Governor's Directive May Undermine State Vaccine Exemption Policies
Oct 18, 2013

Last year, an immunization bill to help protect the children, schools and communities in California from vaccine preventable diseases was introduced to the State Assembly.  This proposed bill (AB 2109) was intended to reduce the number of students claiming non-medical vaccination exemptions and minimize the impact of disease outbreaks caused in part by pockets of under-vaccinated children. After many hearings the bill, which was co-sponsored by the California Immunization Coalition, the California Medical Association, the American Academy of Pediatrics – CA and the Health Officers Association of California, was approved by the State Assembly and signed into law by California Governor Jerry Brown in September, 2012.
However, upon signing the bill the Governor added a specific directive that may impact the way in which the new exemption forms are written and seriously undermine the bill’s original intent. Bill supporters are now left to question whether the Governor’s actions were appropriate.  Were his changes an attempt to re-interpret the law?  And does he have the authority to make such changes?
As approved, AB 2109 would not interfere with parental options to secure personal belief exemptions from required school vaccinations.  Rather, the bill would simply establish new policies regarding the process by which parents would need to file for an exemption.  Instead of allowing parents to just sign a form and it be accepted, the new bill would help ensure parents were making educated immunization decisions.  Starting in January 2014, parents will now be required to meet with a healthcare provider or school nurse to discuss the risks and benefit of immunizations prior to the exemption being submitted.  The parental decision to claim an exemption will not be restricted, however the bill moves to ensure parents are getting credible information to address their vaccine related questions and concerns.  This additional step in the exemption process is also intended to deter parents from filing for exemptions out of convenience.
Various studies suggest that the ease by which parents can obtain vaccine exemptions has a direct correlation on the number of exemptions filled in a particular state and the rising incidence of disease.   In the case of California, a recent Pediatrics article suggests that the increasing rate of nonmedical exemptions has been one of the key factors in the rise of pertussis outbreaks in the state.   Jessica Atwell, lead author of the study highlighted in Pediatrics explains how exemptions have played a role in disease outbreaks by stating,

“The exemptions clustered spatially and were associated with clusters of cases.”

(For news coverage related to this study, readers can refer to USA Today, NPR, Huffington Post, CBS News, and TIME)

These considerations were a large part of the input that legislators received from doctors, public health professionals and parents prior to passing AB 2109.  While the legislators approved the bill as written, Governor Brown chose to add a directive in his signing statement stating that he would “direct the department (California Department of Public Health) to allow for a separate religious exemption on the form.”  
If the Governor’s intent was to accommodate parents seeking religious exemptions, this could easily be accomplished by grouping both religious and personal belief exemptions as nonmedical exemptions, as is seen in other states.  This would maintain the requirement that a parent or guardian discuss their concerns with a medical professional before the form could be processed.   However, it’s possible that a separate religious exemption category will be added to the new form in California that does not require parents to have a discussion with a healthcare provider or provide any other supporting documentation.  This small, but significant change will seriously diminish the impact of the bill.
By providing a way for parents to circumvent the discussion with a health provider, parents could choose to declare a religious exemption as easily as they had once declared a personal belief exemption. For parents looking for the quickest and easiest way to complete the form, there is little doubt that the new religious exemption option may take the place of the personal belief exemptions.   In essence, the governor’s directive will have nullified the new law that he himself had signed and the state legislature had passed.
California has not been the first state to attempt to control exemption rates through legislation.  Washington State passed a similar bill in 2011 which has been credited with decreasing their Kindergarten exemption rates from 6% in 2010-2011, to 4.5% for the 2011-2012 school year.  While California may hope to see a similar decrease in exemptions, the impact of AB 2109 will largely be determined by the way in which the new exemption forms are written.

Catherine Flores Martin, Director of the California Immunization Coalition (CIC), expressed concern in a recent interview, explaining that many reputable organizations have worked very hard to highlight the importance of this bill.
She explains,

“This bill did a great service to parents by ensuring that they will get adequate time to talk to busy physicians and health care providers about their immunization questions and concerns.”

In responding to questions about the way in which religious exemptions may be addressed, Ms. Martin adds,

“We do not believe that any religion is against parents having a conversation with their child’s medical provider and getting information that can assist them with making an informed decision about the health of their child.”

While the public is left questioning how the Governor’s directive will be executed, there is no doubt that this bill will be a disappointment if it fails to accomplish what it was intended to do – reduce student exemptions and minimize outbreaks of vaccine preventable disease among California’s students, schools and communities.

If you would like to stay informed about AB 2109, be sure to connect with the California Immunization Coalition by visiting the director’s page of their website and “liking” them on Facebook.  It’s important to note that many states across the country are considering similar legislation designed to alter current school vaccine exemption processes.  By adding your name to the Vaccinate Your Baby “Get Involved” list, you can request to receive immunization alerts that pertain to your particular state.   Staying informed is just another way you can help to ensure the health of your community.

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