About 1 in 4 people in the U.S. have fatty liver disease. But among Latinos, especially of Mexican and Central American descent, the rate is significantly higher.

This Kaiser Health News article was first published on Friday, April 19, 2019 in California Healthline

By Rob Waters

Saira Diaz uses her fingers to count the establishments selling fast food and sweets near the South Los Angeles home she shares with her parents and 13-year-old son. "There's one, two, three, four, five fast-food restaurants," she says. "And a little mom and pop store that sells snacks and sodas and candy."

In that low-income, predominantly Latino neighborhood, it's pretty hard for a kid to avoid sugar. Last year, doctors at St. John's Well Child and Family Center, a nonprofit community clinic seven blocks away, became alarmed by the rising weight of Diaz's son, Adrian Mejia. They persuaded him to join an intervention study run by the University of Southern California and Children's Hospital Los Angeles (CHLA) that weans participants off sugar in an effort to reduce the rate of obesity and diabetes among children.

It also targets a third condition fewer people have heard of: fatty liver disease.

Linked both to genetics and diets high in sugar and fat, "fatty liver disease is ripping through the Latino community like a silent tsunami and especially affecting children," said Dr. Rohit Kohli, chief of gastroenterology, hepatology and nutrition at CHLA.

Recent research shows about 1 in 4 people in the U.S. have fatty liver disease. But among Latinos, especially of Mexican and Central American descent, the rate is significantly higher. One large study in Dallas found that 45% of Latinos had fatty livers.

The illness, diagnosed when more than 5% of the liver's weight is fat, does not cause serious problems in most people. But it can progress to a more severe condition called nonalcoholic steatohepatitis, or NASH, which is linked to cirrhosis, liver cancer and liver failure. This progressive form of fatty liver disease is the fastest-growing cause of liver transplants in young adults.

The USC-CHLA study is led by Michael Goran, director of the Diabetes and Obesity Program at CHLA, who last year made an alarming discovery: Sugar from sweetened beverages can be passed in breast milk from mothers to their babies, potentially predisposing infants to obesity and fatty livers.

Called HEROES, for Healthy Eating Through Reduction of Excess Sugar, his program is designed to help children like Adrian, who used to drink four or more sugary drinks a day, shed unhealthy habits that can lead to fatty liver and other diseases.

Fatty liver disease is gaining more attention in the medical community as lawmakers ratchet up pressure to discourage the consumption of sugar-laden drinks. Legislators in Sacramento are mulling proposals to impose a statewide soda tax, put warning labels on sugary drinks and bar beverage companies from offering discount coupons on sweetened drinks.

"I support sugar taxes and warning labels as a way to discourage consumption, but I don't think that alone will do the trick," Goran said. "We also need public health strategies that limit marketing of sugary beverages, snacks and cereals to infants and children."

William Dermody, a spokesman for the American Beverage Association said: "We understand that we have a role to play in helping Americans manage consumption of added sugars, which is why we are creating more drinks with less or no sugar."

In 2016, 45 deaths in Los Angeles County were attributed to fatty liver disease. But that's a "gross underestimate," because by the time people with the illness die, they often have cirrhosis, and that's what appears on the death certificate, said Dr. Paul Simon, chief science officer at the L.A. County Department of Public Health.

Still, Simon said, it was striking that 53% of the 2016 deaths attributed to fatty liver disease were among Latinos — nearly double their proportion of total deaths in the county.

Medical researchers consider fatty liver disease a manifestation of something called metabolic syndrome — a cluster of conditions that include excess belly fat and elevated blood pressure, blood sugar and cholesterol that can increase the risk of heart disease, stroke and diabetes.

Until 2006, few doctors knew that children could get fatty liver disease. That year Dr. Jeffrey Schwimmer, a professor of pediatrics at the University of California-San Diego, reviewed the autopsies of 742 children and teenagers, ages 2 to 19, who had died in car crashes or from other causes, and he found that 13% of them had fatty liver disease. Among obese kids, 38% had fatty livers.

After Schwimmer's study was released, Goran began using MRIs to diagnose fatty liver in living children.

A 2008 study by another group of researchers nudged Goran further. It showed that a variant of a gene called PNPLA3 significantly increased the risk of the disease. About half of Latinos have one copy of that high-risk gene, and a quarter have two copies, according to Goran.

