safety and effectiveness],” says Dr. Daniele Gusland, assistant professor of pediatrics at UCSF Benioff Children’s Hospital. (TIME owners and co-chairs Marc and Lynne Benioff have been major donors to the hospital.) “Typically when we make changes to the childhood vaccine schedule, it’s done in a very transparent way—evidence is presented by experts, the [CDC]’s Advisory Committee on Immunization Practices (ACIP) meets, discussion happens, and the public and stakeholders are allowed to comment. None of that happened this time.”

Instead, the change was prompted by a request from President Trump to the U.S. Department of Health and Human Services, headed by vaccine skeptic Robert F. Kennedy Jr., and the CDC to compare vaccines that U.S. children receive to those used by peer nations, some of which recommend fewer immunizations. The changes were outlined in a report presented to Jim O’Neill, acting CDC director, who accepted them.

Which vaccines are affected?

Children in the U.S. have traditionally received 17 immunizations from birth to age 18 to protect against many infectious diseases. The new guidelines no longer recommend six of them for all children: COVID-19, seasonal flu, hepatitis A, hepatitis B, respiratory syncytial virus (RSV), and rotavirus. Instead, the government says these immunizations should either be given to those at high risk for the respective diseases, or after children’s parents and doctors discuss the benefits and risks and decide the vaccines are appropriate—something called shared clinical decision-making. 

What exactly is shared clinical decision-making?

The CDC defines it as “a decision process between the health care provider and the patient or parent/guardian”—and the upshot is that the decision to vaccinate is ultimately up to the parent.

Vaccine experts point out that nearly all medical decisions, including whether to get vaccinated, are based on shared clinical decision-making. The only exception in recent years has been the COVID-19 vaccine, which was required for some people during the height of the pandemic in order for them to return to school or work. But “the federal government has never mandated childhood vaccinations,” says Gusland. “There has always been shared decision-making between pediatricians and parents. Pediatricians overwhelmingly recommend them because they know what it looks like when a country does not vaccinate against these diseases.”

In a recent survey of how the public is responding to and interpreting the changing health recommendations, researchers at the University of Pennsylvania found significant confusion over what shared clinical decision-making means, with more than one in 10 responding in the survey that they were not sure what the process meant. More than two in five people mistakenly interpreted shared clinical decision-making to mean that individuals should make their own decisions about whether or not get vaccinated, and about a quarter surveyed believed that the shared decision-making involved family members only, and not health care professionals.

Shared decision-making also assumes that both patients and health care providers will have the knowledge and the time to discuss, in detail, each vaccine and each individual’s health history to make a determination about whether they should get the vaccine or not. “The notion that doctors and patients will examine the pros and cons and go over the health recommendations for each vaccine is simply naïve,” says Kathleen Hall Jamieson, director of the Annenberg Public Policy Center at the University of Pennsylvania and an author of the recent report. “Doctors don’t have the time, and they don’t have the capacity. And for practical purposes, if people are turning to pharmacists for this discussion, there is no quiet place in most pharmacies where you can sit in an enclosed space to discuss private health matters.”

Why does Denmark, for example, not recommend as many childhood vaccines as the U.S.?

Trump’s request was triggered by the fact that some other developed countries, like Denmark, don’t recommend as many vaccines as the U.S. “Robert F. Kennedy, Jr. and Trump both believe that [U.S.] children are getting too many vaccines, and that is somehow weakening and overwhelming their immune systems, so if you lighten the load, you somehow decrease the burden of chronic disease,” says Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia, who developed the rotavirus vaccine—one of the shots the U.S. no longer recommends for all children. “That’s nonsense.”

He notes that Denmark does not recommend the rotavirus vaccine, but every year, about 1,300 young children there are hospitalized with fever, vomiting, and diarrhea from the infection. Before the implementation of the rotavirus vaccine, the U.S. had comparable hospitalization rates, but nearly eliminated them after introducing universal vaccination for children at age two months and four months. “We chose to eliminate those [hospitalizations], and Denmark did not,” he says. “I’d like to see Danish public-health officials explain why it’s OK to have children hospitalized with rotavirus and RSV when it’s preventable, and children don’t have to suffer like that.”

Denmark has a significantly different health care system from the U.S. Every Denmark resident has access to primary health care, every pregnant woman has regular prenatal care, every child is followed from birth to adulthood, and the country has a national electronic health record system, says former CDC director Dr. Tom Frieden.

By comparison, in the U.S., there are drastic differences in access to health care across the country, which lead to imbalances in immunization rates and incidence of childhood diseases. The broader recommendation to vaccinate all children against a number of diseases is a way to address these discrepancies and protect the greatest number of people possible, says Frieden. Yet in the U.S., there is an increasing focus on individual preferences and autonomy than on the society-wide benefits that come with vaccination.

“There is an increasing sense that we are not really connected, and that I can protect my health all on my own,” says Frieden. “And we can’t, actually. All of us depend to some extent on what other people are doing.”

Can my child still get vaccines that are no longer universally recommended?

Yes. But it might be harder to get those shots, especially at pharmacies, than in the past. Pharmacists are only allowed to give vaccines that are recommended by the CDC’s ACIP. But some states have put in place regulations that supersede this requirement and allow pharmacists to vaccinate children for shots that the CDC has moved to shared clinical decision-making.

Will insurance still cover those immunizations ?

All previously covered vaccines will continue to be covered, both by federal health insurance programs as well as private insurers. No vaccines have been dropped from the recommended list; some are just changing their status from universally recommended to more limited recommendations. “All vaccines currently recommended by CDC will remain covered by insurance without cost sharing,” said Dr. Mehmet Oz, commissioner of the Centers for Medicare and Medicaid Services, in a statement announcing the changes. “No family will lose access.”

Private insurers like Blue Cross Blue Shield and United Healthcare also confirmed that they will continue to cover the childhood immunizations that the government had recommended previously.