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Why This Topic Is Important
According to the American Academy of Pediatrics, every child should receive high-quality health care that is accessible, family centered, culturally effective, coordinated, continuous, compassionate, and comprehensive (1). This care is best delivered through a medical home—a primary care model in which all of a child's health needs are met through partnerships between the family, clinical professionals, and community resources (1). This model is associated with better health outcomes and lower costs, as children who receive care in the context of a medical home are more likely to have regular preventive check-ups (which can lead to the early identification and treatment of problems) and are less likely to have unmet needs, emergency room visits, and in-patient hospital stays (1). However, estimates indicate that less than half of children receive care within a medical home, statewide and nationally (2).

Not surprisingly, children without health insurance are less likely to access needed care than those with coverage (3). The percentage of California and U.S. children without health insurance has risen in recent years, after declining over the previous decade (4, 5). If investments in public insurance programs are not maintained, and additional efforts made to enroll and retain eligible children, even more are at risk of losing coverage (3, 4, 5).
One convenient way for young people to access needed services is through school-based health centers (SBHCs). These centers, whether located on school property or near a school, reduce disparities in access to care by offering a range of services to underserved or uninsured students, such as primary medical care, mental or behavioral health care, dental care, substance abuse services, and health and nutrition education. More than 2,500 SBHCs operate nationwide (6). These centers have become a key part of the health care delivery system, as children spend a significant amount of time at school, and barriers such as transportation and scheduling are reduced. SBHCs can lead to improved health outcomes and school performance, while reducing emergency room visits and health care costs (6).

For more information, see kidsdata.org’s Research & Links section.

Sources for this narrative:

1.  National Resource Center for Patient/Family-Centered Medical Home. (2022). Why is medical home important? American Academy of Pediatrics. Retrieved from: https://www.aap.org/en/practice-management/medical-home/medical-home-overview/why-is-medical-home-important

2.  As cited on kidsdata.org, Receipt of care within a medical home. (2021). National Survey of Children's Health.

3.  Williams, E., & Garfield, R. (2021). How could the Build Back Better Act affect uninsured children? Kaiser Family Foundation. Retrieved from: https://www.kff.org/medicaid/issue-brief/how-could-the-build-back-better-act-affect-uninsured-children

4.  Lebrun-Harris, L. A., et al. (2022). Five-year trends in U.S. children's health and well-being. JAMA Pediatrics, 176(7), e220056. Retrieved from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789946

5.  The Children's Partnership. (2021). Why is children's enrollment in Medi-Cal lagging in California at a time when children are in most need? Retrieved from: https://www.childrenspartnership.org/research/medical-brief

6.  Love, H. E., et al. (2019). Twenty years of school-based health care growth and expansion. Health Affairs, 38(5), 755-764. Retrieved from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05472
Policy Implications
Children with health insurance are more likely to receive the medical care they need, are less likely to have costly emergency room visits and hospitalizations, and tend to have better health and educational outcomes than their uninsured peers (1, 2). Providing quality, accessible, and affordable health care to all children requires comprehensive, continuous insurance coverage and an appropriately trained and diverse provider base with a sufficient number of subspecialists; it also requires effective systems of care, including medical homes, in which parents, clinicians, and service providers are partners in a whole-family approach to improving child health (2, 3). Children of color and those living in poverty or in immigrant families—especially children with undocumented parents—are at particular risk of being uninsured and without regular health care (1, 2, 4).

The U.S. health policy landscape has changed significantly in the last two decades. The Affordable Care Act and expansion of the Child Health Insurance Program led to the lowest percentages of uninsured children in U.S. history (1, 2). California's investments and policymaking further bolstered coverage and access to care for many of the state's children and families (5). However, the share of children without health insurance has increased in recent years, statewide and nationally, threatening to undo progress (4, 6, 7). Additionally, the COVID-19 pandemic has exacerbated existing challenges in access to care, particularly among already vulnerable groups (1, 6, 8). Concerted efforts are needed to maintain gains of the previous decade and to continue strengthening children's health care systems (2, 6, 7, 8).

Policy and systems strategies that could improve children's health care include:
  • Supporting ongoing efforts to ensure continuous insurance coverage for all low-income children and families, including immigrant families; this includes maintaining investments in public insurance programs serving children and continuing to improve enrollment processes and community-based outreach to families (1, 2, 7)
  • Improving financial incentives for providers serving children in Medi-Cal (California's Medicaid program), particularly in underserved communities (2, 5)
  • Ensuring that all children, particularly those with chronic conditions, have access to family centered, culturally competent, and coordinated health care; that there is an adequate number of pediatric specialty care providers; and that pediatricians are trained on medical home implementation and management of care for children with complex needs (2, 3, 5)
  • Increasing the diversity of the health care workforce and expanding training for health professionals on culturally effective practice (2, 3)
  • Promoting health education for families and providers in service settings, such as child care, home-visiting programs, and foster care homes (2)
  • Ensuring the financial viability of safety net providers, such as county hospitals and community clinics, which are important sources of care for low-income people and undocumented immigrants (5)
  • Continuing to expand school-based health services, which have been shown to improve access to care for students of color and low-income children (9, 10)
  • Promoting collaboration across sectors—health, education, social services, and others—to improve prevention, screening, and early intervention services for children; also, supporting a comprehensive approach to health care that goes beyond treating illness to addressing social determinants of health, such as access to healthy food and safe housing (2)
For more information, see kidsdata.org’s Research & Links section or visit the California Health Care Foundation, the National Academy for State Health Policy, and the American Academy of Pediatrics.