He began a new study, which showed that among children as young as 8, those who had two copies of the risky gene and consumed high amounts of sugar had three times as much fat in their livers as kids with no copy of the gene. Now, in the USC-CHLA study, he is testing whether reduced consumption of sugar decreases the fatty liver risk in children who have the PNPLA3 gene variant.

At the start of the study, he tests kids to see if they have the PNPLA3 gene, uses an MRI to measure their liver fat and catalogs their sugar intake. A dietitian on his team educates the family about the impact of sugar. Then, after four months, they measure liver fat again to assess the impact of the intervention. Goran expects to have results from the study in about a year.

More recently, Goran has been investigating the transmission of sugar from mothers to their babies. He showed last year that in nursing mothers who drank beverages sweetened with high-fructose corn syrup — the primary sweetener in standard formulations of Coca-Cola, Pepsi and other sodas — the fructose level in their breast milk rose and stayed elevated for several hours, ensuring that the baby ingested it.

This early exposure to sugar could be contributing to obesity, diabetes and fatty livers, based on previous research that showed fructose can enhance the fat storage capacity of cells, Goran said.

At Torrance Memorial Medical Center, Dr. Karl Fukunaga meets with a patient, Margarita Marrou, a retired medical clerk originally from Peru. She was diagnosed several years ago with a severe form of fatty liver disease and has cut down her sugar consumption and lost weight. (Rob Waters for KHN)

In neighborhoods like South Los Angeles, where Saira Diaz and Adrian Mejia live, a lack of full-service markets and fresh produce makes it harder to eat healthily. "Access to unhealthy food options — which are usually cheaper — is very high in this city," Derek Steele, director of health equity programs at the Social Justice Learning Institute in Inglewood, Calif., told Kaiser Health News.

The institute has started farmers markets, helped convert two corner stores into markets with healthier food options and created 109 community gardens on public and private lands in South L.A. and neighboring Inglewood, which has 125 liquor and convenience stores and 150 fast-food outlets.

At Torrance Memorial Medical Center, 10 miles down the road, Dr. Karl Fukunaga, a gastroenterologist with Digestive Care Consultants, said he and his colleagues are seeing so many patients with fatty liver disease that they plan to start a clinic to address it. He urges his patients to avoid sugar and cut down on carbohydrates.

Adrian Mejia and his mother received similar advice from a dietitian in the HEROES program. Adrian gave up sugary beverages, and his liver fat dropped 43%. Two months ago, he joined a soccer league.

"Before, I weighed a lot and it was hard to run," he said. "If I kept going at the pace I was going, probably later in my life I would be like my [diabetic] grandma. I don't want that to happen."

This KHN story first published on California Healthline, a service of the California Healthcare Foundation.

Workers in the wellness programs self-reported healthier behavior, but saw no differences in health measures, such as improved blood sugar, how much they spent on healthcare, or how often they missed work.

This article was first published on Tuesday, April 16, 2019 by Kaiser Health News.

By Julie Appleby

Workplace wellness programs have become an $8 billion industry in the U.S. But a study published Tuesday in JAMA found they don't cut costs for employers, reduce absenteeism or improve workers' health.

Most large employers offer some type of wellness program — with growth fueled by incentives in the federal Affordable Care Act.

A host of studies over the years have provided conflicting results about how well they work, with some showing savings and health improvements while others say the efforts fall short.

Many studies, however, faced a number of limitations, such as failing to have a comparison group, or figuring out whether people who sign up for such wellness programs are somehow healthier or more motivated than those who do not.

Now researchers from the University of Chicago and Harvard may have overcome these obstacles with one of the first large-scale studies that is peer-reviewed and employs a more sophisticated trial design.

They randomly assigned 20 BJ's Wholesale Club outlets to offer a wellness program to all employees, then compared results with 140 stores that did not.

The big-box retailer employed nearly 33,000 workers across all 160 clubs during the test.

After 18 months, it turned out that yes, workers participating in the wellness programs self-reported healthier behavior, such as exercising more or managing their weight better than those not enrolled.

But the efforts did not result in differences in health measures, such as improved blood sugar or glucose levels; how much employers spent on health care; or how often employees missed work, their job performance or how long they stuck around in their jobs.

"The optimistic interpretation is there is no way we can get improvements in health or more efficient spending if we don't' first have changes in health behavior," said one study author, Katherine Baicker, dean of the Harris School of Public Policy at the University of Chicago. (Dr. Zirui Song, an assistant professor of health policy and medicine at Harvard Medical School, was its co-author.)

