Policy Feedback and the Politics of Childhood Vaccine Mandates: Conflict and Change in California, 2012-2019.

Context: In 2012, California instituted a new requirement for parents to consult with a clinician before receiving a personal belief exemption (PBE) to its school entry vaccine mandate. In 2015, the state removed this exemption altogether. In 2019, legislators cracked down on medical exemptions to address their misuse by vaccine refusers and supportive clinicians. This article uses "policy feedback theory" to explore these political conflicts, arguing that PBEs informed the emergence and approaches of two coalitions whose conflict reshaped California's vaccination policies.

Methods: The authors analyzed legal, policy, academic, and media documents; interviewed 10 key informants; and deductively analyzed transcripts using NVivo 20 transcription software.

Findings: California's long-standing vaccination policy inadvertently disseminated two fundamentally incompatible social norms: vaccination is a choice, and vaccination is not a choice. Over time, the culture and number of vaccine refusers grew, at least in part because the state's policy sanctioned the norm of vaccine refusal.

Conclusions: The long-term consequences of California's "mandate + PBE" policy-visible, public, and socially sanctioned vaccine refusal-undermined support for it over time, generating well-defined losses for a large group of people (the vaccinating public) and specifically for the provaccine parent activists whose experiences of personal grievance drove their mobilization for change.