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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.

You are a policy aide employed by the State of Evergreen. Your supervisor—the governor’s special
advisor on health—has asked you to review the proposed legislation, consider all relevant perspectives
and facts, and draft a policy memorandum. Specifically, your memorandum must make a
recommendation regarding whether the governor should support the legislation, oppose the legislation
(and veto it if passed), or take some other action. Be sure your policy memorandum addresses both
pieces of legislation discussed above.

Policy Memorandum: Immunizations
Executive Summary
The State of Evergreen has put it mandatory for public school children to undergo immunizations in the past 60 years, with the exemption being medical safety reasons and firm religious beliefs. Regardless of the requirements in place, in the last year, an adult and two children died in a whooping cough outbreak. At the same time, all counties with the State of Evergreen have seen measles outbreaks, with Pine County experiencing an extremely bad flu season. The need to remove the firm religious beliefs on immunization has seen divided support among different stakeholders such as the business sector, elected officials, healthcare professionals, parents, school administrators, teachers, and religious groups.
The key issue, in this case, is whether the adoption of the religious exemption in the immunization process is justified in the protection of public health. According to Rundall (2016), most states now have some sort of religious exemption when it comes to the topic of immunization. However, there also exist some other difficulties in the adoption of this legislation for mandatory immunizations, and such include there is no central electronic health record system in the primary care offices, thus making it hard to know who needs vaccination. The public health department further lacks an effective insurance plan for the vaccination costs, and the school administrators are concerned about the burden this would add to the enforcement of new guidelines, especially with the current minimal funding. However, looking at the 1905 case of Jacobson vs. Massachusetts, the Supreme Court decided that a State has the authority to enact and enforce laws that protect public health, and this includes mandatory vaccinations.
The Governor ought to abolish the religious exemption to vaccination. The State of Evergreen has suffered public health crises due to upholding individual preferences; thus, the state needs to protect public health.
Factual Overview
Importance
In the prevention of diseases within the United States, immunizations have played a significant role. Preventing communicable diseases outbreaks is vital in the health and safety of the public; thus, taking the necessary precautions is critical (Ventola, 2016). It is for this reason that the State of Evergreen has been at the forefront to change the immunization legislation. The Evergreen legislation is aimed at removing the religious beliefs exemptions and implement mandatory vaccination to all public-school children. As more of the population receives an immunization to a given disease, they become immune to a particular disease, thus leading to its eradication. Outbreaks can lead to economic downturns, and this is evident in the Evergreen State, where businessmen have incurred losses due to these outbreaks. It is for this reason that supporting immunization legislation is crucial to ensure that preventable diseases are eradicated and ensure the safety of the general population (Rodrigues & Plotkin, 2020). However, it is important to note that the removal of the religious beliefs exemption can result in legal disputes and unrest, which can further hamper economic growth.
Stakeholders
The key stakeholders affected by the change of legislation include the school-going children, parents, school nurses, school administrators, healthcare providers, the business community of Evergreen State, and the religious leaders in the communities. The children and parents are the ones who are most affected since the implementation of mandatory immunization will go against the religious beliefs they possess (Randall, 2016). The religious leaders who are also the custodians of these beliefs will feel offended by the legislation which violates the religious beliefs. Nurses, on the other hand, will be afraid of facing backlash from the community on the aiding of the violation of the religious beliefs, while school administrators will be concerned with the increased burden. Lastly, the business community will support the legislation to avert another economic loss like the one they incurred in the past outbreak. It is thus crucial to have a thorough and joint agreement on all the stakeholders affected by the mandatory immunization legislation. Undertaking public education, community engagement, and providing adequate funding for school administrators can help the legislation to be accepted.
Role
Some stakeholders such as the religious entities, children, and parents positively contributed to the formulation of the legislation since they wanted to exercise the constitutional right to religious freedom. By using the religious freedoms to refuse the vaccinations, these stakeholders positively contributed to the past outbreaks that occurred. Therefore, the elected representatives thus viewed the religious exemption as the reason as to why the past outbreaks occurred as well as the business community sees this religious exemption as a threat to the whole population (Randall, 2016). Therefore, as the role of the elected individuals is to protect the whole population and maintain public safety, mandatory vaccinations are thus crucial regardless of religious beliefs.
Legal Risks and Malpractice Issues
The legal risks linked to the legislation are immense due to the outcomes on the different stakeholders. For instance, if the State of Evergreen experiences another outbreak that emanates from the unvaccinated individuals, the business community can sue the state for incurred losses and damages. They can hold the state accountable for failing to prevent another public health crisis. On the other hand, with the passing of the legislation, the parents will have the right to sue because their rights to practice their religious beliefs freely have been infringed. Clinical professionals also can be sued for not respecting patient autonomy as the patients have the right to refuse or accept any form of treatment. Therefore, the healthcare professional forcing to implement the legislation can further be sued for infringing this right. Although the Supreme Court ruled that States have the mandate to use police powers in protecting the health and safety of the public, States can still be sued for infringing religious freedom.
Value Conflicts
