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Colorado Passes Bill To Improve Vaccination Rates. To Some, It's A Goldilocks Approach.

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A health care provider gives a child a flu vaccine.

After a failed attempt last year, Colorado lawmakers have passed a bill that would make it harder to get a vaccine exemption for school children. 

Right now, parents seeking an exemption for their children for religious or personal reasons can just submit a handwritten note. If the bill gets signed into law, parents would either have to fill out a form and get it signed by a healthcare provider, or they’d have to take an online class about vaccines. 

“Washington state has something similar. I think Utah has something similar. The province of Ontario has something similar,” said Mark Navin, a bioethicist at Oakland University who has studied different approaches to vaccine exemptions. 

As Navin wrote in the journal Public Health Ethics, there are three paths a state can take to vaccine exemptions. 

The California route eliminates all non-medical exemptions. Vaccination rates improve, but it can cause some parents to remove their kids from the school system in order to avoid immunization, and may also “cultivate political polarization” around public health messages. 

The Vermont route eliminates exemptions for personal reasons, but keeps exemptions for religious reasons (as is the case in Montana, Wyoming, Nevada and New Mexico). That option can be perceived as unfair, and it may not change much from a health standpoint, if those who previously sought personal exemptions just switch to a religious exemption. 

The Michigan route maintains exemptions, but makes them “inconvenient” to get. Starting in 2015, parents had to fill out a standardized form and attend an in-person class from the local health department in order to get a waiver. Statewide, the change led to a 35% drop in non-medical exemptions the first year. This is similar to Utah’s approach, and now Colorado’s. According to Navin, it’s the Goldilocks approach.

“It’s a compromise,” he said. “If the state had gotten rid of non-medical exemptions entirely like California, almost certainly they would lower exemption rates and, correspondingly, increase immunization rates. But the point is, we don't care only about immunization rates and exemption rates. We care also about children being in school. We care about not politicizing our public health policies.”

Studies have shown that only about 1% or 2% of parents refuse all vaccines for their children. That passionate sliver of voters was very present at the Colorado Capitol this year, including at a big rally in early June.

“The kind of people that show up for the protest outside the Colorado state house – those are a very extreme minority fringe of people who you're never going to persuade to vaccinate,” Navin said. “But there's a substantial minority of people who are not fully vaccinated, who only need a kind of nudge towards vaccination.”

“Washington state found and Michigan found, other states have found, that somewhere between a third and 40% or more of people are what we call ‘convenience exemption seekers,’” Navin continued. “They're getting exemptions because it's easier than making an appointment to go to the doctor.”

Romain Garnier, a disease ecologist at Georgetown University, recently published a paper looking at the effect of the three policy approaches on immunization rates. As Navin did, Garnier concluded that California’s approach was the most effective at boosting immunization rates. 

Other policy changes didn’t have as clear of an effect. For example, in 2015, Illinois did something similar to Michigan, making it harder for parents to obtain non-medical exemptions for their children. 

“So we looked at Illinois and we found that literally the change had no effect in terms of where the clusters of exemptions were,” said Garnier. Some counties saw improvement, but others remained exemption-heavy, before and after the policy change. 

A population has to hit a certain threshold in order to gain herd immunity, also known as community immunity.  

“It’s important that it’s 95% everywhere, not 99% in some places and 91% in some others,” said Garnier. “Because the only thing that will prevent outbreaks of vaccine-preventable diseases across the board is 95% across the board.”

The best long-term strategy for disease prevention would be simply to build more public confidence in vaccines, he said, but Colorado’s move is “definitely an improvement on signing a random piece of paper.”

The Colorado bill passed in the final days of the legislative session, with an exception added for homeschoolers. Gov. Jared Polis has said he would sign the bill if it made it to his desk.

That’s all well and good, said Mark Navin. But what concerns him is just how politically polarized the issue has become. Among voters, the issue doesn’t fall along party lines, but in the legislature it does.

“I think if you were starting 20 or 30 years ago, you might flip a coin about which party would be more likely to lead the fight for and against vaccine mandates in the early 21st century,” he said. 

As Navin pointed out, anti-vaccine activists tend to include both ends of the red-blue spectrum. 

“The exemption behaviors among individual parents are not tightly connected to whether they’re Democrats or Republicans,” he said. But when the issue reaches the Capitol, a shift occurs.

In Colorado, the House vote cleaved perfectly along party lines, with Democrats for and Republicans against.

This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUNR in Nevada, the O'Connor Center for the Rocky Mountain West in Montana, KUNC in Colorado, KUNM in New Mexico, with support from affiliate stations across the region. Funding for the Mountain West News Bureau is provided in part by the Corporation for Public Broadcasting.

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