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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 competent, coordinated, continuous, compassionate, and comprehensive (1). This care is best offered through a medical home, an ongoing family-centered partnership with a child health professional or team in which all of the patient's needs are met (1). 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 emergency room visits (1). However, the latest 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). While the percentage of uninsured children has decreased in recent years, many remain without coverage, and many insured children are at risk of losing coverage if investments in public insurance programs are not maintained (3).
One convenient way for children and youth to access needed services is through school-based health centers (SBHCs). These centers, whether located on school property or in the vicinity of a school, offer 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 (4). These centers have become a key part of the health care delivery system, as children and youth spend a significant amount of time at school, and barriers such as transportation and scheduling are reduced. SBHCs can lead to improved access to medical and dental care, health outcomes, and school performance (5, 6). They also reduce emergency room visits and health care costs (5, 6).

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

Sources for this narrative:

1.  National Resource Center for Patient/Family-Centered Medical Home. (2020). Why is medical home important? American Academy of Pediatrics. Retrieved from: https://medicalhomeinfo.aap.org/overview/Pages/Evidence.aspx

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

3.  Schneider, L., et al. (2016). The Affordable Care Act and children's coverage in California: Our progress and our future. The Children's Partnership. Retrieved from: https://www.childrenspartnership.org/research/the-affordable-care-act-and-childrens-coverage-in-california-our-progress-and-our-future

4.  Love, H., et al. (2018). 2016-17 national school-based health care census. School-Based Health Alliance. Retrieved from: https://www.sbh4all.org/what-we-do/school-based-health-care/national-census-of-school-based-health-centers

5.  American Academy of Pediatrics Council on School Health. (2019). School-based health centers and pediatric practice. Pediatrics, 129(2), 387-393. Retrieved from: https://pediatrics.aappublications.org/content/129/2/387

6.  Community Preventive Services Task Force. (2016). Promoting health equity through education programs and policies: School-based health centers. Retrieved from: https://www.thecommunityguide.org/sites/default/files/assets/Health-Equity-School-Based-Health-Centers_1.pdf
Policy Implications
Children with health insurance are more likely to receive needed medical care, are less likely to have costly hospitalizations, and tend to perform better in school than their uninsured peers (1). Providing quality, accessible, and affordable health care to all children requires comprehensive insurance coverage and an appropriately trained and compensated provider base including a sufficient number of subspecialists; it also requires effective systems of care including medical homes and parental understanding about what care is needed and how to obtain it (2, 3, 4). Immigrant children, especially those with undocumented parents or those who are themselves undocumented, are at particular risk of being uninsured and without regular health care (2, 5).

The Affordable Care Act, which expanded health care coverage and enacted other major health system changes, has increased the percentage of insured children in the state and nation (2). California also has enacted numerous policy and program changes in recent years, bolstering coverage and access to health care for millions of children and families (2). While progress has been made, ongoing efforts are needed to maintain these gains and to continue strengthening children's health care, particularly for low-income and vulnerable populations (2).

Policy options that could improve children's health care include:
  • Supporting ongoing efforts to ensure continuous insurance coverage for all low-income children, including immigrant children; this includes maintaining and increasing investments in public insurance programs serving children, and continuing to improve enrollment processes and community-based outreach to families (2, 5)
  • Ensuring that every child has access to family centered, culturally competent, and coordinated care within a medical home, particularly children with chronic conditions (3, 6)
  • Increasing the number of health care providers serving children in Medi-Cal (California's Medicaid program) by improving financial incentives and ensuring that reimbursement for pediatric visits covers the time required to focus on children's development and family-centered care (2, 4, 6)
  • Ensuring that there is an adequate number of pediatric specialty care providers and that pediatricians are trained on management of care for children with special health care needs, medical home implementation, and culturally effective pediatric practice (3, 4)
  • Expanding access to health consultation and education for families and service providers in programs serving young children, such as child care settings, home-visiting programs, and foster care homes (6)
  • Monitoring the capacity and financial viability of safety net providers, such as county hospitals, which are important sources of care for low-income people (7)
  • Promoting collaboration across sectors—health, education, social services, and others—to improve prevention, early intervention, and treatment services for children, and supporting a comprehensive approach to health care that goes beyond treating illness to addressing community factors that impact health, such as access to healthy food or safe housing; in these ways, health inequities at the population level could be reduced and costs related to preventable conditions lowered (8, 9)
For more policy ideas and research on this topic, 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.  Murphey, D. (2017). Health insurance coverage improves child well-being. Child Trends. Retrieved from: https://www.childtrends.org/publications/health-insurance-coverage-improves-child-well

2.  Schneider, L., et al. (2016). The Affordable Care Act and children's coverage in California: Our progress and our future. The Children's Partnership. Retrieved from: https://www.childrenspartnership.org/research/the-affordable-care-act-and-childrens-coverage-in-california-our-progress-and-our-future

3.  National Resource Center for Patient/Family-Centered Medical Home. (2020). Why is medical home important? American Academy of Pediatrics. Retrieved from: https://medicalhomeinfo.aap.org/overview/Pages/Evidence.aspx

4.  American Academy of Pediatrics Committee on Pediatric Workforce. (2013). Pediatrician workforce policy statement. Pediatrics, 132(2), 390-397. Retrieved from: https://pediatrics.aappublications.org/content/132/2/390

5.  Linton, J. M., et al. (2019). Providing care for children in immigrant families. Pediatrics, 144(3), e20192077. Retrieved from: https://pediatrics.aappublications.org/content/144/3/e20192077

6.  Kossen, J., & Rosman, E. (2012). Leading the way to a strong beginning: Ensuring good physical health of our infants and toddlers. Zero to Three. Retrieved from: https://www.zerotothree.org/resources/996-leading-the-way-to-a-strong-beginning-ensuring-good-physical-health-of-our-infants-and-toddlers

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

8.  Halfon, N., et al. (2014). The changing nature of children's health development: New challenges require major policy solutions. Health Affairs, 33(12), 2116-2124. Retrieved from: https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2014.0944

9.  Arkin, E., et al. (Eds.). (2014). Time to act: Investing in the health of our children and communities. Robert Wood Johnson Foundation Commission to Build a Healthier America. Retrieved from: https://www.rwjf.org/en/library/research/2014/01/recommendations-from-the-rwjf-commission-to-build-a-healthier-am.html
How Children Are Faring
An estimated 97% of California children ages 0-18, and 95% of children nationwide, had some form of health insurance coverage in 2018—up from less than 90% in 2008. Despite these gains, gaps persist. For example, 8% of American Indian/Alaska Native children in California were uninsured in 2018, more than twice the estimate for children in other racial/ethnic groups.

Two in every three California children ages 0-18 (67%) were enrolled in Medicaid or CHIP at some point in 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 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.