"But if employers are offering these programs in hopes that health spending and absenteeism will go down, this study should give them pause," Baicker said. 

The study comes amid widespread interest in wellness programs.

The Kaiser Family Foundation's annual survey of employers found that 53% of small firms and 82% of large firms offer a program in at least one of these areas: smoking cessation, weight management and behavioral or lifestyle change. (Kaiser Health News is an editorially independent program of the foundation.)

Some programs are simple, offering gift cards or other small incentives to fill out a health risk assessment, take a lunch-and-learn class or join a gym or walking group. Others are far more invasive, asking employees to report on a variety of health-related questions and roll up their sleeves for blood tests.

A few employers tie financial incentives to workers actually lowering risk factors, such as high blood pressure or cholesterol — or making concerted efforts to participate in programs that might help them do so over time.

The Affordable Care Act allowed employers to offer financial incentives worth up to 30% of the cost of health insurance, leading some employers to offer what could be hundreds or even thousands of dollars off workers' deductibles or premiums to get them to participate. That led to court challenges about whether those programs are truly voluntary.

In the study reported in JAMA, the incentives were modest. Participants got small-dollar gift cards for taking wellness courses on topics such as nutrition, exercise, disease management and stress control. Total potential incentives averaged $250. About 35% of eligible employees at the 20 participating sites completed at least one module.

Results from those workers — including attendance and tenure data, their self-reported health assessment and results from lab blood tests — were specifically compared with similar reports from 20 primary comparison sites where workers were not offered the wellness gift cards and classes. Overall employment and health spending data from all worksites were included in the study.

Wellness program vendors said details matter when considering whether efforts will be successful.

Jim Pshock, founder and CEO of Bravo Wellness, said the incentives offered to BJ's workers might not have been large enough to spur the kinds of big changes needed to affect health outcomes.

Amounts of "of less than $400 generally incentivize things people were going to do anyway. It's simply too small to get them to do things they weren't already excited about," he said.

An accompanying editorial in JAMA noted that "traditional, broad-based programs like the one analyzed by Song and Baicker may lack the necessary intensity, duration, and focus on particular employee segments to generate significant effects over a short time horizon."

In other words, don't give up entirely on wellness efforts, but consider "more targeted approaches" that focus on specific workers with higher risks or on "health behaviors [that] may yield larger health and economic benefits," the editorial suggested.

It could be, the study acknowledges, that 18 months isn't enough time to track such savings. So, Baicker and Song also plan to publish three-year results once they are finalized.

Still, similar findings were recently reported in another randomized control trial conducted at the University of Illinois, where individuals were randomly selected to be offered wellness programs.

In one interesting point, that study found that wellness-program participants were likely already healthier and more motivated, "thus a primary benefit of these programs to employers may be their potential to attract and retain healthy workers with low medical spending."

Everyone involved in studying or conducting wellness agrees on one thing: Changing behavior — and getting people motivated to participate at all — can be difficult.

Steven Aldana, CEO of WellSteps, a wellness program vendor, said that for the efforts to be successful they must cut across many areas, from the food served in company cafeterias to including spouses or significant others to help people quit smoking, eat better or exercise more.

"Behavior is more complicated than simply taking a few wellness modules," said Aldana. "It's a lifestyle matrix or pattern you have to adopt."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Many presidential hopefuls, even official co-sponsors of Sanders' Medicare-for-All proposal, are at the same time edging toward a more incremental approach, called 'Medicare for America.'

This article was published by Kaiser Health News on April 11, 2019.

By Shefali Luthra, Kaiser Health News

As Democratic presidential primary candidates try to walk a political tightrope between the party's progressive and center-left wings, they face increasing pressure to outline the details of their health reform proposals.

On Wednesday, Sen. Bernie Sanders (I-Vt.) reaffirmed his stance by reintroducing a "Medicare-for-all" bill, the idea that fueled his 2016 presidential run.

As with its previous iterations, Sanders' latest bill would establish a national single-payer "Medicare" system with vastly expanded benefits, prohibit private plans from competing with Medicare and eliminate cost sharing. New in this version is a universal provision for long-term care in home and community settings (but Medicaid would continue to cover institutional care).

