It looks like a contradiction: How could a children’s advocacy group give California an A-minus grade for providing kids with critically needed health insurance, but a D-plus for their health care access and accountability overall?
To the evaluators at Children Now, those grades don’t conflict; they reflect the current state of play. The fact that children have health insurance does not mean they’ve actually got access to the care they need.
“It’s not a new story, but it is exactly what is happening,” said Kelly Hardy, senior managing director of health and research for the organization, which pushes for legislative and state administrative solutions to challenges facing the 13.7 million Californians aged 0 to 26.
“We should applaud what a great job California has done in getting kids covered, because it used to be that 20% of California kids had no health insurance [compared with 3% now],” Hardy said. “But that’s only the first step. There are many more steps to go.”
The grades are contained in the advocacy group’s 2024 California Children’s Report Card, the latest installment in an evaluation of kids’ status in areas like health, education, family support and child welfare. Using established metrics and consulting with coalition partners and experts, Children Now has issued grades every two years for more than three decades. This is done, the group says, primarily so it can hand legislators and the California governor’s administration what the advocates see as a roadmap to helping young people grow and thrive in the state.
Children Now’s most recent edition shows the state is barely passing. Among 33 issues of importance to youth on which California was graded, the state received marks of C-minus or below in almost half. And it did better than a C in only one of nine issues under the general heading of health.
It’s not merely a thought exercise for Children Now. The organization works with legislators to draft bills that can change the path for many young Californians, and it focuses heavily on children from lower-income families and those of color. Some 47% of those aged 26 and younger in California are Latino, by far the largest such cohort.
In the last few years, the state has made remarkable progress in getting young people insured. Medi-Cal, the state’s version of Medicaid, grew to include 5.7 million California children prior to redeterminations, and Gov. Gavin Newsom’s expanded the program to take in more young people regardless of their immigration status. The state also made insurance through Covered California more affordable for thousands of families beginning this year.
But when Children Now researchers dug into the question of whether young people could actually get the care they need when they need it, they found the state wanting. In 2021, more than half the state’s managed care plans fell below minimum performance levels for immunization rates, well-infant visits and well-child visits, among other things. Considering that the state pays those plans to coordinate and provide Medi-Cal services, it’s a red flag.
“The accountability is ultimately on the state of California,” said Lishaun Francis, the advocacy group’s senior director of behavioral health. “You have a contractual obligation to young people to make sure they’re getting the care they were promised under their health insurance coverage, and they’re not getting that. It’s not happening at Medi-Cal, but it’s also not happening in commercial insurance.”
The state’s health companies are also lagging in providing mental health services, a reality that cuts across all age groups but is keenly felt among California’s youth. Between 2016 and 2020, the percentage of children aged 3 to 17 in California who were diagnosed with anxiety or depression skyrocketed by 70%, according to data analyzed by the Annie E. Casey Foundation. Only South Dakota experienced a more dramatic rise during that period.
Children Now gave the state a D-plus on supporting mental health. “When families are able to find children’s mental health services and support from schools, physicians, and community-based organizations, it’s due to perseverance, privilege and luck rather than a comprehensive system,” the report’s authors wrote.
Francis was part of an effort to turn that around in 2023, as Children Now sponsored a bill that would have triggered an automatic appeal to the state level anytime a person 26 or younger was denied mental health care services by their provider. The proposed law was furiously opposed by the health care industry, and the state’s Department of Managed Health Care concluded that implementing it would cost tens of millions of dollars. The bill was shelved by the Assembly Appropriations Committee.
In 2024, the bill’s author, state Sen. Scott Wiener (D-San Francisco), is introducing a similar measure. This time, Francis said, the bill designates that only the denial of emergency or life-threatening services be automatically appealed to the state, with all other denials going into an auto appeal to the provider itself. That would shift much of the financial burden to the health plans and away from the state.
Children Now organizers also hope to hold the line on education funding. California spends 3% of its economic output on K-12 education, a level that falls below the national average, and the organization says the state ranks 43rd of 50 for outcome gaps by race and ethnicity. But the state’s projected $68 billion budget deficit calls into question any ramped-up spending.
“Nothing that we talk about can’t be solved by someone,” Francis said. Based on the latest set of grades, the state has plenty to talk about — but the budget is a different question entirely.
