RFK

For most American infants, the hepatitis B shot comes just before their first bath, in the blur of pokes, prods and pictures that attend a 21st century hospital delivery.

But as of this week, thousands of newborns across the U.S. will no longer receive the initial inoculation for hepatitis B — the first in a litany of childhood vaccinations and the top defense against one of the world’s deadliest cancers.

On Dec. 5, the Centers for Disease Control and Prevention’s powerful vaccine advisory panel voted to nix the decades-old birth-dose recommendation.

The change was pushed by Health and Human Services Secretary Robert F. Kennedy Jr. and his “Make America Healthy Again” movement, which has long sought to rewrite the CDC’s childhood vaccine schedule and unwind state immunization requirements for kindergarten.

California officials have vowed to keep the state’s current guidelines in place, but the federal changes could threaten vaccine coverage by some insurers and public benefits programs, along with broader reverberations.

“It’s a gateway,” said Jessica Malaty Rivera, an infectious disease epidemiologist in Los Angeles. “It’s not just hepatitis B — it’s chipping away at the entire schedule.”

Democratic-led states and blue-chip insurance companies have scrambled to shore up access. California joined Hawaii, Oregon and Washington in forming the West Coast Health Alliance to maintain uniform public policy on vaccines in the face of official “mis- and dis-information.”

“Universal hepatitis B vaccinations at birth save lives, and walking away from this science is reckless,” California Gov. Gavin Newsom said in a statement. “The Trump administration’s ideological politics continue to drive increasingly high costs — for parents, for newborns, and for our entire public-health system.”

The issue is also already tied up in court.

On Tuesday, the Supreme Court sent a lawsuit over New York’s vaccine rules back to the 2nd U.S. Circuit Court of Appeals for review, signaling skepticism about the stringent shots-for-school requirements pioneered in California. On Friday, public health officials in Florida appeared poised to ax their schools’ hepatitis B immunization requirement, along with shots for chickenpox, a dozen strains of bacterial pneumonia and the longtime leading cause of deadly meningitis.

Boosters of the hep B change said it replaces impersonal prescriptions with “shared clinical decision-making” about whether and how to vaccinate, while preserving the more stringent recommendation for children of infected mothers and those whose status is unknown.

Critics say families were always free to decline the vaccine, as about 20% did nationwide in 2020, according to data published by the CDC. It’s the only shot on the schedule that children on Medicaid receive at the same rate as those with private insurance.

Rather than improve informed consent, critics say the CDC committee’s decision and the splashy public fight leading up to it have depressed vaccination rates, even among children of infected mothers.

“Hepatitis B is the most vulnerable vaccine in the schedule,” said Dr. Chari Cohen, president of the Hepatitis B Foundation. “The message we’re hearing from pediatricians and gynecologists is parents are making it clear that they don’t want their baby to get the birth dose, they don’t want their baby to get the vaccine.”

Much of that vulnerability has to do with timing: The first dose is given within hours of birth, while symptoms of the disease might not show up for decades.

“The whole Day One thing really messes with people,” Rivera said. “They think, ‘This is my perfect fresh baby and I don’t want to put anything inside of them.’ ”

U.S. surgeon general nominee Casey Means called the universal birth dose recommendation “absolute insanity,” saying in a post on X last year that it should “make every American pause and question the healthcare system’s mandates.”

“The disease is transmitted through needles and sex exclusively,” she said. “There is no benefit to the baby or the wider population for a child to get this vaccine who is not at risk for sexual or IV transmission. There is only risk.”

In fact, at least half of transmission occurs from mother to child, typically at birth. A smaller percentage of babies get the disease by sharing food, nail clippers or other common household items with their fathers, grandparents or day-care teachers. Because infections are often asymptomatic, most don’t know they have the virus, and at least 15% of pregnant women in the U.S. aren’t tested for the disease, experts said.

Infants who contract hepatitis B are overwhelmingly likely to develop chronic hepatitis, leading to liver cancer or cirrhosis in midlife. The vaccine, by contrast, is far less likely than those for flu or chickenpox to cause even minor reactions, such as fever.

“We’ve given 50 billion doses of the hepatitis B vaccine and we’ve not seen signals that make us concerned,” said Dr. Su Wang, medical director of Viral Hepatitis Programs and the Center for Asian Health at the Cooperman Barnabas Medical Center in New Jersey, who lives with the disease.

Still, “sex and drugs” remains a popular talking point, not only with Kennedy allies in Washington and Atlanta, but among many prominent Los Angeles pediatricians.

“It sets up on Day One this mentality of, ‘I don’t necessarily agree with this, so what else do I not agree with?’” said Dr. Joel Warsh, a Studio City pediatrician and MAHA luminary, whose recent book “Between a Shot and a Hard Place” is aimed at vaccine-hesitant families.