Already, it has an impressive list of Senate cosponsors — including Sanders' rivals for the Democratic presidential nomination, Cory Booker (D-N.J.), Kirsten Gillibrand (D-N.Y.), Kamala Harris (D-Calif.) and Elizabeth Warren (D-Mass.).

But many of the candidates — even official Medicare-for-all co-sponsors — are at the same time edging toward a more incremental approach, called "Medicare for America." Proponents argue it could deliver better health care to Americans while avoiding political, budgetary and legal objections.

It comes as politicians tread carefully over the political land mines a Medicare-for-all endorsement could unleash, while seeking to capitalize on a growing appetite for health reform.

During the 2018 midterm election campaigns, some congressional candidates talked about allowing people older than 55 to join Medicare, or allowing people younger than 65 to buy into it if they choose (the "public option"). Many aren't eager to face the industry opposition that a full-on Medicare expansion would surely trigger.

From the consumer perspective, sweeping reform poses a risk. Despite Medicare's popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous Medicare-for-all plan that promises everything would break the bank without any patient payments.

That tension is pushing a number of candidates toward an emerging option called "Medicare for America." The bill was introduced last December to little fanfare by two Democrats, Rep. Rosa DeLauro (Conn.) and Rep. Jan Schakowsky (Ill.). It hasn't been reintroduced in the new Congress.

This proposed system would guarantee universal coverage, but leaves job-based insurance available for those who want it. Unlike Medicare-for-all, though, it preserves premiums and deductibles, so beneficiaries would still have to pay some costs out-of-pocket. It allows private insurers to operate Medicare plans as well, a system called Medicare Advantage that covers about a third of the program's beneficiaries currently, and which would be outlawed under Medicare-for-all.

"Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack," said Celinda Lake, a Democratic pollster. "A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about."

Medicare for America got its first high-profile endorsement from former Texas Rep. Beto O'Rourke, who launched his own 2020 bid in mid-March. Other candidates — including Warren, Gillibrand and Pete Buttigieg, the mayor of South Bend, Ind. — have tiptoed toward it without making any endorsements, suggesting they back Medicare-for-all in theory but also support a system that retains private insurance, at least temporarily.

Such an approach is perhaps unsurprising. Polling indicates voters want strong health reform. Candidates, election experts say, need something powerful to deliver.

Related: Seema Verma Links 'Medicare-for-All' to 'Failed Socialist Healthcare'

Related: 'Medicare-For-All' Gets Buzzy In Unexpected Locales

Improving the Affordable Care Act, an idea backed by Sen. Amy Klobuchar, a Minnesota Democrat running in the primary's moderate lane, may not suffice.

"The ACA is popular at the 50 percent level, but it's not energetic. It doesn't get people who really like it," Blendon said. "What they're looking for is something that is exciting but isn't threatening."

Both Medicare-for-all and Medicare for America, experts noted, offer something that presidential candidates can campaign on and a health alternative that at first blush sounds appealing to many. But the latter could skirt some potential obstacles.

Approval for Medicare-for-all drops when people learn that, under such a program, they would likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).

The cost-sharing element of Medicare for America, meanwhile, would ostensibly quiet some of the concerns about paying for Medicare's expansion, though critics on the left worry it would mean some people would still be unable to afford care.

This also tracks with recent polling which suggests that, while Medicare-for-all support can be swayed, voters of all political stripes favor some sort of way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.

Employers would have to offer plans that were at least as generous as the government program, or direct employees to Medicare. Employers who stop offering health benefits would have to pay a Medicare payroll tax.

For now, most candidates are still avoiding a concrete stance on Medicare for America. Despite signs of interest, the Buttigieg, Gillibrand and Warren campaigns all declined to directly answer questions about whether they endorse Medicare for America. The campaigns of other candidates in the race — Harris, Klobuchar, Booker, former Housing and Urban Development Secretary Julian Castro and Washington Gov. Jay Inslee — similarly declined to comment.

Reading between the lines, though, their promises to achieve universal health care by expanding Medicare — while retaining private insurance — leaves them few options besides something like Medicare for America, argued one of its main architects.

"There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you're going to have to do the kinds of things" spelled out in Medicare for America, argued Jacob Hacker, a political scientist at Yale University, who played a lead role in devising this proposal.

Still, though, it has prompted objections from both the left and the right.

