Uninsurance of children, parents inched back up in 2017, report finds

https://www.healthcaredive.com/news/uninsurance-of-children-parents-inched-back-up-in-2017-report-finds/554590/

Dive Brief:

  • After improving for several years, insurance gains and participation in Medicaid and the Children’s Health Insurance Program tilted downward in 2017, a new Urban Institute report shows.
  • In the first three years following implementation of the Affordable Care Act, the uninsurance rate dropped from 7% to 4.3% among children and from 17.6% to 11% among parents, or about 40% for both groups. In 2017, however, the children’s uninsurance rate inched back up to 4.6%, or an additional 281,000 uninsured children, and parents’ coverage rate stalled.
  • Uninsurance rates rose both in states with and without the ACA’s Medicaid expansion, but the increase was more pronounced in states without expansion programs.

Dive Insight:

The findings jibe with recent data from the Centers for Disease Control’s National Health Interview Survey, which showed more than 1.1 million Americans lost health coverage in 2018, pushing the total number of uninsured from 29.3 million in 2017 to 30.4 million last year. Among surveyed adults between 18 and 64 years old, 13.3% were uninsured, 19.4% had public health coverage and 68.9% had private coverage.

The trend coincides with Trump administration efforts to weaken the ACA by eliminating several mechanisms meant to stabilize payers participating in ACA exchanges and pushing stripped-down, noncompliant health plans. The result has been rising premiums and a resurgence in the number of uninsured.

Adding to uncertainty about the ACA’s future is the U.S. Department of Justice’s support for a Texas federal district court that ruled the law unconstitutional without its individual mandate penalty, which a Republican-led Congress removed in 2017. A previous Urban Institute report estimated up to 20 million Americans would lose health insurance if the lawsuit prevails — a majority of whom are currently covered through Medicaid expansions and ACA exchanges.

While the ACA remains in legal jeopardy, Democrats and presidential candidates are looking at ways to increase the numbers of insured Americans, from shoring up the ACA to implementing some type of single-payer system or “Medicaid for All.”

According to the Urban Institute, participation in Medicaid/CHIP among children increased from 88.7% in 2013 to 93.7% in 2016, and from 67.6% to 79.9% for parents. Those gains reversed in 2017, however, with Medicaid/CHIP participation dropping to 93.1% among children and remaining unchanged for parents.

Among those who did not enroll in Medicaid/CHIP in 2017, 2 million children and 1.7 million parents were eligible for the programs — versus 1.9 million and a steady 1.7 million, respectively, in 2016.

More than half of the uninsured children and parents who were eligible for the Medicaid/CHIP lived in California, Florida, Georgia, Illinois, Indiana, New York, Pennsylvania and Texas, according to combined 2016-2017 data.

Parents were more than twice as likely to be uninsured as children in 2017. For example, children’s uninsurance rate was less than 5% in most states and under 10% in nearly every state, while parents’ uninsurance was less than 5% in just four states and over 10% in close to half the states, the report says.

The decline in improvement was worse among certain subgroups. “In 2017, the uninsurance rate was nearly 6% or higher among adolescents, Hispanic and American Indian/Alaska Native children, citizen children with noncitizen parents, and noncitizen children,” according to the report. “And consistent with prior years, one in six parents or more who were ages 19 5o 24, Hispanic or American Indian/Alaska Native, below 100 percent of FPL [federal poverty level], receiving SNAP [Supplemental Nutrition Assistance Program] benefits, or noncitizen were uninsured in 2017.”

 

 

 

 

 

 

Segment 3 – Healthcare Reform Successes & Failures

Segment 3 – Healthcare Reform Successes & Failures

Slide15

In Segment 2, we looked at the history of medical care in the U.S. until 1965, the year Congress enacted Medicare and Medicaid.

In Segment 3 we will look at reform movements, starting with Medicare and Medicaid. We will look at why later reforms failed and where that leaves us now.

By the early 1960s, nearly all employees were covered by Blue Cross/Blue Shield.

But problems emerged. First, low-wage workers were often not covered by their small businesses, and elderly retirees were not covered. Costs were going up because pre-paid insurance increased patient demand for services. Harry Truman had proposed national health insurance after he surprisingly was re-elected in 1948. But the AMA launched a multi-million-dollar publicity campaign to deride the plan as “Communism” and “socialized medicine.” Truman’s public insurance plan failed.

