In summary Three years after California stopped allowing families to easily opt out of childhood vaccines, the number of kids getting medical waivers has tripled—the result, critics say, of some doctors loosely issuing exemptions to help families get around the law. Legislators and health experts are debating what to do next. One proposal would be modeled on an existing state requirement that any veterinarian seeking to exempt a sick dog from rabies vaccination must obtain approval from a health official.

Updated March 26, 2019—State Sen. Richard Pan today unveiled legislation proposing to give state health officials oversight over the exemptions, similar to the process the state uses to approve exemptions for veterinarians who deem it too risky to vaccinate certain dogs against rabies. Pan’s bill also would enable the state to keep a database of children who have medical exemptions from vaccination, and would provide information to the state medical board about physicians issuing those exemptions.

Three years after California stopped allowing families to easily opt out of childhood vaccines, the number of kids getting medical waivers has tripled—the result, critics say, of some doctors loosely issuing exemptions to help families get around the law.

The decrease has left some counties, including Nevada and Plumas, below the recommended vaccination rate required for “community immunity” against dangerous diseases such as measles and whooping cough.

And the number of medical exemptions will continue to rise unless the state clamps down, warns a study in the journal of the American Academy of Pediatrics. The authors interviewed local public health officers across the state, some of whom complained of doctors charging fees in exchange for writing exemptions.

This winter—as an outbreak of measles strikes several states that allow parents to opt out of vaccinating their children because of personal or philosophical objections—California is one of three states that allow only medical exemptions. Since the law was enacted, California’s vaccination rate has risen more than 2 percent. It’s now just over 95 percent, above the 94 percent rate the state health department says should be sufficient to protect those who can’t be vaccinated, but regional pockets of the population remain at risk.

Legislators and health experts are debating what to do next. One proposal would be modeled on an existing state requirement that any veterinarian seeking to exempt a sick dog from rabies vaccination must obtain approval from a health official.

“We delegated that authority to licensed physicians, and the problem is we have physicians abusing that authority,” said Democratic state Sen. Richard Pan, a Sacramento-area pediatrician who authored the state’s controversial ban on personal waivers after a measles outbreak originating at Disneyland infected 136 people. “I think we need the health departments to basically say when someone is abusing that authority—and to withdraw that authority and invalidate exemptions that were fraudulent.”

State Public Health Department data shows medical exemptions among kindergartners rose to now represent 0.7 percent statewide in the last school year, from 0.2 percent two years earlier—an uptick largely in private schools, where more than 1 in 50 students now have a medical waiver from the vaccination law. All told, 4,111 California kindergarteners had permanent medical exemptions from vaccination in the last school year, out of more than a half-million kindergarteners enrolled.

Other ideas under state discussion:

Creating a new review process and oversight managed by local public health officials

Giving local public health officials authority to review exemptions

Collecting data on physicians granting exemptions

Invalidating exemptions and remove authority from physicians who are found in violation

Robert Kim-Farley, professor at the UCLA Fielding School of Public Health, said adapting for doctors requirements similar to those veterinarians must meet to exempt dogs from rabies vaccines. Vets must submit a form to a local health official for review, and a granted waiver expires after one year. “When that oversight occurs, they quickly learn they are not going to get this through unless it’s a really serious situation like the dog is having chemotherapy,” Kim-Farley said. Similarly, “physicians need to give a cogent, logical reason why this patient should not receive a vaccine.”

Pan has yet to propose a legislative remedy, saying he is working with the state health department and the California Medical Board on how to deal with physicians who may be in violation.

The California Medical Association, a doctors’ organization that supported eliminating the personal exemption, is again working with Pan. The organization supports “having standards in place to make sure the medical exemption system is not being abused,” said association spokesman Anthony York.

But critics say any new rules would amount to overkill by lawmakers, who had promised to leave medical exemptions to the discretion of doctors.

“The state is inserting itself in between the patient-doctor relationship,” said Rebecca Estepp, an advocate who campaigned against jettisoning the personal waiver and calls the increase in medical waivers “nothing.”

She attributes most of the rise to the fact that many parents whose children qualified for a medical exemption used to just sign a personal exemption card because it was easier.

The U.S. Centers for Disease Control urges vaccinations for the vast majority of children, saying they are generally safe, and that the benefits of protection against potentially fatal disease are worth the risk. It acknowledges that vaccines can cause side effects, ranging from the most common like soreness and fever to, in rare cases, seizures and brain damage.

Federal guidelines advise avoiding or delaying certain vaccines for children with compromised immune systems, and those with a personal or family history of seizures, or those who have experienced encephalopathy after receiving a vaccine. California law also allows family medical history to be taken into account.

The October study in Pediatrics reported that most California county and city health officers and immunization staff reported said few or no problems with medical exemptions. But other staffers did report problems, noting that said some doctors were listing questionable conditions such as a family history of allergies, or charging fees in exchange for writing exemptions, or charging families for medical tests to establish family history and exemptions signed by doctors who do not usually treat children.

One local health officer, the study noted, cited the example of a physician charging families to watch a video before issuing a 3-month exemption at a cost of $300. Parents would then be required to return for a fresh exemption at additional cost.

One immunization coordinator told the researchers, “The way that the law is written, the physician is the one who makes the decision….. I see some really lame reasons (for medical exemptions.). But I’m not the physician, and it’s not in my capacity to be able to say, ‘Well, that’s not a valid medical exemption.’”

Under California’s law, physicians are allowed to take family medical history into consideration, and to use their expertise to decide what qualifies as an exemption.

Last summer the California Medical Board disciplined Orange County pediatrician Bob Sears— known for his stance against the current schedule required for vaccines—and gave him a 35-month probation for exempting a toddler from all vaccines without examining the child.

At that time Sears declared on Facebook that his punishment was political: “Isn’t it my job to listen to my patients and believe what a parent says happened to her baby?” he wrote. “Isn’t that what ALL doctors do with their patients?”

Kenneth Stoller, a former board-certified pediatrician who is now an integrative physician in San Francisco, opposed the law eliminating personal waivers for childhood vaccines. Now he advertises on his website that he will see families seeking exemptions and will consider issuing one after an exam and a full family medical history consultation.

He argues that public health officials should not become the arbiters of medical exemptions.

“I and my colleagues would object to that because we practice medicine. This needs to be approached on an individual personal medical basis,” Stoller said. “Public health departments are not practicing medicine. They are far more administrative and bureaucratic. They are also constrained by one of their main funding sources—the CDC.

More than half of the state’s Public Health budget is from federal funds.

“We need an independent state commission to come up with guidelines and parameters for writing (medical exemptions) so the act of writing (them), as per the law, is not considered either negligent or inappropriate,” said Stoller

Lawmakers may be reluctant to invite a sequel to the turbulent Capitol fight four years ago over vaccinations exemptions; instead they may urge state regulators to more aggressively crack down on dubious medical exemptions. If a new law is proposed, Estepp said, legislators should expect to see vocal parents and advocates who oppose tighter vaccine regulation flood their offices like they did last time.