On the far left, the cost sharing is a dominant concern. (Under Medicare for America, an individual would have a $3,500 out-of-pocket limit; a family would have a $5,000 limit. Premiums would be capped at almost 10% of a household's income.) Those critics also say the plan's accommodations to private insurance limit the government's ability to negotiate lower prices.

Conservatives repeat many of the arguments levied against Medicare-for-all — too expensive, too disruptive.

Hospitals, insurance, drugmakers and doctors, who have already mobilized against Medicare-for-all, also can be expected to make just as strong a showing against Medicare for America, political analysts said. More Medicare means less revenue for the medical industry.

Said David Blumenthal of the Commonwealth Fund: "The fact of expanded Medicare will be the focus of attacks."

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Parents have found end runs around the new law requiring vaccinations. And they have done so, often, with the cooperation of doctors — some not even pediatricians.

This article was first published on Friday, April 5, 2019 in Kaiser Health News.

By Barbara Feder Ostrov

SAN JOSE, Calif. — At two public charter schools in the Sonoma wine country town of Sebastopol, more than half the kindergartners received medical exemptions from state-required vaccines last school year. The cities of Berkeley, Santa Cruz, Nevada City, Arcata and Sausalito all had schools in which more than 30% of the kindergartners had been granted such medical exemptions.

Nearly three years ago, with infectious disease rates ticking up, California enacted a fiercely contested law barring parents from citing personal or religious beliefs to avoid vaccinating their children. Children could be exempted only on medical grounds, if the shots were harmful to health.

Yet today, many of the schools that had the highest rates of unvaccinated students before the new measure continue to hold that alarming distinction. That's because parents have found end runs around the new law requiring vaccinations. And they have done so, often, with the cooperation of doctors — some not even pediatricians. One prolific exemption provider is a psychiatrist who runs an anti-aging clinic.

Doctors in California have broad authority to grant medical exemptions to vaccination, and to decide the grounds for doing so. Some are wielding that power liberally and sometimes for cash: signing dozens — even hundreds — of exemptions for children in far-off communities.

"It's sort of the Hail Mary of the vaccine refusers who are trying to circumvent SB 277," the California Senate bill signed into law by Gov. Jerry Brown in 2015, said Dr. Brian Prystowsky, a Santa Rosa pediatrician. "It's really scary stuff. We have pockets in our community that are just waiting for measles to rip through their schools."

The number of California children granted medical exemptions from vaccinations has tripled in the past two years.

Across the nation, 2019 is shaping up to be one of the worst years for U.S. measles cases in a quarter-century, with major outbreaks in New York, Texas and Washington state, and new cases reported in 12 more states, including California. California's experience underlines how hard it is to get parents to comply with vaccination laws meant to protect public safety when a small but adamant population of families and physicians seems determined to resist.

When Senate Bill 277 took effect in 2016, California became the third state, after Mississippi and West Virginia, to ban vaccine exemptions based on personal or religious beliefs for public and private school students. (The ban does not apply to students who are home-schooled.)

In the two subsequent years, SB 277 improved overall child vaccination rates: The percentage of fully vaccinated kindergartners rose from 92.9% in the 2015-16 school year to 95.1% in 2017-18.

But those gains stalled last year due to the dramatic rise in medical exemptions: More than 4,000 kindergartners received these exemptions in the 2017-18 school year. Though the number is still relatively small, many are concentrated in a handful of schools, leaving those classrooms extremely vulnerable to serious outbreaks.

Based on widely accepted federal guidelines, vaccine exemptions for medical reasons should be exceedingly rare. They're typically reserved for children who are allergic to vaccine components, who have had a previous reaction to a vaccine, or whose immune systems are compromised, including kids being treated for cancer. Run-of-the-mill allergies and asthma aren't reasons to delay or avoid vaccines, according to the U.S. Centers for Disease Control and Prevention. Neither is autism.

Before California's immunization law took effect, just a fraction of 1% of the state's schoolchildren had medical exemptions. By last school year, 105 schools, scattered across the state, reported that 10% or more of their kindergartners had been granted medical exemptions. In 31 of those schools, 20% or more of the kindergartners had medical exemptions.

Seesawing Exemptions

As of July 2016, California no longer allows parents to exempt their children from state-required vaccinations based on personal beliefs. Many of the same schools that once had the highest percentage of students with personal belief exemptions now lead the state in student medical exemptions.

