Health Policy$ense

Vaccine Exemption Laws: Learning What Works

Alison Buttenheim's Primer for State Legislators

How can state lawmakers decrease non-medical vaccination exemptions without infringing on parental choice? That’s the question that LDI Senior Fellow Alison Buttenheim seeks to answer in her new Governing magazine article. As outbreaks of disease like measles and pertussis increase, and more parents choose not to vaccinate their children, many states are considering tightening their vaccine-exemption laws.

After the Disneyland measles outbreak in late 2014, California enacted a Senate Bill allowing no non-medical exemptions for routine vaccines. New York is considering another strategy: a bill in committee would prohibit taxpayers from claiming a tax deduction for a child not fully immunized. In 2017 alone, at least 17 state legislatures have considered bills related to vaccine exemptions.


Alison Buttenheim, PhD, MBA is Associate Professor of Nursing and Health Policy at Penn, and an LDI Senior Fellow.

Of course, these proposals deeply anger the anti-vaccine groups. Buttenheim notes that, as often happens with heated topics, personal passions can get in the way of good policy based on good science. But, she states, we now have evidence on best practices for exemption policies that maximize health while preserving parental choice. We know that, the easier it is for parents to obtain exemptions, the more parents will choose to do so. We know that higher exemption rates are associated with more disease outbreaks. And evidence shows that steps making exemptions harder to obtain – such as mandatory vaccine education or a health care provider’s signature – can reduce rates of exemptions, such as in Washington state.

However, Buttenheim also argues that we don’t yet fully understand the conditions in which these new policies work, nor do we truly know the consequences of eliminating non-medical exemptions altogether. After the passage of the new California law prohibiting non-medical exemptions, the number of medical exemptions shot up by 150 percent. Of course, the number of children with legitimate medical reasons to avoid vaccination didn’t increase nearly that much in a year; it appears that the law drove some parents to request medical vaccinations (and some doctors to acquiesce). Furthermore, policies may not go far enough to change behavior (such as requiring parents to simply check a box on a form or speak with a health care provider), or they may actually reinforce anti-vaccine sentiment (such as requiring parents to write a brief statement explaining their opposition to vaccines).

So, how should lawmakers improve anti-exemption policies, given what we know and don’t know? Buttenheim has three recommendations for best practices:

  • Policymakers should ensure that complying with state immunization requirements is the easy choice, thereby making it the default choice. Adding a “hassle factor” to make obtaining exemptions more difficult is likely to change behavior.
  • Exemption policies should place minimal burden on schools and health care providers in carrying out requirements.
  • Mandates should be fully funded, and school staff should receive adequate training and resources to handle the transition to stricter vaccine requirements.