Most states allow a variety of exemptions to vaccine laws, but that's not enough to keep kids safe, says the doctor behind the California bill.

Rich Pedroncelli / AP

Four years after California led the nation in rolling back religious exemptions for vaccines, lawmakers are pushing to tighten remaining medical exemptions after a handful of skeptic doctors helped anti-vax parents exploit a loophole that’s resulted in hundreds of schools no longer having immunity from dangerous diseases like measles.

On Friday, the bill, which would create oversight of the medical exemption process and allow investigation of exploitative doctors, faces its last committee hurdle before going to the full legislature for final votes. Gov. Gavin Newsom has said if passed, he’ll sign it into law, in spite of ferocious opposition from anti-vaccine parents and lobbying by celebrity skeptics including Robert F. Kennedy Jr. and Jessica Biel. Activists rallied on Wednesday at the California capitol in an event they called "The Last Stand," with other protesters also coordinating this week.

Even before becoming law, the bill has already inspired rule changes in New York, and more states may follow as record-breaking measles outbreaks highlight how disease can overtake communities with low vaccination rates. Only two states, West Virginia and Mississippi, have never given parents with healthy schoolchildren room to wriggle out of vaccine requirements; exemptions based on a personal belief, religion, or an unverified doctor’s note remain the norm in most of the country. In 2015, California was the first state to repeal religious and personal belief exemptions after a measles outbreak at Disneyland; several other states, including New York in June, have followed suit. The 2015 law was initially a success — more kids entering schools were vaccinated. But since then, anti-vax parents and doctors have turned to medical exemptions, which have quadrupled. “We want to be sure that children who genuinely need a medical exemption get one. They need them,” Dr. Richard Pan, the state senator behind the bill, told BuzzFeed News. “That means we can’t have a bunch of other kids, whose parents basically bought the medical exemption, who don’t really need them.”

Damian Dovarganes / AP

New data on the immunization of 2018–19 California kindergarteners illustrates the problem. Statewide, the immunization rate is high, but for the last two years in a row, it's been trending downward. More than 600 schools around the state reported that their campus no longer has herd immunity protection against measles, with less than 93% of kindergartners up-to-date on their MMR shots. More than 100 schools reported that at least 10% of their students are unvaccinated because of medical exemptions. Statistically, just 1% of kids are likely to have medical conditions that prevent them from being vaccinated, Pan said. That adds up to a dangerous situation for children who can’t be safely vaccinated, and it’s now up to the state to step in and protect them, he added. “They need to be able to go to school and be safe as well. All children deserve to be safe at school,” he said.

California Department of Public Health

The bill aims to create that safer environment in several ways: Medical exemptions would be tracked in a state database, and public health officials would flag those that required review. That review would be done by a doctor or nurse working for the state, and it would begin whenever a school’s immunization rate drops below 95%, a school fails to report its immunization rate, or one doctor writes five or more exemptions in a year. Decisions by the state’s health department would be appealable to an independent panel of physicians, who would consider whether the doctor who signed off on the medical exemption was acting reasonably to protect a child’s health and safety. The bill also gives the California Medical Board new power to investigate doctors who are unethically gaming the medical exemption system. Pan pointed to doctors advertised as “vaccine friendly” online and offering medical exemptions for a fee. “If a physician was selling handicapped placards … we’d be pretty outraged about that. Especially if you actually need a handicap placard and you can’t find a parking space,” Pan said. “In this case, we’re talking about actually putting someone at risk, not just access to something you should have.” Those doctors are a minority, but they're capable of doing outsize damage, Pan added. In San Diego, one doctor was responsible for a third of medical exemptions, the Voice of San Diego found. Five doctors, several of whom had been singled out on social media by parents as "vaccine flexible," signed more than half of the medical exemptions at Bay Area schools, the Mercury News reported.

Rich Pedroncelli / AP

But currently, to obtain medical records that would reveal misconduct, the medical board must gain permission from parents, who can refuse to participate in an investigation. That’s limited the board's ability to crack down on anti-vax doctors who abuse the system. With their pathway to legally getting out of vaccines coming under threat, anti-vax parents have for months been mobilizing on social media. California has long been a center of the anti-vaccine movement in the US, with generations of hippies skipping shots in favor of alternative medicine, and Hollywood celebrities pushing false claims linking autism and vaccines into the mainstream. Outside of the state’s liberal strongholds, conservative anti-vaxxers have championed their beliefs as medical choice and balked against vaccine mandates as government overreach. Dr. Bob Sears, the author of The Vaccine Book who has promoted delayed shot schedules popular with vaccine-hesitant parents, practices medicine in Orange County.

Letter writing campaigns have for months targeted lawmakers considered friendly to their cause, and one anti-vaccine activist was cited for assault after confronting and pushing Pan near the capitol last week. The senator also criticized a poster used by some activists featuring his face branded in red with what he said looked like blood spatter. (A protest organizer said the image was not meant to look like blood or promote violence.)

@ShannanVelayas @RobertKennedyJr @DrPanMD You've seen that Pan graphic up close @ShannanVelayas and you know it's not intended to be BLOOD. That's clearly why you had to use a long shot if the graphic. Here's an up close version of that graphic to clarify what it actually looks like.