Eliminating nonmedical exemptions: a radical shift in how childhood vaccine mandates govern

ABSTRACT

Introduction

Every state in the US has had school vaccine mandates for decades, and all except West Virginia and Mississippi offered nonmedical exemptions (NMEs) in addition to medical exemptions. Several states recently eliminated NMEs, and others have attempted to do so. These efforts are transforming America’s immunization governance.

Areas covered

What we call the ‘mandates & exemptions’ regime of vaccination policy from the 1960s and 1970s functioned to orient parents toward vaccination, but did not coerce or punish them for not vaccinating. The article identifies how policy tweaks in the 2000s – including education requirements and other bureaucratic burdens – delivered enhancements to the ‘mandates & exemptions’ regime. Finally, the paper illustrates how the recent elimination of NMEs, first in California and then in other states, represents a radical transformation of America’s vaccine mandates.

Expert opinion

Today’s ‘unencumbered vaccine mandates’ (mandates without exemptions) directly govern and punish non-vaccination, unlike the ‘mandates & exemption’ regime that aimed to make it harder for parents to avoid vaccination. This kind of policy change introduces new problems for implementation and enforcement, especially within America’s underfunded public health system, and in the context of post-COVID public health political conflicts.

KEYWORDS:

• California
• nonmedical exemptions
• philosophical exemptions
• religious exemptions
• schools
• vaccination
• vaccine hesitancy
• vaccine mandates

Article highlights

• American state governments are removing long-standing nonmedical exemptions to vaccine mandates for school entry.

• Advocates of removing exemptions may believe that they are re-instituting ‘pure’ mandate policies.

• Removing nonmedical exemptions transforms mandates from their original function, which was to motivate parents to vaccinate.

• Exemption removal generates challenges for implementation and may promote further post-COVID political polarization about vaccination policy.

• American states should take lessons from other jurisdictions about how to implement coercive vaccine policy effectively.

Declaration of interest

K Attwell is a specialist advisor to the Australian Technical Advisory Group on Immunisation. She is a past recipient of a Discovery Early Career Researcher Award funded by the Australian Research Council of the Australian Government (DE19000158). She leads the ‘Coronavax’ project, which is funded by the Government of Western Australia. She leads ‘MandEval: Effectiveness and Consequences of Australia’s COVID-19 Vaccine Mandates,’ a new project funded by the Medical Research Future Fund of the Australian Government (2019107). All funds were paid to her institution. Funders are not involved in the conceptualization, design, data collection, analysis, decision to publish, or preparation of manuscripts. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or material discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Author contributions

K Attwell and M Navin conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript. K Attwell conducted the interviews. Both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Acknowledgments

The authors thank the anonymous reviewers of an earlier draft of the manuscript for their helpful suggestions. They also thank their wider network of supporters and research collaborators, and the interviewees who gave their time and thoughts to this research project.

Additional information

Funding

This manuscript was funded by the Australian Research Council of the Australian Government, under DE190100158. The Australian Research Council had no role in this manuscript or the research underpinning it.