Dr. Tara Zandvliet, a pediatrician based in San Diego, has a pretty typical doctor's website. The design is reminiscent of a late-90s Dreamweaver template; the color palette is beige, yellow, and brown. There's an online system where you can book an appointment, a list of the services she offers and the prices, and a short bio listing her credentials.
But there's one part of the site that stands out: a page that lists qualifying conditions to obtain a medical exemption from having your child vaccinated. These conditions include things like asthma, eczema, and psoriasis, and for $120 per child, Zandvliet will offer a 40-minute consultation to decide whether or not you qualify.
Last year, California changed its laws to eliminate personal belief and religious exemptions for vaccines. These exemptions were what anti-vaxxer parents had been using to continue sending their kids to school unvaccinated. Now, in order for children to attend school (private or public) in California, they must be up to date on the required shots. No special treatment for personal beliefs. So some parents are now turning to medical exemptions to take the place of their personal belief coverage.
Typically, medical exemptions are rare. They're intended for children who aren't able to get some or all of their shots for health reasons, like a life-threatening allergy to a vaccine ingredient, or a weakened immune system from chemotherapy. The Centers for Disease Control has a list of reasons why a child shouldn't get certain vaccinations, and it's not very long. It doesn't include conditions like asthma and eczema.
"Can doctors abuse medical exemptions? The answer is, right now, yes."
But some California doctors are starting to advertise medical exemptions based on a long list of unrelated conditions. And since medical exemptions are essentially just a letter written by the family doctor and submitted to a child's school, they aren't vetted by any regulatory body.
"If you're asking can doctors abuse [medical exemptions]? The answer is, right now, yes," said Dorit Rubinstein Reiss, a law professor who specializes in vaccination law at the University of California Hastings College of the Law. "A doctor who abuses this exemption is failing his or her patients just as much as a doctor who doesn't take care of a child in other ways."
California's law change was considered an important win in the fight against vaccine-preventable diseases, many of which have seen a reemergence in recent years. Public vaccination needs to reach a vast majority of the population in order to achieve herd immunity—enough people who are immune to the disease to protect those who can't be vaccinated, like kids going through chemotherapy.
For some diseases, like measles, the immunization rate needs to be as high as 95 percent to achieve herd immunity. So when the vaccination rates of new kindergarteners started to dip around 90 percent and outbreaks of previously rare diseases increased, it was clear something needed to change.
Under the new law, students with existing belief-based exemptions were grandfathered in, but as soon as those kids enter a new grade span (starting preschool, entering kindergarten, or beginning the seventh grade) they'll need to get up to date on all the required shots. That's unless they are eligible for a medical exemption, which can only be issued by a licensed medical doctor.
"The guidelines for providing medical exemptions are extremely broad in the new California law," Dr. Bob Sears, a Capistrano Beach pediatrician who advocates a delayed vaccine schedule, wrote on his Facebook page. "This means that is it up to the personal judgement of each physician and patient to work together to determine if a child qualifies for a medical exemption."
Sears's post goes on to say that a family history of conditions including Type 1 Diabetes, Celiac disease, and autism may be reason for a doctor to provide a medical exemption.
"There is no scientifically established link between any of these diseases and receipt of immunizations," said Dr. Mark H. Sawyer, a pediatrician and professor of clinical pediatrics at the University of California San Diego. "On the contrary, diabetes, for example, is a risk factor for diseases that can be prevented through vaccination, such as Hepatitis B."
In Fair Oaks, Dr. Kelly Sutton has started offering online webinars (for a fee) to walk parents through the process of seeking a medical exemption. In one free webinar, Sutton explains that the idea doctors can't or won't offer medical exemptions is a "myth" and recommends two books so patients can "learn what a doctor is looking for" and "increase their chances."
None of these doctors explicitly promise medical exemptions for any of the conditions they list, but it's troubling to see what they might consider. I reached out to Sutton, Zandvliet, and Sears, but none of the doctors responded to a request for comment.
I also cold-called a random selection of California clinics listed on Sears's website as "vaccine friendly," and posed as a patient inquiring about medical exemptions. Most of the clinics told me it was highly unlikely my child would qualify for a medical exemption and that they would not consider it for anyone who wasn't already an established patient.
But a few offered other responses. One clinic told me new patients hoping for a medical exemption must first get DNA testing done by 23andme, "so that we have proof of a genetic predisposition." Another suggested I use the form on Zandvliet's site as a guideline before coming in for a consultation. One other suggested I attend an upcoming seminar hosted by Sears.
Sawyer told me that it was clear when the law was passed that there would be some room for abuse and that everybody in the medical community will be watching closely to see if medical exemption rates—which currently sit at less than 1 percent of students—start to rise. A spokesperson from the California Department of Public Health told me there has been no reported increase in medical exemptions yet. But given that many students still have their grandfathered personal belief exemption, that could still change.
"Our medical exemptions rate has been flat and very low for decades and so we will clearly be able to measure to what extent this phenomenon takes off in response to this law," Sawyer said.
It's also not totally clear that, if a doctor did offer a medical exemption for a child because his or her grandmother has psoriasis, it would be illegal. There are no official "rules" for what qualifies a patient for a medical exemption, outside of the CDC's recommendations, and the law leaves it up to the discretion of the doctor. In general, that's a good thing, because it would be difficult to very precisely account for every possible situation when a medical exemption would make sense.
"They kind of deserve to be closely monitored."
But it also opens up the possibility of medical exemptions being used to fill the role of personal belief exemptions. The only way a doctor might be subject to discipline for handing out questionable medical exemptions would be through the Medical Board of California.
"You could complain to the board and say it's a violation of the standard of care, but it's not formalized," Reiss said. "Doctors that advertise online saying they'll give medical exemptions are kind of natural targets. They kind of deserve to be closely monitored."
A spokesperson for the Medical Board told me it's not specifically monitoring who gives out medical exemptions or how many, but that just like anything else a doctor does, this decision would need to meet the board's standard of care.
So does this all mean that California's strict new law is actually toothless? Not necessarily.
For one, we've already seen the vaccination rates in California start to rise, from 90.4 percent in the 2014-2015 school year to 92.9 percent this past year. Sawyer told me that increase is more likely due to an earlier change in the law that required families to visit the doctor before applying for a personal belief exemption, rather than the new change, but that it's a good indicator some families might not be as staunchly anti-vaxx as we thought.
And if dodgy medical exemptions do start to stand out as a problem, there are measures California could put in place. In West Virginia, where only medical exemptions are allowed, doctors have to submit requests for exemption to a state immunization officer for review.
"We'll just have to see what happens," Sawyer said. "This question is on everybody's radar here."