Sources for this narrative:

1.  Guzman, L., et al. (2020). The rate of children without health insurance is rising, particularly among Latino children of immigrant parents and white children. National Research Center on Hispanic Children and Families. Retrieved from: https://www.hispanicresearchcenter.org/research-resources/the-rate-of-children-without-health-insurance-is-rising-particularly-among-latino-children-of-immigrant-parents-and-white-children

2.  National Academies of Sciences, Engineering, and Medicine. (2019). Vibrant and healthy kids: Aligning science, practice, and policy to advance health equity. National Academies Press. Retrieved from: https://nap.nationalacademies.org/catalog/25466/vibrant-and-healthy-kids-aligning-science-practice-and-policy-to

3.  National Resource Center for Patient/Family-Centered Medical Home. (2022). Why is medical home important? American Academy of Pediatrics. Retrieved from: https://www.aap.org/en/practice-management/medical-home/medical-home-overview/why-is-medical-home-important

4.  Williams, E., & Garfield, R. (2021). How could the Build Back Better Act affect uninsured children? Kaiser Family Foundation. Retrieved from: https://www.kff.org/medicaid/issue-brief/how-could-the-build-back-better-act-affect-uninsured-children

5.  McConville, S., & Cha, P. (2020). California's future: Health care. Public Policy Institute of California. Retrieved from: https://www.ppic.org/publication/californias-future-health-care

6.  Lebrun-Harris, L. A., et al. (2022). Five-year trends in U.S. children's health and well-being. JAMA Pediatrics, 176(7), e220056. Retrieved from: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2789946

7.  The Children's Partnership. (2021). Why is children's enrollment in Medi-Cal lagging in California at a time when children are in most need? Retrieved from: https://www.childrenspartnership.org/research/medical-brief

8.  Williams, E. (2021). Back to school amidst the new normal: Ongoing effects of the coronavirus pandemic on children's health and well-being. Kaiser Family Foundation. Retrieved from: https://www.kff.org/coronavirus-covid-19/issue-brief/back-to-school-amidst-the-new-normal-ongoing-effects-of-the-coronavirus-pandemic-on-childrens-health-and-well-being

9.  Love, H. E., et al. (2019). Twenty years of school-based health care growth and expansion. Health Affairs, 38(5), 755-764. Retrieved from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05472

10.  Wilkinson, A., et al. (2020). Early evidence of Medicaid's important role in school-based health services. Child Trends. Retrieved from: https://www.childtrends.org/publications/early-evidence-medicaid-role-school-based-heath-services
How Children Are Faring
An estimated 97% children ages 0-18 in California, and 95% of U.S. children, had some form of health insurance coverage in 2016-2020. Rates vary across counties with data, and were as low as 90% for this period. Gaps by race/ethnicity also persist: For example, around 1 in 15 American Indian/Alaska Native children statewide were uninsured in 2016-2020, compared with 1 in 25 Hispanic/Latino children, and fewer than 1 in 40 white children.

Two in every three California children ages 0-18 (67%) were enrolled in Medicaid or CHIP at some point during the 2019 federal fiscal year, a larger share than the percentage enrolled nationally (58%). On average, nearly half (49%) of the state's young people ages 0-20 were enrolled in Medi-Cal per month in calendar year 2020, with figures ranging from 28% (Placer) to 77% (Lake) across counties with data. Statewide, average monthly Medi-Cal enrollments among African American/black (61%) and Hispanic/Latino (59%) children and youth were more than double the enrollment rates for their Asian/Pacific Islander (28%) and white (22%) peers.

Parent reports from 2016-2019 show that 43% of the state's children ages 0-17 received health care within a medical home, compared with 48% nationwide. Across California regions, estimates of children receiving care within a medical home ranged from 35% (Merced County) to 54% (Marin County).
In 2017-2018, 9% of California children ages 0-17, and 12% of lower-income children, had no usual source of health care. Estimates by race/ethnicity ranged from 8% (white, multiracial) to 18% (Hispanic/Latino). Statewide and across demographic groups, children's usual source of health care was most commonly a doctor's office or HMO, rather than hospitals, clinics, urgent care, emergency rooms, or other settings. For children living below 200% of the federal poverty threshold, 45% usually used a doctor's office or HMO, compared with 76% of children in higher-income families. Among children who needed medical care in 2017-2018, 3% either did not receive the care they needed or received it after a delay. For around a third of these children (32%), needed care was delayed or foregone for cost or insurance reasons, and for a quarter (25%) because of system or provider issues.

California had 291 school health centers in 2021, up from 153 in 2009. However, many of the state's counties (23 of 58) did not have any school health centers in 2021. When asked whether their school provides adequate health services for students, 29% of responses from elementary school staff, 26% of responses by middle school staff, 22% of responses by high school staff, and 31% of responses by staff at non-traditional schools reported strong agreement in 2017-2019.