The next attempt at reform was successful – the 1965 passage of Medicare and Medicaid. Lyndon Johnson succeeded because coverage targeted the uninsured poor-and- elderly, leaving the rest of the private for-profit health system unaffected.

Senator Teddy Kennedy tried in 1971 to extend Johnson’s success to build a single-payer system, and won support from President Nixon. But this plan was derailed by the Watergate scandal.

The next attempt came from Bill and Hillary Clinton. After Clinton took office in 1992, Hillary and expert panels devised a plan for universal coverage including essential benefits and pre-existing conditions with mandated employer insurance and expanded Medicaid. This plan failed because the insurance industry launched a stinging publicity campaign featuring a down-home couple named “Harry and Louise.” Americans also balked at the tax increases needed to fund it.

The Clinton’s failure made it necessary to find another solution to rising costs. Managed care, which had first appeared in 1973, became that solution. And it did work, slowing growth to under 6%. But around the year 2000 came a backlash over mammograms and so-called “drive-by” deliveries, which undermined the ability of managed care to control costs.

What do we make of this history? Here are the main take-aways that help us understand our present health system. First, there has always been a tension between the profit motive in the free marketplace and a health promotion motive. Second, Americans have given special treatments to the health industry in return for medical advances. And third, powerful vested interests (doctors, hospitals, insurance, drug companies) have often used polemics and ideological arguments to defend their favored status, not necessarily actual health outcome data.

Slide09

So, this leaves the US with the largest, most expensive healthcare system in the world. In 2011 shown here it took in payments of 2.7 trillion dollars, mostly private insurance, Medicare, Medicaid and out-of-pocket. The figure for 2015 was 3.2 trillion dollars, representing 1/6 of the entire economy of the entire Gross Domestic Product. Government’s share of payments was almost 50% in 2016.

Slide10

This graph shows the dollars spent in 2011 – mostly on hospitals, doctors, drugs, long-term care. Remember that 25% of this pie graph actually goes to administrative costs, not medical services.

Slide11

In defense of U.S. healthcare, in 2012 then-House-Speaker John Boehner and then Senate Minority Leader Mitch McConnell famously said, “the U.S. has the finest health care system in the world,” and further that “wealthy foreigners flock to the U.S. because of its cutting edge facilities.”

2017-10-13-boehner-mcconnell.png

However, the World Health Organization rates the U.S. 15th in performance (life expectancy and delays in care), and only 37th in overall attainment (including financial and service fairness).

In 2015 the Kaiser Foundation compared the US with 10 other developed countries. Here are their results showing areas in which US is better, equal or lacking.

Here are the Commonwealth Fund’s 20-11 rankings – US is in the middle of the pack for most areas but dead last on several others and overall rank.

Slide14Source: http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

What about “foreigners flocking-for-care”? This pertains to highly specialized treatments available only in certain centers such as Mayo, Cleveland Clinic or Hopkins. Some centers in Florida and Texas do market to wealthy foreigners, who pay the full charge in cash, not discounted insurance rates like the rest or us. Boehner and McConnell pointed to Canadians coming to Michigan hospitals, but the Commonwealth study found that Canada is worst in timeliness and 10th worst overall, just ahead of the US in 11th place, so not surprising.

The further truth is that, according to Centers for Disease Control, 3/4 million Americans go abroad each year for medical treatments, such as for holistic care or dental care, but mostly seeking lower cost.

In the next Segment we will talk about cost, namely how the rising cost of healthcare is affecting our economy, our politics, our society – and some say our very existence.

I’ll see you then.

 

 

 

Washington is under a state of emergency as measles cases rise

https://www.cnn.com/2019/01/26/health/washington-state-measles-state-of-emergency/index.html?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202019-01-28%20Healthcare%20Dive%20%5Bissue:19128%5D&utm_term=Healthcare%20Dive

Image result for Washington is under a state of emergency as measles cases rise

As of Sunday, there are 35 confirmed cases of measles in the state of Washington — an outbreak that has already prompted Gov. Jay Inslee to declare a state of emergency.

