All three studies examine vaccination rates among kindergarteners in California, which, in 2015, became the first state in almost 30 years to eliminate non-medical exemptions. The new law, referred to as Senate bill 277, took effect in 2016.
Among their key findings:
- While the percentage of kindergarteners who were up to date on their shots increased in 2016, the vast majority of the increase was linked to a different change made by school officials. Schools cut back on the number of children allowed to enter kindergarten on a conditional basis.
- After schools in California did away with personal belief exemptions, they saw a sharp increase in students submitting medical exemptions. The researchers suspect that some parents who could no longer use personal belief exemptions obtained authorization from doctors to skip vaccinations for medical reasons.
- While a larger share of kindergarteners had all their required vaccinations after Senate bill 277 took effect in 2016, the trend reversed the following year. The drop in up-to-date students, researchers explain, is connected to the spike in children using medical exemptions as well as an increase in the number of kindergarteners enrolled in school who were designated as “overdue” for vaccinations, oftentimes because they had missed a dose of a vaccine. In addition, Senate bill 277 effectively created a new exemption, allowing more than 5,000 kindergarteners in 2017 to forgo vaccinations if they attended a school without classroom-based instruction or had what are called “individualized education plans.”
Delamater says other states can learn a lot from California.
“California has been trying to be very proactive about this via legislation and for us, as researchers, it gives us a very interesting opportunity to evaluate how these big changes in policy relating to vaccinations – how people actually react to that,” he says. “As you’ve probably seen from looking at these papers, it’s not a really straightforward and easy-to-understand thing. There is a lot of nuance to this.”
Chelsea Richwine, the lead author on a working paper from the National Bureau of Economic Research that investigated the effects of Senate bill 277, stressed the importance of kids getting all their required vaccinations. It’s as dangerous for a child to have incomplete vaccinations as it is to skip them altogether, she says.
She recommends restricting vaccine exemptions while also making it clear when and under what circumstances youth should be allowed medical exemptions from one or more required vaccines. In many cases, kids need only to delay vaccinations for a certain period of time, not avoid them completely. Both the American Medical Association and American Academy of Pediatrics support eliminating non-medical exemptions.
In California, lawmakers are considering a bill that would make it tougher for parents to obtain a medical exemption after discovering that some doctors have been distributing large numbers of medical exemptions, some of which might not have been in response to a true medical problem. In San Diego, for example, one doctor has provided almost a third of the 486 medical exemptions used by students in the San Diego Unified School District since mid-2015, according to the Voice of San Diego news outlet.
Under the proposed legislation, the State Department of Health would review vaccination reports from doctors who submit five or more medical exemption forms in a calendar year.
“Exemptions are appropriate in certain circumstances, especially medical exemptions,” explains Richwine, a fourth-year doctoral candidate studying health policy at George Washington University. “I think we have to take a more holistic approach to looking at medical and non-medical exemptions. It’s not an effective policy on its own — if there’s an opportunity to substitute [one exemption for another].”
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