In 2015, the passage of SB 277 eliminated all non-medical exemptions for immunizations required for school entry. While SB 277 was successful in raising immunization rates across the state, there has also been a substantial increase in the number of medical exemptions issued. In fact, the percentage of kindergartners with medical exemptions has more than quadrupled, rising from 0.2 percent of students in the 2014-15 school year to 0.9 percent of students in 2018-19.1
Equally concerning as the rise in medical exemptions is the geographic clustering of exemptions within schools and school districts. Concentrated pockets of unvaccinated individuals are one of the primary causes of recent increases in measles cases.2 A 2017 Los Angeles Times report found that at almost 60 schools in the state more than ten percent of kindergarteners had medical exemptions, with seven schools having exemption rates over twenty percent.3
According to public health officials, the rise in medical exemptions is associated with an increase in physicians issuing exemptions for children without medically justified contraindications.4 While the vast majority of physicians continue to uphold standards of care, a small number of unethical physicians have monetized their license by selling medical exemptions for profit.
SB 276 will restore integrity to California’s medical exemption process by requiring the California Department of Public Health (CDPH) to review medical exemptions submitted for schools that lack community immunity and those issued by physicians who submit a large number of exemptions. The state public health officer and clinically-trained immunization staff may revoke exemptions that do not align with CDC or ACIP guidelines and are inconsistent with standard of care.
Additionally, the bill will require the use of a statewide database of exemptions, establish minimum requirements for exemption forms, require the establishment of an expert panel to review appeals, and require CDPH share information to the Medical Board of California on physicians whose medical exemptions pose a public health risk.
Immunizations against vaccine-preventable diseases are one of our most effective tools to protect public health. In addition to protecting us individually, when a sufficient percentage of the population is immunized, community immunity is established and further guards against outbreaks. Those most vulnerable to infectious diseases, including infants, the elderly, and the immunocompromised, rely on community immunity for protection. A 2017 analysis found that at almost 750 Californian schools less than 90% of kindergartners were fully vaccinated, which falls below the percentage needed to ensure community immunity.3
Recently, numerous measles outbreaks have occurred across the country in states including Washington, New York, and California. Since the start of 2019, 1,203 measles cases have been reported across thirty states, representing the largest number of U.S. cases in a year since the disease was declared eliminated in 2000.5 In addition to the serious health repercussions, outbreak response is also costly and places a significant financial burden on our public health resources. A recent JAMA article reported that response to a single case of measles can be as high as $142,000.6
Currently, California law requires no state-level oversight, approval, or standardization of medical exemptions. As a result, medical exemptions often contain incomplete information and may be issued for reasons that fall outside established standards of care. Furthermore, state and local health officers have limited information upon which to base public health strategies during outbreaks.
SB 276 is necessary to protect Californians from deadly outbreaks and provide public health officials with the resources they need to strategically respond to outbreaks.
SB 276 will address the dramatic increase in medical exemptions from vaccinations required for school entry. Specifically, the bill will strengthen oversight of medical exemptions by establishing the following:
- To issue a medical exemption, physicians will use a standardized form submitted via a statewide database. The form will require minimum information such as the name, address, license number, and address of the physician issuing the exemption; the child’s name, address, and school address; information regarding the child’s primary physician; and description of the medical basis for requesting the exemption.
- CDPH will annually review exemption forms which meet any of the following criteria: 1) submitted to schools with overall immunizations rates less than 95%; 2) submitted by physicians who have submitted more than five medical exemptions in one year; or 3) submitted to schools that have failed to report their immunization records to CDPH.
- CDPH will identify exemptions that do not meet CDC/ACIP or AAP criteria. Clinically trained immunization staff may accept these exemptions if the issuing physician has documented that the exemption is consistent with standard of care.
- The State Public Health Officer or their physician designee may deny or revoke medical exemptions that do not align with CDC/ACIP or AAP guidelines if the exemption is determined to be inconsistent with standard of care.
- Parents may appeal revoked exemptions to an independent expert review board, which will consist of three licensed physicians appointed by the Secretary of California Health and Human Services.
- The Department will notify the Medical Board of any physician who submits an exemption that is denied or revoked, and of any physician from whom they are not accepting exemptions.
- The Department will not accept medical exemptions from physicians who pose a risk to the public’s health, or from physicians with pending accusations with the Medical Board of California, until the accusation is resolved in favor of the physician.
- Existing exemptions must be submitted to CDPH by January 1, 2021 in order to remain valid and will be reviewed according to the same thresholds and standards as exemptions going forward.
- American Academy of Pediatrics CA (Sponsor)
- California Medical Association (Sponsor)
- Vaccinate California (Sponsor)
- Advanced Medical Technology Association
- AIDS Healthcare Foundation
- American College of Cardiology, California
- American College of Physicians California
- Bikur Cholim Jewish Healthcare Foundation
- California Academy of Eye Physicians and Surgeons
- California Academy of Family Physicians
- California Academy of Pain Medicine
- California Acadamy of Preventive Medicine
- California Association of Professional Scientists
- California Chapter American College of Cardiology
- California Children’s Hospital Association
- California Chronic Care Coalition
- California Hospital Association
- California Immunization Coalition
- California Life Sciences Association
- California Optometric Association
- California Orthopedic Association
- California School Nurses Association
- California Society for Asthma, Allergy, and Immunology
- California Society of Health Systems Pharmacists
- California State Association of Counties
- California State PTA
- Children Now
- Children’s Defense Fund of California
- Children’s Specialty Care Coalition
- County Healthy Executives Association of California
- County of Contra Costa
- County of Los Angeles
- County of Marin
- County of Santa Barbara
- County of Santa Clara
- County of Santa Cruz
- Children’s Specialty Care Coalition
- Donate Life California
- First 5 California
- Health Officers Association of California
- Hundreds of Individuals
- Infectious Disease Association of California
- Kaiser Permanente
- LA Care Health Plan
- March of Dimes
- Medical Board of California
- Orthopaedic Surgery Specialists Medical Group
- Providence St. Joseph Health
- San Mateo Democratic Party
- Sonoma County Health Action Committee for Healthcare Improvement
- Sutter Health
- United Democrat Club
Diana Douglas, Office of Senator Pan
firstname.lastname@example.org | 916-651-4006
Shannan Velayas, Office of Senator Pan
email@example.com | 916-651-4006
Morgan Carvajal, California Medical Association
Leah Russin, Vaccinate California
firstname.lastname@example.org | 650-434-3073
Kris Calvin, American Academy of Pediatrics CA
email@example.com | 626-825-7444
1 California Department of Public Health. 2018-2019 “Kindergarten Immunization Assessment Executive Summary.”
2 United States Centers for Disease Control and Prevention. “Frequently Asked Questions About Measles in the U.S.”
3 Karlamangla and Poindexter. “Despite California’s strict new law, hundreds of schools still don’t have enough vaccinated kids.” Los Angeles Times. Aug. 13, 2017.
4 Mohanty, et. al. “Experiences With Medical Exemptions After a Change in Vaccine Exemption Policy in California.” Journal of Pediatrics. Vol. 142, Issue 5. Nov. 2018.
5 United States Centers for Disease Control and Prevention. Cases and Outbreaks
6 Sundaram, et. al. “The True Cost of Measles Outbreaks During the Postelimination Era.” JAMA. Vol. 321, Issue 12. March 2019.
Last updated: 8/23/2019