“Measles is a highly contagious infectious disease that can be fatal in small children,” Inslee said in his proclamation on Friday, adding that these cases create “an extreme public health risk that may quickly spread to other counties.”
There were 34 cases of the measles in Clark County, which sits on the state’s southern border, just across the Columbia River from Portland, Oregon. Officials said 30 of the cases involved people who have not had a measles immunization; the other four are not verified. Of the 34 cases, 24 are children between age 1 and 10. There are also nine suspected cases in Clark County.
There is also one case in King County, which includes Seattle. While the King County website says the patient, a man in his 50s, is a “suspected case,” the governor said in a news release it is a confirmed case of measles.
In a health alert from King County, it was said the man had recently traveled to Clark County.
Inslee’s proclamation allows agencies and departments to use state resources and “do everything reasonably possible to assist affected areas.”
A news release on the governor’s website says the Washington State Department of Health, or DOH, has implemented an infectious disease incident management structure so it can manage the public health aspects of the outbreak through investigations and lab testing.
The Washington Military Department, the release says, is organizing resources to assist the DOH and local officials in easing the effects on people, property and infrastructure.
Last week, a person infected with measles attended a Portland Trail Blazers home game in Oregon amid the outbreak. Contagious people also went to Portland International Airport, as well as to hospitals, schools, stores, churches and restaurants across Washington’s Clark County and the two-state region, county officials said.

Most patients with symptoms should call first

Measles is a contagious virus that spreads through the air through coughing and sneezing. Symptoms such as high fever, rash all over the body, stuffy nose and red eyes typically disappear without treatment within two or three weeks. One or two of every 1,000 children who get measles will die from complications, according to the US Centers for Disease Control and Prevention.
In 1978, the CDC set a goal to eliminate measles from the United States by 1982. Measles was declared eliminated — defined by absence of continuous disease transmission for greater than 12 months — from the United States in 2000.
But there has been a recent rise in unvaccinated children. The proportion of children receiving no vaccine doses by 2 years old rose from 0.9% among those born in 2011 to 1.3% among those born in 2015, the CDC reported in October.
The CDC recommends people get the measles, mumps and rubella vaccine to protect against those viruses. The typical recommendations are that children should get two doses of MMR vaccine, the first between 12 to 15 months of age and the second between 4 and 6 years old.

10 Notable Health Care Events of 2018

https://www.commonwealthfund.org/blog/2018/10-notable-health-care-events-2018?omnicid=CFC%25%25jobid%25%25&mid=%25%25emailaddr%25%25

2018

Between the fiercely competitive midterm elections and ongoing upheaval over the Trump administration’s immigration policies, 2018 was no less politically tumultuous than 2017. The same was true for the world of health care. Republicans gave up on overt attempts to repeal and replace the Affordable Care Act (ACA) through legislation, but the administration’s executive actions on health policy accelerated. Several states took decisive action on Medicaid and some of the struggles over the ACA made their way to the courts. Drug prices remain astronomically high, but public outrage prompted some announcements to help control them. At the same time, corporate behemoths made deeper inroads into health care delivery, including some new overtures from Silicon Valley. Here’s a refresher on some of the most notable events of the year.

1. The ACA under renewed judicial assault

Texas v. Azar, a suit brought by Texas and 19 other Republican-led states, asked the courts to rule the entire ACA unconstitutional because Congress repealed the financial penalty associated with the individual mandate to obtain health insurance that was part of the original law. District Judge Reed O’Connor ruled in favor of the plaintiffs, creating confusion at the end of the ACA’s open enrollment period, and setting up what may be a years-long judicial contest (yet again) over the constitutionality of the ACA. To learn more about the legal issues at stake, see Timothy S. Jost’s recent To the Point post.

2. Turnout for open enrollment in health insurance marketplaces surged at the end of the sign-up period

The federal and state-based marketplaces launched their sixth enrollment season on November 1 for individuals seeking to buy health coverage in the ACA’s individual markets for 2019. Insurer participation remained strong and premiums fell on average. While some states have extended enrollment periods, HealthCare.gov, the federal marketplace, closed on December 15. After lagging in the early weeks, enrollment ended just 4 percent lower this year than in 2017.

3. The administration continues efforts to hobble ACA marketplaces

While the reasons behind lower enrollment cannot be decisively determined, executive action in 2018 may have contributed. The Trump administration dramatically cut back federal investments in marketplace advertising and consumer assistance for the second year in a row. The federal government spent $10 million on advertising for the 34 federally facilitated marketplaces this year (the same as last year but an 85 percent cut from 2016) and $10 million on the navigator program (down from $100 million in 2016), which provides direct assistance to hard-to-reach populations.