The different stakeholders possess their own personal conditions, and each is considered justifiable from the different stakeholders’ points of view. However, what is specified in this scenario is not what is best for an individual stakeholder, but it is the best approach for the collective good of the whole population. For that reason, there are some value conflicts that are more likely to occur between the legislators and the stakeholders who do not want their religious beliefs to be interfered with. Healthcare providers will further experience a value conflict since, as the personnel who are tasked with offering healthcare services, they have the moral obligation to administer care to patients (Tumpey et al., 2016). However, in the case of infringing the individual rights to administer the vaccine, the healthcare professionals may feel conflicted about doing the same. In a nutshell, the decision to get the school children to be immunized or not is not a personal choice as it may seem but one that is well integrated into public health. Therefore, parents, religious leaders, and any other stakeholder opposed to it may feel conflicted as they must conform to the public health requirements regardless of their beliefs.
Immunization Analysis
Needs and Interests
The legislation on immunization has had the stakeholders debating the issue from both ends. While some stakeholders support mandatory vaccinations, some parents and religious organizations are opposing the legislation, and both sides offer a valid argument. The main concern held by those in opposition to the legislation is the infringement of autonomy and their violation of the first amendment, but importantly they are concerned about their safety as the vaccine efficacy is unknown (Rodrigues & Plotkin, 2020). Nevertheless, despite holding these opposing views, referring to the Jacobson vs. Massachusetts 1905 case, individual liberty is not an absolute aspect and is subject to state police powers. This means that despite their opposition, they can be forced to take the vaccine to enhance public safety.
Current Laws, Policies, and Financing
With the vaccination policies in schools being state based, the state of Evergreen has the risk of financial consequences when the vaccination law is implemented. There will be increased insurance premiums that will lead to a possible decrease in the number of children enrolling in public school (Ventola, 2016). The increased risk of illness due to children adopting homeschooling techniques can further result in a negative financial impact on the state. Therefore, it is for the State of Evergreen to adopt a vaccination policy that appropriately meets the different stakeholders’ needs.
Conflicts
The potential value conflict that emanates from this immunization legislation is the possibility of infringing the people’s rights that are well documented in the First Amendment (McKee &Bohannon, 2016). While the State and some business owners are concerned with maintaining public safety some parents, children and religious leader hold their religious beliefs dearly.
Legal Risks and Malpractice Issues
The legal risks linked to the legislation include the legal actions for the state mandating the parents to vaccinate the children against their religious belief or wishes or if the vaccine makes the children become ill. However, according to the Prince vs. Massachusetts 1940 verdict, the government has broad authority on regulating and treatment of children; thus, it is evident that the State of Evergreen has some legal backing in implementing the legislation.
Analysis of Stakeholder Needs and Interests
The State of Evergreen has proposed legislation that seeks to remove vaccine exemptions for special groups that cite religious beliefs. This proposed legislation has amassed support from the business communities since they seek to protect their business from losses as it happened in the last outbreak. However, there is vast opposition from parents, religious leaders and some local government representatives who argue that the residents have the freedom to practice their religious beliefs devoid of government interference (Rodrigues & Plotkin, 2020). Similarly, the debate has created an unfavorable situation for school administrators and staff who are unsure of how to implement the suggested legislation due to limited resources and maintain compliance with the state policies. In the event that this legislation passes, it will affect the different stakeholders in different ways. However, the State of Evergreen will be hit hard with the legislation as it will face the challenge of fully implementing the immunization campaign due to the shortage of resources.
Application of Laws, Policies, and Financing Practices
The State of Evergreen can use the current healthcare laws and policies relevant to the issue at hand to satisfy the different stakeholders. The U.S. Constitution mandates the state to exercise its police powers as far as maintaining public health and safety is concerned. The U.S. Constitution further recognizes the freedom of religion; however, a constitutional requirement for nonmedical exemptions does not exist. Vaccines have further proven to have the possibility of reducing communicable diseases; thus, all stakeholders need to recognize the real-world implications of taking proper precautions (Rodrigues & Plotkin, 2020). Understanding the correlation that exists between vaccination and morbidity rates is further necessary as a means for Evergreen to adopt the immunization policy that protects the public. On the financial constraints that are rampant in public schools, the school administrators ought to seek alternative sources of funding. These alternatives include federal grants such as the Vaccines for Children Program (VFC), which can help to purchase the vaccine and meet other vaccine administration purposes.
Conflicts
The stakeholder value conflicts mostly emanate from individual bias and misinformation on the concept of vaccination. Most of the disagreement of mandatory vaccination stems from the parents and other stakeholders’ limited information on the health benefits of the vaccines (McKee & Bohannon, 2016). On the other hand, religious beliefs tend to be taken out of context, where despite most religions supporting the need for healthy living, some interpret the mandatory vaccination from an out of context, thus generating unnecessary fear. Therefore, there is a need to ensure that necessary education is conducted on the potential benefits of the vaccine to allay any underlying fears among the different stakeholders.
Legal Risks and Malpractice Issues
The State of Evergreen needs to proceed with utmost precaution while debating the issue to avoid any possibility of being sued. Residents can sue the state for the failure to protect their health and safety if the immunization is not carried out and an outbreak occurs (Ventola, 2016). To protect the general public and avoid any potential suit, the State of Evergreen needs to use the Supreme Court case of Jacobson vs. Massachusetts where infringing of the religious freedoms as a means to protect public health does not in any way violate the First Amendment. On the other hand, the current immunization and health record management procedures within Evergreen state are insufficient and not compliant with the electronic health record federal mandate. This exposes the public health department and the primary care physicians to malpractice litigation; hence this needs to be put into consideration.

