When Sen. Richard Pan introduced a new bill to crack down on the growing number of medical vaccine exemptions, he knew things would get ugly. Not so ugly that someone would push him from behind while streaming video  of the attack (the assailant said Pan should be “hanged for treason”) or that someone else would throw a menstrual cup of red liquid  (presumably blood) onto lawmakers on the Senate floor. But definitely ugly.
Pan and Assemblywoman Lorena Gonzalez announced the bill in late March. In explaining the need for tighter restrictions, both cited a report from Voice of San Diego that showed one doctor was responsible for nearly a third of all medical vaccine exemptions  in San Diego Unified School District. Many of her exemptions fell outside generally accepted medical guidelines for when to grant an exemption.
“You had a handful of unscrupulous doctors selling medical exemptions, which erodes community immunity,” Pan told me. “The public policy goal here is to keep schools and children safe.”
As protests at the Capitol raged, the bill went through several major changes. But in the end, Pan and Gonzalez passed a measure that will have a major impact on schools, doctors and vaccination rates across the state.
The new law will go into effect on Jan. 1, 2021. It will give public health officials the ability to step in at schools where the vaccination rate is less than 95 percent and in cases where one physician writes more than five medical exemptions in a calendar year. In those cases, public health officials will have the power to revoke exemptions they believe to be illegitimate.
If the law were in effect today, it would have big implications on the ground. In San Diego, 19 schools and six doctors would come under review, according to data from the California Department of Public Health and other documents obtained by Voice of San Diego. Dozens of medical exemptions would likely be revoked for falling outside the scope of generally recognized standards of care.
Vaccinations are not required in California. But they are required for a child to attend public or private school. The only way a child can attend school without a vaccination is if a doctor has written the child a medical exemption. The vast majority of doctors agree that patients should be written a medical exemption in limited cases – for instance, if a patient has a serious immune condition or if they have undergone an extreme medical procedure such as a heart transplant.
The 95 percent threshold within schools is important, because that is the vaccination rate at which doctors say a group of people achieves “herd immunity.” Once 95 percent of a population is vaccinated, diseases like measles do not spread to those who aren’t immune. When vaccination rates dip below 95 percent, non-vaccinated people within the community are at risk. That group can include infants or people who cannot be vaccinated, along with those who chose not to.
The law, in its initial form, would have given officials at the California Department of Public Health the power to approve or disapprove any medical exemption in the state. In the end, lawmakers settled on granting public health officials that authority only in cases where schools are in danger of losing herd immunity or in cases where a single doctor is providing a relatively large number of exemptions.
Dr. Tara Zandvliet, who practices medicine in South Park, wrote nearly a third of all 486 medical exemptions in San Diego Unified between July 2015 and March 2019, according to a list of medical exemptions  obtained earlier this year by VOSD through a public records request. Zandvliet wrote far more than any other physician.
Zandvliet charges $180 for a visit related to a medical exemption. She previously told me she did not grant an exemption in most cases and that she charged for the visit, not for the exemption itself.
Narrowing the list to 2018, the most recent full calendar year, Zandvliet and five other doctors wrote more than five medical exemptions. (These do not count medical exemptions the doctors may have written in other local school districts.) The new law would give public health officials the power to review, and potentially overturn, each exemption written by Zandvliet and the five other doctors.
During the review process, public health officials will follow standards for granting a medical exemption established by the Centers for Disease Control and Prevention and the American Academy of Pediatricians. If the reasons for a medical exemption fall outside the CDC’s or AAP’s established guidelines, public health officials would be expected to revoke the exemption.
Of the six physicians whose exemptions would be reviewed, all but one, Dr. George Madany, wrote exemptions which appear to fall outside the CDC guidelines. The other doctors often relied on the family history of a patient in order to grant an exemption, often citing family history of autoimmune disease.
That’s a “soft reason” for an exemption, Dr. Mark Sawyer, an infectious disease specialist at Rady Children’s Hospital, told me earlier this year. Sawyer said it’s possible genetics could increase a child’s risk of having an adverse reaction to a vaccine, but so far it’s an untested theory promoted by a small group of doctors.
Among the doctors whose exemptions would be reviewed, only Zandvliet and Dr. Timothy Dooley responded to a request for comment.
“There will be far more vaccine injuries” under the new law, Dooley wrote. The new law “is worse than stupid; it is truly horrifying.”
The American Academy of Pediatrics, California, which represents 5,000 pediatricians throughout the state, disagreed. That group endorsed and co-sponsored the bill.
Zandvliet said she will continue to recommend that children with certain family histories not be vaccinated. She said she will not, however, write them the exemption letter to go to school that she previously would have. That means if her patients follow her recommendations, they’d need to homeschool their child or find another option.
Another little-noticed provision of the bill would require that all medical exemptions written by a single doctor be revoked if that doctor is ever sanctioned for inappropriately providing a medical exemption.
To date, Dr. Bob Sears is the only doctor to ever be sanctioned for inappropriate medical exemptions in California. On the day the law goes into effect, all his medical exemptions will become invalid, Pan told me.
Sears, who practices medicine in Orange County, wrote 16 exemptions for students in San Diego Unified in recent years that would immediately become invalid.
A spokesman for the Medical Board of California, which issues sanctions against doctors, previously declined to comment on whether any of the reasons contained in San Diego Unified’s list of exemptions might be sanction-worthy. The Medical Board is “now in possession of the list … and will be taking a close look at it,” he wrote.
The Medical Board previously had difficulty investigating claims of inappropriate medical exemptions, because families would not agree to allow the Medical Board access to medical records, Pan told me. The new law will require any parent obtaining a medical exemption for their child to sign a waiver allowing the Medical Board access to any vaccine-relevant records.
This would, in theory, make it easier for the Medical Board to investigate claims of fraudulent exemptions. Even though the Medical Board would have access to these records, they would still have to abide by patient privacy laws, which do not allow the public release of patient information.
If a child’s medical exemption is revoked, parents will have the ability to appeal the decision.