4. Insurers encouraged to sell health plans that don’t comply with the ACA

Another tactic the Trump administration is using to undercut the ACA is increasing the availability of health insurance products, such as short-term health plans, that don’t comply with ACA standards. Short-term plans, previously available for just three months, can now provide coverage for just under 12 months and be renewed for up to 36 months in many states. These plans may have gaps in coverage and lead to costs that consumers may not anticipate when they sign up. By siphoning off healthy purchasers, short-term plans and other noncompliant products segment the individual market and increase premiums for individuals who want to — or need to — purchase ACA-complaint insurance that won’t discriminate against people with preexisting conditions, for example.

5. Medicaid expansion in conservative states

Few states have expanded Medicaid since 2016, but in 2018, a new trend toward expansion through ballot initiatives emerged. Following Maine’s citizen-initiated referendum last year, Idaho, Nebraska, and Utah passed ballot initiatives in November to expand Medicaid. Other red states may follow in 2019. Medicaid expansion not only improves access to care for low-income Americans, but also makes fiscal sense for states, because the federal government subsidizes the costs of newly eligible Medicaid enrollees (94 percent of the state costs at present, dropping to 90 percent in 2020).

6. Red states impose work requirements for Medicaid

A number of states submitted federal waivers to make employment a requirement for Medicaid eligibility. Such waivers were approved in five states — Arkansas, Kentucky, Wisconsin, New Hampshire, and Indiana — and 10 other states are awaiting approval. At the end of 2018, lawsuits are pending in Arkansas and Kentucky challenging the lawfulness of work requirements for Medicaid eligibility. About 17,000 people have lost Medicaid in Arkansas as a result of work requirements.

7. Regulatory announcements respond to public outrage over drug prices

Public outrage over prescription drug prices — which are higher in the U.S. than in other industrialized countries — provided fodder for significant regulatory action in 2018 to help bring costs under control. Of note, the Food and Drug Administration announced a series of steps to encourage competition from generic manufacturers as well as greater price transparency. The U.S. Department of Health and Human Services in October announced a proposed rule to test a new payment model to substantially lower the cost of prescription drugs and biologics covered under Part B of the Medicare program.

8. Corporations and Silicon Valley make deeper inroads into health care

Far from Washington, D.C., corporations and technology companies made their own attempts to alter the way health care is delivered in the U.S. Amazon, Berkshire Hathaway, and J.P. Morgan Chase kicked 2018 off with an announcement that they would form an independent nonprofit health care company that would seek to revolutionize health care for their U.S. employees. Not to be outdone, Apple teamed up with over 100 health care systems and practices to disrupt the way patients access their electronic health records. And CVS Health and Aetna closed their $69 billion merger in November, after spending the better part of the year seeking approval from state insurance regulators. In a surprise move, a federal district judge then announced that he was reviewing the merger to explore the potential competitive harm in the deal.

9. Growth in health spending slows

The annual report on National Health Expenditures from the Centers for Medicare and Medicaid Services estimates that in 2017, health care spending in the U.S. grew 3.9 percent to $3.5 trillion, or $10,739 per person. After higher growth rates in 2016 (4.8%) and 2015 (5.8%) following expanded insurance coverage and increased spending on prescription drugs, health spending growth has returned to the same level as between 2008 to 2013, the average predating ACA coverage expansions.

10. Drug overdose rates hit a record high

Continuing a tragic trend, drug overdose deaths are still on the rise. The Centers for Disease Control and Prevention reported 70,237 fatalities in 2017. Overdose deaths are higher than deaths from H.I.V., car crashes, or gun violence, and seem to reflect a growing number of deaths from synthetic drugs, most notably fentanyl. 2018 was the first year after President Trump declared the opioid crisis a public health emergency. National policy solutions have so far failed to stem the epidemic, though particular states have made progress.

As we slip into 2019, expect health care issues to remain front and center on the policy agenda, with the administration continuing its regulatory assault on many key ACA provisions, Democrats harassing the executive branch with House oversight hearings, both parties demanding relief from escalating pharmaceutical prices, and the launch of health care as a 2020 presidential campaign issue.

 

 

The 2017 Flu Killed 80,000 in the US. Get a Flu Shot!

https://theincidentaleconomist.com/wordpress/healthcare-triage-the-2017-flu-killed-80000-in-the-us-get-a-flu-shot/

Image result for Healthcare Triage: The 2017 Flu Killed 80,000 in the US. Get a Flu Shot!