References
McKee, C. &Bohannon, K. (2016). Exploring the reasons behind parental refusal of vaccines.
Journal of Pediatric Pharmacology and Therapeutics, 21(2), 104–109. doi:10.5863/1551-6776-21.2.104
Randall, K. (2016). Kansas, Please Protect Our Children: Why Kansas Should Remove the
Religious Exemption for Mandatory School Vaccinations. Kansas Law Review, 64(5),
1217–1254. https://doi.org/10.17161/1808.25546
Rodrigues, C., & Plotkin, S. A. (2020). Impact of vaccines; health, economic and social perspectives. Frontiers in Microbiology, 11, 1526.
Tumpey, A. J., Daigle, D., & Nowak, G. (2018). Communicating during an outbreak or public health investigation. CDC, Epidemic Intelligence Service. [(accessed on 30 January 2020)].
Ventola, C. L. (2016). Immunization in the United States: recommendations, barriers, and measures to improve compliance: part 1: childhood vaccinations. Pharmacy and Therapeutics, 41(7), 426

Using the attached paper and prompt on Immunizations answer the below questions you can use the sources already listed in the FINAL document if needed.

Recommendations
a. Recommend a course of action to the healthcare executive. The course of action you recommend must be supported by your analysis.
b. Propose how you plan to reconcile divergent stakeholder needs and interests.
c. Assess the extent to which legal risks and potential malpractice issues shaped your decision, if at all. Be sure to explain your reasoning.
d. Assess the extent to which your recommended course of action addresses financing practices that impact key stakeholders, if any. Be sure to
explain your reasoning.
e. Propose how you plan to resolve potential conflicts you identified. Be sure to identify the risk management strategies you would employ.
f. Propose a strategy for key stakeholders to influence the healthcare executive’s decision.
g. Discuss how the strategy for key stakeholders may improve population health outcomes. Be sure to explain your reasoning.
h. Summarize your analysis and recommendations in a brief concluding paragraph.