Hepatitis B also disproportionately affects immigrant communities, further stigmatizing an illness that first entered the mainstream consciousness as an early proxy for HIV infection in the 1980s, before it was fully understood.

At the committee meeting last week, member Dr. Evelyn Griffin called illegal immigration the “elephant in the room” in the birth dose debate.

The move comes as post-pandemic wellness culture has supercharged vaccine hesitancy, expanding objections from a long-debunked link between the measles-mumps-rubella vaccine and autism to a more generalized, equally false belief that “healthy” children who eat whole foods and play outside are unlikely to get sick from vaccine-preventable diseases and, if they do, can be treated with “natural” remedies such as beef tallow and cod liver oil.

“It’s about your quality of life, it’s about what you put in your body, it’s about your wellness journey — we have debunked this before,” Rivera said. “This is eugenics.”

Across Southern California, pediatricians, preschool teachers and public health experts say they’ve seen a surge in families seeking to prune certain shots from the schedule and many delay others based on “individualized risk.” The trend has spawned a cottage industry of e-books, Zoom workshops by “vaccine friendly” doctors offering alternative schedules, bespoke inoculations and post-vaccine detox regimens.

CDC data show state exemptions for kindergarten vaccines have surged since the height of the COVID-19 pandemic, with about 5% of schoolchildren in Georgia, Florida and Ohio, more than 6% in Pennsylvania and nearly 7% in Michigan waved out of the requirement last year.

In Alaska and Arizona, those numbers topped 9%. In Idaho, 1 in 6 kindergartners are exempt.

California is one of four states — alongside New York, Connecticut and Maine — with no religious or personal-belief exemptions for school vaccines.

It is also among at least 20 states that have committed to keep the hepatitis B birth dose for babies on public insurance, which covers about half of American children. It is not clear whether the revised recommendation will affect government coverage of the vaccine in other states.

Experts warn that the success of the birth-dose reversal over near-universal objection from the medical establishment puts the entire pediatric vaccination schedule up for grabs, and threatens the school-based rules that enforce it.

Ongoing measles outbreaks in Texas and elsewhere that have killed three and sickened close to 2,000 show the risks of rolling back requirements, experts said.

Hepatitis is not nearly as contagious as measles, which can linger in the air for about two hours. But it’s still fairly easy to pick up, and devastating to those who contract it, experts said.

“These decisions happening today are going to have terrible residual effects later,” said Rivera, the L.A. epidemiologist. “I can’t imagine being a new mom having to navigate this.”

It’s a bad look when Robert F. Kennedy Jr. is ahead of you on scientifically sound health policy — women’s health, to make matters worse — but that’s exactly what happened to Gov. Gavin Newsom last week.

Ouch.

In a Cabinet meeting, Kennedy went on a six-minute-plus grovel to Trump. That’s pretty standard for these increasingly weird meetings, but the secretary of Health and Human Services specifically praised the president for ending a “20-year war on women by removing the black box warnings from hormone replacement therapy.”

As much as it shocks me to say it, RFK Jr. has a reasonable point.

A couple of days later, appearing onstage at the New York Times’ DealBook Summit, Oscar-winning actor Halle Berry took an unexpected and harsh shot at Newsom for vetoing a bill on menopause treatment.

“But that’s OK,” she said of Newsom killing the Menopause Care Equity Act (AB 432), which she had lobbied to pass and which had strong bipartisan support in the Legislature.

“Because he’s not going to be governor forever, and with the way he has overlooked women, half the population, by devaluing us in midlife, he probably should not be our next president either,” Berry said. “Just saying.”

The two events show just how complicated and controversial menopause care has become in the past few years, as women not only talk about it more openly, but demand care that for, well, basically always, has been denied or denigrated as unnecessary.

Looking a bit deeper, this seemingly out-of-the-blue menopause moment gets to the heart of an insurance problem that, male or female, most Americans have an opinion on: How much power should insurance companies have to deny care that a doctor deems reasonable?

To keep it simple, menopause is a phase that all women go through when their fertility ends, meaning 50% of the population deals with it. It has specific and life-altering symptoms — most of which can be treated, but often aren’t because many doctors aren’t trained in menopause care (or perimenopause, which comes first), and the science is too-often overlooked or misunderstood.

The result is that way too many women stumble through menopause not understanding what is happening to them, or that there are excellent, scientifically backed treatments to help.

A prime example of that is the “black box” warning that has been on many hormone replacement drugs since the turn of the millennium, when one large but flawed study found that such drugs might increase the risk of cancer or other diseases.

