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Who Should Approve Medical Vaccine Exemptions?

Amid concerns over "fake" exemptions, California is debating a bill that would make public health officials sign off on them like they do in other states. Doctors support the legislation, but the Democratic governor has criticized it.

Doctors standing in line to speak at a microphone.
Dr. Marti Baum, left, a pediatrician, joined others urging lawmakers to approve S.B. 276.
(AP/Rich Pedroncelli)


  • California Gov. Gavin Newsom has criticized S.B. 276, a bill that would require state health officials to sign off on medical exemptions to vaccines.
  • Major medical organizations support the legislation.
  • Other states have similar laws, and some of them haven't had a measles case in years.
Once declared eradicated by vaccines, measles cases have resurged to their highest level in nearly three decades, infecting more than 1,000 people this year across 28 states.

The outbreak has spurred some states to revisit their vaccine laws. Last month, Maine ended religious exemptions as a means of parents not vaccinating their children, making it the fourth state to ban all nonmedical exemptions. The three other states are California, Mississippi and West Virginia.

In Mississippi and West Virginia, state health officials sign off on the exemptions that doctors approve. Now, there's a physician-backed effort for California to adopt that rule.

But Democratic Gov. Gavin Newsom raised eyebrows this month when he suggested that he might not support the measure. 

"I like doctor-patient relationships; bureaucratic relationships are more challenging for me," Newsom said June 1 at the California Democratic Party Convention. "I’m a parent. I don’t want someone that the governor of California appointed to make a decision for my family."

The bill in question, S.B. 276, would require the state’s Department of Public Health to make the final decision on whether a medical exemption fits the criteria set by the Centers for Disease Control and Prevention. In Mississippi, the public health department gets the final say; in West Virginia, a state immunization officer makes that call.

"Through passage of S.B. 276, we are taking a preventive approach to keep schools safe for all students by applying a model successfully used in West Virginia, which has not experienced measles in a decade," said state Democratic Sen. Richard Pan, the bill's author, in a statement.


'Phony Exemptions'

Medical reasons for forgoing vaccines include undergoing chemotherapy, having a gelatin allergy or suffering from a severe immunodeficiency disorder. But there are some concerns that some doctors are approving unwarranted exemptions.

"Physicians are profiting off of phony exemptions," says Peter Hotez, codirector of the Texas Children’s Hospital Center for Vaccine Development and dean of the National School of Tropical Medicine at Baylor College of Medicine.

According to a 2018 study from the American Academy of Pediatrics, some doctors in California would advertise that they would sign off on medical exemptions for a fee.

California outlawed nonmedical exemptions in 2015 after a measles outbreak was traced back to a single child at Disneyland. Since then, there has been an uptick in medical exemptions -- from 0.7 percent to 0.9 percent. Various health-care providers -- including dermatologists and cardiologists, not known for treating children -- are allowed to sign a medical exemption. (In Mississippi and West Virginia, only a family doctor or pediatrician approves exemptions.) A parent then submits the exemption directly to the school, which can raise a red flag to a state health official if they feel it’s "fake."

Although the bill would add a layer of bureaucracy, advocates of the measure say it wouldn't be a significant additional hurdle.

"Doctors have to submit a written exemption anyway; providing a uniform form makes the process more streamlined, and allows to easily and smoothly assess the process," says Dorit Reiss, a vaccine law expert at the University of California, Hastings.

Reiss told Governing in December that it might be worth waiting a few years to see if the issue of unjustified exemptions is truly a problem before introducing legislation to address it. But as the public health crisis has escalated, she reversed her position.

"If the question is support the proposed bill or not, I strongly support it," Reiss said in an email last week.


The State of S.B. 276

The California bill passed the state Senate in May and awaits action in the state Assembly. It's sponsored by major health organizations, including the California Medical Association and the California chapter of the American Academy of Pediatrics.

Medical experts view Newsom's comments as harmful.

"You have an important elected leader throwing cold water on it, and that is very troublesome," says Hotez. "I don’t see any downside to doing it. There’s no benefit in not closing that loophole."

Measles can cause pneumonia, swelling of the brain and even death, particularly for children.

In Maine, the new law explicilty prohibits the state's health department from reviewing exemptions. But doctors caught signing off on fake ones will be subject to license discipline.

Mattie covers all things health for Governing.

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