Influenza killed 80,000 people last year in the United States. That is the highest number of deaths since the CDC started keeping records in the 1970s. Help protect yourself and those around you. Get a flu shot!

Essentia to continue mandatory flu shot policy

https://www.beckershospitalreview.com/human-capital-and-risk/essentia-to-continue-mandatory-flu-shot-policy.html?origin=bhre&utm_source=bhre

Related image

Duluth, Minn.-based Essentia Health rolled out a mandatory flu shot policy last year, and the health system will continue the program this year.

Under the program, employees had until Nov. 20, 2017, to receive a flu shot, obtain a medical/religious exemption or face termination. Essentia reported more than 99.5 percent compliance with the program.

For 2018, Essentia will continue its mandatory flu shot program, which also applies to students who train and vendors who operate at the health system’s facilities, as well as people who volunteer through Essentia programs.

To ensure there is plenty of time to review medical/religious exemptions before this year’s Nov. 20 compliance deadline, Essentia moved up the deadline to submit exemption requests.

“The first year [is] the most difficult because everyone [is] doing first-time medical and religious exemption requests,” said Rajesh Prabhu, MD, infectious disease and chief patient quality and safety officer for the system. “Those granted medical exemptions last year still [have their medical exemptions] in place. For religious exemptions, they just have to confirm their belief hasn’t changed from last year.”

He expects compliance to increase this year since fewer people need to request medical exemptions for the first time. Essentia now has 14,700 employees and began its flu shot campaign Oct. 2.

Dr. Prabhu encouraged other systems or hospitals considering a mandatory flu shot program to focus on the reasoning behind beginning the program.

“It’s not just a technical change. You have to get everyone to feel why this is important for not only our employees but [also] the patients we serve. We focus a lot of efforts on that end,” he said.

Dr. Prabhu said support from leadership helped make the first year of Essentia’s mandatory flu shot program a success.

“We had support from our CEO and everyone in leadership,” he said. “[They had] direct, in-person communication with some of those hesitant to get vaccinated because sometimes it’s good to talk to people to understand their concerns and barriers.”

Lessons learned

Essentia announced its mandatory flu shot program in September 2017 and some employees felt they didn’t get enough notice to comply. However, Dr. Prabhu said he believes some employees would not have complied with the program even if they were given more time.

“No matter how much lead time you give, I don’t think it will change the minds of people who are resistant to get the influenza vaccine,” he said.

Essentia’s flu shot policy encountered opposition from unions as well. The Minnesota Nurses Association and some other labor groups that represent Essentia employees continue to challenge the flu shot policy. In July, an arbitrator sided with Essentia over the United Steelworkers Union regarding the policy.

Despite the opposition and a few challenges in the initial rollout, Dr. Prabhu said Essentia needed the policy. He said the system was not going to get to where it wanted to be with its previous voluntary policy, which had 82 percent compliance. And, after evaluating the first year, Essentia decided it was necessary to continue the policy into the 2018-19 flu season.

2018-19 flu season

For this flu season, the CDC recommends everyone 6 months and older receive a flu vaccine by the end of October. Nasal spray FluMist was not recommended last season, but it is recommended for 2018-19 as an option for flu vaccination of nonpregnant individuals age 2 to 49.

It’s unclear how severe the 2018-19 flu season will be. Last year’s flu season was particularly severe, with about 900,000 people hospitalized and about 80,000 people dead due to the virus.

Dr. Prabhu said the flu season hasn’t hit the Duluth area yet, but Essentia is trying to do everything possible to prevent the spread of the virus among patients and staff.

 

 

Percentage of young U.S. children who don’t receive any vaccines has quadrupled since 2001

https://www.washingtonpost.com/national/health-science/percentage-of-young-us-children-who-dont-receive-any-vaccines-has-quadrupled-since-2001/2018/10/11/4a9cca98-cd0d-11e8-920f-dd52e1ae4570_story.html?noredirect=on&utm_term=.bff48313afaa&wpisrc=al_health__alert-hse&wpmk=1

A small but increasing number of children in the United States are not getting some or all of their recommended vaccinations. The percentage of children under 2 years old who haven’t received any vaccinations has quadrupled in the last 17 years, according to federal health data released Thursday.

