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Confronting a national measles outbreak, California lawmakers this week are mulling how to tighten the state’s already-strict vaccine policy for students while balancing parental rights.

State Sen. Richard Pan, a pediatrician representing Sacramento, on Tuesday announced changes to legislation he previously unveiled intending to stop unnecessary exemptions from mandatory immunizations. According to a statement from Pan’s office, the senator crafted the changes with Gov. Gavin Newsom, who previously expressed concern that the bill would give the state health department purview over medical exemptions from vaccinations.

“I’m a parent, I don’t want someone that the governor of California appointed to make a decision for my family,” Newsom said in early June.

Senate Bill 276 would require government oversight of exemptions for children who attend schools where the vaccination rate falls below 95 percent. Under the bill, a doctor in the state health department would also review all rejected applications for medical exemptions, a safeguard that was not included in the initial draft.

The earlier version of the bill would have required health department oversight in all cases, not just those in schools with low vaccination rates. The revised proposal also standardizes the exemption form and allows a wider range of reasons for students to skip their shots. For example, family medical history can now be considered, The Los Angeles Times reports.

The California Assembly Health Committee is expected to vote on the bill Thursday, and protesters, who object to any government involvement in granting medical exemptions, are expected to show up to oppose it, The L.A. Times reports.

Additionally, the revised bill includes a provision that will trigger a review if an individual doctor issues more than five exemptions in a year because “medical exemptions should be rare,” Pan’s office said in a statement. Certain allergies or autoimmune disorders could qualify a child for a medical exemption.

Research published last year in Pediatrics indicated some doctors in California were granting medical exemptions for children who did not need them, sometimes charging parents a fee in exchange for the exemption form. Pan’s amended bill would not allow doctors to charge patients for the forms, the L.A. Times reported.

Newsom has expressed support for the updated bill.

UPDATED: California lawmakers make big changes to vaccine bill, earning support from @GavinNewsom https://t.co/natgTDXuXu

— Melody Gutierrez (@MelodyGutierrez) June 18, 2019

Vaccinate California, the California Medical Association and the American Academy of Pediatrics, California are co-sponsoring the bill.

“I want to thank Gov. Newsom for his leadership on children’s health and standing up for science and the importance of vaccination by supporting SB 276,” Pan said in a statement. “I appreciate that the governor has worked with me in crafting a California solution to halting the abuse of medical exemptions that endanger our children. The governor recognizes that we need to ensure that children who truly need medical exemptions get them and they will be safe in their schools with community immunity.”

Spurred by the measles outbreak unfolding around the country, New York, Maine and Washington state have all taken steps this year to restrict vaccine exemptions based on religious beliefs, a type of exemption that California had already banned.

Since Jan. 1, 1,044 cases of measles have been reported in the United States. The disease was declared eliminated from the U.S. in 2000, but the Centers for Disease Control warned in May that if the outbreaks continue through the summer and fall, the United States could lose its status as a country that has eradicated measles.

California has reported 52 cases of measles so far in 2019; 10 were in Los Angeles county.

The most recent measles death in the U.S. occurred in 2015, but before the vaccine was common, the disease killed hundreds of children each year, according to the CDC.

New York lawmakers voted last week to end religious exemptions for all required vaccines. The state does not allow for personal or philosophical exemptions, so now all children must receive the mandatory vaccinations to attend school unless they have a medical reason they cannot receive them. The law went into effect immediately but gives students 30 days to catch up on immunizations after they enroll in school.

New York has seen the worst of the current measles outbreak, with New York City alone reporting 588 cases since September.

Democratic Assemblyman Nader Sayegh voted against the measure, saying he was concerned about taking away parental freedom and children potential missing class because of their immunization record.

“Having my educator hat on, having kids out of school really is upsetting for me,” said Sayegh, a former principal and school board member.

Gov. Andrew Cuomo signed the bill ending religious exemptions as soon as it reached his desk. The New York outbreak has largely been concentrated in ultra-Orthodox Jewish communities in Brooklyn and Rockland County, where misinformation has spread rapidly and some see vaccine refusal as a religious freedom issue.

“The science is crystal clear: Vaccines are safe, effective and the best way to keep our children safe,” Cuomo said in a statement. “This administration has taken aggressive action to contain the measles outbreak, but given its scale, additional steps are needed to end this public health crisis.”

All 50 states and Washington, D.C., have vaccine requirements for children to attend school, according to the National Conference of State Legislatures. The Supreme Court ruled in the 1905 case Jacobson v. Massachusetts that states have the authority to make vaccines mandatory. That ruling was reaffirmed in a 1922 case that allowed the San Antonio, Texas, school district to exclude unvaccinated children from school.

All states allow medical exemptions and most allow exemptions for philosophical or religious reasons as well.

In Maine, where the vaccine opt-out rate is above the national average, lawmakers voted to end all nonmedical exemptions earlier this month.

A Massachusetts lawmaker has also introduced a bill to end religious exemptions there.

Lawmakers in Washington state have also reacted to the measles outbreak. They were not able to get enough support to fully end nonmedical exemptions, but they did pass a law that ends the personal and philosophical exemptions from the measles, mumps, rubella (MMR) shot. Washington was an early epicenter of the measles outbreak, prompting Gov. Jay Inslee to declare a state of emergency in January.

“We would have preferred removing the personal exemption for all vaccines, but we weren’t able to — there was so much political pushback,” said Washington state Rep. Monica Stonier, a Democrat. “We just wanted to get something done.”

After a 2014 measles outbreak originated at Disneyland, California enacted some of the country’s strictest vaccine policies, requiring students to have a doctor’s form citing a medical reason if they are not vaccinated.

The proposed changes gained national attention last week when actress Jessica Biel appeared in Sacramento to lobby against them.

Biel said that she is in favor of vaccines generally but thinks the proposal goes too far.

“I support children getting vaccinations and I also support families having the right to make educated medical decisions for their children alongside their physicians,” she wrote on Instagram.

• Read more: Commentary: What state and local education leaders can do to stop the spread of measles