The Health Law and Policy Issue: 
The State of Evergreen adopted comprehensive immunization legislation 60 years ago. The legislation addresses compulsory immunization requirements for children attending public school and for healthcare workers. The language mandating compulsory immunizations for children makes available two exemptions: one for firmly held religious beliefs and the other for medical safety reasons. The only exemption available for healthcare workers is the exemption for medical safety reasons. The legislation has remained largely intact and without modification since it was passed. 
Three major counties in the State of Evergreen—Cedar, Fir, and Pine—experienced large whooping cough outbreaks during the past year. Two children and one adult died in the outbreaks. It is unclear whether any of the three had been vaccinated against whooping cough. In the past 10 years, Pine County experienced a measles outbreak and several particularly bad flu seasons. Cedar County and Fir County experienced occasional measles outbreaks. 
In response to the outbreaks, the Evergreen Legislature is considering legislation to remove the exemption for firmly held religious beliefs. If the legislation passes, public schools will continue to be responsible for enforcing the immunization requirements. 
The Tourism Bureau in Evergreen looked at statistics for the last 10 years and concluded that tourism to the state was negatively impacted by the outbreaks. As a result, the business community largely supports the proposed legislation. Elected representatives from Cedar County and Fir County oppose the bill. Several large congregations in those counties oppose vaccinations on religious grounds. Representatives from Cedar and Fir Counties have sponsored a bill to add a third exemption to the existing immunization legislation. That provision would allow parents to exempt their children from vaccination if they have a “personal objection” to the vaccine or vaccines. 
School nurses in all three counties are concerned about public backlash if the religious exemption is removed from the law. School administrators are worried that they will not have the funds and staff power to enforce the more restrictive immunization requirements. Funding is lean as it is. The state association of school administrators has argued in the past that it is difficult to enforce the immunization requirements. It is hard to ban a child from school if he or she is not sick. 
The primary care association in Evergreen was asked to provide comment on the proposed legislation. While the association refused to comment on the legislation, the association offered the following statements for consideration: 
•	 It is expensive to purchase and maintain a supply of vaccines in a primary care office. 
•	 Many primary care offices (including pediatric practices) are choosing not to administer 
vaccinations. 
•	 The practices send their patients to public health departments for vaccinations. 
•	 Public health departments do not know when a patient has been referred for vaccinations. 
There is no regional health information exchange or shared electronic medical record system. 
•	 Public health departments in Evergreen cannot bill commercial insurance plans for 
administration of vaccines.