A black box warning is the most serious caution the Food and Drug Administration can put on a medication, and its inclusion on hormone replacement theory, or HRT, put a severe chill on its use.

Twenty years of subsequent research not only revealed the flaws in that first analysis, but also showed significant benefits from HRT. It can protect against cognitive decline, decrease heart disease and alleviate symptoms such as hot flashes, among many other benefits.

In early November, the FDA removed those warnings from many HRT drugs. The result will likely be greater access for more women as doctors lose a hesitancy to prescribe them, and women lose fear of using them.

“The misconceptions around the risks have been overblown for decades, fringing on dogma over real science and have led to population-level missed opportunities for life improvements for our aging women of the developed world,” wrote Michael Rodgers, chairman of the Santa Clara County Health Advisory Commission, on a public comment about the change.

While Rodgers is right, insurance coverage and doctor know-how remain problems for women seeking care — ones that the Menopause Care Equity Act hoped to address.

The bill would have required private insurance companies to cover FDA-approved menopause treatments and rewarded doctors who took voluntarily continuous education classes on menopause topics. That final version had already been watered down from earlier proposals that would have mandated coverage of even more treatment options (such as non-FDA approved compounded hormones) and made menopause training required for doctors.

But Newsom seemed to take issue with a part of the bill that banned insurance companies from applying “utilization management” to menopause treatments — and here’s where we get back to agreeing with RFK Jr.

Utilization management, or UM, is basically when insurance companies get to decide what a patient needs and what they don’t — the pre-approvals, the reviews and the denials, which all too often seem to be far more about cost than care.

Now artificial intelligence is getting in on the utilization management business, potentially meaning it’s not even a human deciding our treatments. UM is a multibillion-dollar industry that, under the premise of keeping healthcare affordable, too often does so by denying care.

Which is why Assemblymember Rebecca Bauer-Kahan (D-Orinda), the author of the California bill, put in a prohibition against UM.

“The standard is ‘medically necessary‘” when it comes to insurance coverage, Bauer-Kahan points out.

“When you talk about menopause, that’s a really fuzzy term, right? I mean, I will survive in the short term without any treatment,” she said. “So what is ‘medically necessary’ is this very vague thing when it comes to menopausal care.”

In his veto message, Newsom said the UM prohibition “would limit the ability of health plans to engage in practices that have been shown to ensure appropriate care while limiting unnecessary costs.”

But the truth, and problem, with menopause care is that it is specific to the individual woman. Like birth control pills, a treatment that works for one woman might cause side effects for another. There is often a lot of trial and error to find the right path through menopause, and women need to be able to have the freedom and flexibility to work one-on-one with their doctor. Without interference.

In June, Kennedy called out prior authorization across the healthcare industry as a problem, and announced shortly after that he had received a pledge from many large insurance companies to reform that process by 2026, removing the need for prior authorization from many treatments and procedures and streamlining the process overall.

If that reform comes to pass, it will indeed be terrific — I am hopeful — but also, let’s wait and see. Those changes are supposed to begin in January.

Back in California, Newsom has also pledged to do something about menopause coverage in January, when he announces his budget proposal. In his veto message, Newsom said he would go this route — adding it into his budget package — rather than work on a new bill in the regular legislative session. This remains the plan, though no details are yet available.

Apparently, someone forget to mention it to Berry.

The budget has increasingly become a catch-all for legislation the governor wants to get done with less fuss because the budget and its trailer bills always pass at some point, and it can be an easier route for him to control.

Newsom has made it a core part of his policies, and his presidential campaign, to be a backer of women’s rights, especially around reproductive care — and equity for women is a cause championed by his wife, First Partner Jennifer Siebel Newsom.

But the governor also has long been hesitant to pass legislation that has costs attached (the menopause bill could raise individual premiums by less than 50 cents a month for most private-pay consumers). With federal cuts, increasing premiums and the generalized hot mess of healthcare, his caution is not unwarranted.

But also, in this case, maybe it is misguided. The only real opposition to the California bill came from insurance companies. Go figure.

Bauer-Kahan said she has been in touch with the governor’s office, but remains committed to pursuing a law that limits utilization management.

“I am happy to hear that we are going to hopefully achieve this, but it needs to be achieved in a way that actually meaningfully makes a difference for getting the menopausal care women need,” she said.

Newsom’s October veto made barely a ripple. Thanks to Berry’s punch, his January proposal will be not just noticed, but scrutinized.

If he does eliminate the restrictions on UM, he’ll need to answer the broader question that action would raise — how much power should insurance companies have to override the decisions of doctors and patients?

It would be strange days if January saw Kennedy and his chaotic and questionable Department of Health and Human Services offering better healthcare options for women than the state of California.

And stranger still if Newsom puts a price tag on the well-being of women.