This is a Physician in the Loop special topic.

The wrong suspects

Measles cases this year are more than twice last year's. Texas is investigating the pediatricians who vaccinate children, and the children who depend on those doctors will pay.

America had confirmed 4,852 cases of measles this year by Oct. 29, according to the Centers for Disease Control and Prevention. That is more than twice the total for 2025 and more than three times that of 2019, which the agency said had the most cases in a single year since 1992. Pennsylvania alone has confirmed nearly 1,400. The CDC counts three deaths nationally, fewer than Pennsylvania reports on its own, and says the number may change. A regional health commission is due to decide this month whether the United States keeps the measles elimination status it has held since 2000.

Last December a pediatrician who has treated children in central Texas for 20 years received a letter from the attorney general's consumer protection division. It demanded ten years of her vaccine purchase records, The New York Times reported. It also wanted her vaccine policy, and said citing the CDC's schedule would not be sufficient. It asked her not to tell others, because the request "relates to an ongoing confidential investigation that would be jeopardized and impeded by disclosure." Answering it had cost her nearly $15,000 in legal fees by October, and sent her digging for receipts for $18 vaccines given a decade ago. The Times used only her middle name, Rachel, to protect her from retaliation. She has begun to reconsider whether to keep practicing. That letter will hurt children. Investigating the doctors who vaccinate, in the two worst measles years in more than three decades, pushes doctors and families away from the vaccine that stops the disease.

Ken Paxton, Texas's attorney general, has given his reasons. They deserve a hearing. In January his office announced an inquiry into whether pediatric practices, insurers, vaccine makers and others engaged in "deceptive or unlawful conduct by failing to disclose financial incentives connected to their administration of childhood vaccines." "Doctors' wages, bonuses, and even employment often hinge on the number of vaccinations they administer," it said, and children are being "expelled from pediatric practices and denied medical care based on their vaccination status." Texans, Mr. Paxton said, deserve "full faith in the recommendations of their medical providers." In August he opened a second inquiry, into the American Academy of Pediatrics, whose top corporate donors, his office said, are drug companies that would lose money if the CDC's revised schedule recommended fewer vaccines. Recommendations should be driven by science, he said, "not by financial gains or bribes from Big Pharma." Mr. Paxton lost the Nov. 3 election for the United States Senate to James Talarico, in a race the Associated Press called that night.

Parts of that are fair. Parents are entitled to know whether money shapes medical advice. Some insurers pay doctors for quality care, which can include vaccinating children. A child turned away from a practice is harmed too. Neither problem needs ten years of receipts, or a request for silence. But the office's own words reach further than disclosure. Its January release describes a scheme that has illegally incentivized doctors to recommend childhood vaccines "that are not proven to be safe or necessary." That is a claim about the vaccines, not the money. And the money is thin. Pediatricians call the incentives nominal. They buy vaccines up front, then haggle with insurers to be repaid. In a 2007 survey of a random sample of 1,280 pediatricians and family physicians, about half of those who answered said their practice had put off buying some vaccines for financial reasons in the previous three years. One in nine said it had seriously considered, in the previous year, whether to stop vaccinating privately insured children altogether.

Mr. Paxton's line about full faith is the right test. Vaccination runs on the faith he says Texans deserve, and that faith is thin. In a survey of more than 440,000 American adults, the share who trusted physicians and hospitals a lot fell from about seven in ten in April 2020 to four in ten by January 2024. Those who trusted more were far more likely to report a flu shot or a COVID vaccine. The survey was of adults, and it shows an association rather than a cause. Still, a state that hints to parents that their pediatrician takes bribes spends the little faith that is left. Neither the January release nor the August one mentions measles.

Texas knows the cost. Last year's West Texas outbreak ran to 762 cases and put 99 people in the hospital. Two school-aged children died. Neither had been vaccinated. Neither had a known underlying condition. Nationally, measles vaccine coverage among kindergartners has slipped from 95.2% to 92.4% in six school years, leaving about 280,000 of them at risk. A pediatrician who quits, or stops stocking vaccine, is one fewer door a family can walk through. A parent who wonders what the doctor is paid will be slower to say yes.

The office can keep its question and still stop most of the harm. It can say how many practices it has written to and what it has found, and lift its request for silence from small practices. Insurers can publish what their quality incentives pay for vaccinating each child. If the sums are as small as pediatricians say, that answers the charge against insurers. If not, parents should know. Health systems that employ pediatricians can say whether any doctor's pay or job depends on how many shots are given. That is the office's own charge.

The Times's story opens on a bustling Monday morning in Rachel's office. She was delighted when a woman she had cared for as a child came in with a newborn. The CDC counts measles every week. It has no column for the shots that were never given. In Pennsylvania, of 1,398 confirmed cases this year, four were in people who had been vaccinated.

This special topic was read by an AI voice. Its sources are linked at physicianintheloop.org.