The spike in medical exemptions is taking place amid a politically tinged, often rancorous national conversation over vaccines and personal liberty as measles resurges in the U.S. and worldwide. At least 387 cases of measles had been reported nationwide through March 28, according to the CDC. In California, 16 cases had been reported, two of them requiring hospitalization.

The problem in California, state officials say, is how the immunization law was structured. It removed the ability of parents to cite "personal belief" as a reason for exempting their children from vaccine requirements in day care and schools. Exemptions now must be authorized by a licensed physician who provides a written statement citing a medical condition that indicates immunization "is not considered safe."

But the law does not specify the conditions that qualify a student for a medical exemption, nor does it require physicians to follow federal guidelines.

The wording has led to a kind of gray market in which parents share names of "vaccine-friendly" doctors by word of mouth or in closed Facebook groups. And some of those doctors are granting children blanket exemptions — for all time and all vaccines — citing a range of conditions not supported by federal guidelines, such as a family history of eczema or arthritis.

Amid growing concerns about suspect exemptions, the California Department of Public Health recently launched a review of schools with "biologically unlikely" numbers of medical exemptions, said the agency's director, Dr. Karen Smith. Doctors who have written questionable exemptions will be referred to the Medical Board of California for possible investigation.

The medical board, which licenses doctors, has the authority to levy sanctions if physicians have not followed standard medical practice in examining patients or documenting specific reasons for an exemption.

In recent years, however, the board has sanctioned only one doctor for inappropriately writing a medical vaccine exemption in a case that made headlines. Since 2013, the board has received 106 complaints about potentially improper vaccine exemptions, including nine so far this year, said spokesman Carlos Villatoro.

One pending case involves Dr. Ron Kennedy, who was trained as a psychiatrist and now runs an anti-aging clinic in Santa Rosa.

Medical board investigators took the unusual step of subpoenaing 12 school districts for student medical records after receiving complaints that Kennedy was writing inappropriate exemptions. They found that Kennedy had written at least 50 exemptions, using nearly identical form letters, for students in multiple communities, including Santa Rosa, Fremont and Fort Bragg, saying that immunizations were "contraindicated" for a catchall list of conditions including lupus, learning disability, food allergies and "detoxification impairment."

Dr. Dean Blumberg, chief of pediatric infectious diseases at UC Davis Children's Hospital and the medical board's expert witness, said that the exemptions issued by Kennedy appear to have been provided "without an appropriate evaluation," according to court documents.

Kennedy has refused to respond to the board's subpoenas seeking the medical records of three of his patients, according to court documents. The board has yet to file a formal accusation against Kennedy, and he continues to practice.

Like Kennedy, many of the doctors granting unorthodox exemptions cite their belief in parental rights or reference concerns not supported by conventional medical science. Kennedy is suing the medical board and its parent agency, the California Department of Consumer Affairs, saying the state did not have the legal right to subpoena school districts for his patients' medical records without first informing him so he could challenge the action in court. The case is ongoing.

Kennedy declined comment to Kaiser Health News. "I don't want to be out in the open," he said in a brief phone exchange. "I've got to go. I've got a business to run."

In Monterey, Dr. Douglas Hulstedt is known as the doctor to see for families seeking medical exemptions. In a brief phone interview, he said he was worried about being targeted by the state medical board. "I have stuck my neck way out there just talking with you," he said. Hulstedt does not give exemptions to every child he examines, he said, but does believe vaccines can cause autism — a fringe viewpoint that has been debunked by multiple studies.

In March, the online publication Voice of San Diego highlighted doctors who write medical exemptions, including one physician who had written more than a third of the 486 student medical exemptions in the San Diego Unified School District. District officials had compiled a list of such exemptions and the doctors who provided them.

State Sen. Richard Pan (D-Sacramento), a pediatrician who sponsored California's vaccine law, has been a vocal critic of doctors he says are skirting the intent of the legislation by handing out "fake" exemptions. Last month, he introduced follow-up legislation that would require the state health department to sign off on medical exemptions. The department also would have the authority to revoke exemptions found to be inconsistent with CDC guidelines.

"We cannot allow a small number of unethical physicians to put our children back at risk," Pan said. "It's time to stop fake medical exemptions and the doctors who are selling them."

California Healthline digital reporter Harriet Blair Rowan and California politics correspondent Samantha Young contributed to this report.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Barbara Feder Ostrov: barbarao@kff.org, @barbfederostrov