Overall, immunization rates remain high and haven’t changed much at the national level. But a pair of reports from the Centers for Disease Control and Prevention about immunizations for preschoolers and kindergartners highlights a growing concern among health officials and clinicians about children who aren’t getting the necessary protection against vaccine-preventable diseases, such as measles, whooping cough and other pediatric infectious diseases.

The vast majority of parents across the country vaccinate their children and follow recommended schedules for this basic preventive practice. But the recent upswing in vaccine skepticism and outright refusal to vaccinate has spawned communities of undervaccinated children who are more susceptible to disease and pose health risks to the broader public.

Of children born in 2015, 1.3 percent had not received any of the recommended vaccinations, according to a CDC analysis of a national 2017 immunization survey. That compared with 0.9 percent in 2011 and with 0.3 percent of 19- to 35-month-olds who had not received any immunizations when surveyed in 2001. Assuming the same proportion of children born in 2016 didn’t get any vaccinations, about 100,000 children who are now younger than 2 aren’t vaccinated against 14 potentially serious illnesses, said Amanda Cohn, a pediatrician and CDC’s senior adviser for vaccines. Even though that figure is a tiny fraction of the estimated 8 million children born in the last two years who are getting vaccinated, the trend has officials worried.

“This is something we’re definitely concerned about,” Cohn said. “We know there are parents who choose not to vaccinate their kids . . . there may be parents who want to and aren’t able to” get their children immunized.

Some diseases, like measles, have made a return in the United States because parents in some areas have failed or chosen not to vaccinate their children. Last year, Minnesota suffered a measles outbreak, the state’s worst in decades. It was sparked by anti-vaccine activists who targeted an immigrant community, spreading misinformation about the measles vaccine. Most of the 75 confirmed cases were young, unvaccinated Somali American children.

The data underlying the latest reports do not explain the reason for the increase in unvaccinated children. In some cases, parents hesitate or refuse to immunize, officials and experts said. Insurance coverage and an urban-rural disparity are likely other reasons for the troubling rise.

Among children aged 19 months to 35 months in rural areas, about 2 percent received no vaccinations in 2017. That is double the number of unvaccinated children living in urban areas.

The new data shows health insurance plays a significant role, as well. About 7 percent of uninsured children in this age group were not vaccinated in 2017, compared with 0.8 percent of privately insured children and 1 percent of those covered by Medicaid.

Those differences are concerning because uninsured and Medicaid-insured children are eligible for free immunizations under the federally funded Vaccines for Children program.

“Parents may not be aware of this, so this may be an education issue,” Cohn said.

Other issues, such as child care, transportation and a shortage of pediatricians in rural areas, are also likely to affect vaccination coverage.

A second report on vaccination coverage for children entering kindergarten in 2017 also showed a gradual increase in the percentage who were exempted from immunization requirements. (The exemptions do not distinguish between one vaccine versus all vaccines.)

Eighteen states allow parents to opt their children out of school immunization requirements for nonmedical reasons, with exemptions for religious or philosophical beliefs.

The overall percentage of children with an exemption was low, 2.2 percent. But the report noted “this was the third consecutive school year that a slight increase was observed.” The report does not provide a breakdown, but the majority of exemptions are nonmedical, according to data reported by the states.

Saad Omer, a professor of global health, epidemiology and pediatrics at Emory University, said that an analysis he and colleagues conducted a few years ago found the rate of increase in nonmedical exemptions had appeared to stabilize by the 2015-2016 school year after many years of increase.

But the latest CDC data appears to reflect a change, he said. “It seems that in recent years, exemptions are going up, and the trend is likely due to parents refusing to vaccinate,” he said.

In the 2017-2018 school year, 2.2 percent of U.S. kindergartners were exempted from one or more vaccines, up from 2 percent in the 2016-2017 school year, and from 1.9 percent in the 2015-2016 school year, according to the CDC report.

Reasons for the increase couldn’t be determined from the data reported to CDC, the agency said. But researchers said factors could include the ease of obtaining exemptions or parents’ hesitancy or refusal to vaccinate.

States such as West Virginia and Mississippi, which do not allow nonmedical vaccine exemptions, have higher percentages of children getting vaccinated, said Mobeen Rathore, a pediatric infectious disease physician in Jacksonville, Fla., and a spokesman for the American Academy of Pediatrics (AAP).

Earlier this year, researchers from several Texas academic centers identified “hotspots” where outbreak risk is rising in 12 of the 18 states that allow nonmedical exemptions because a growing number of kindergartners have not been vaccinated.