California Has an Opportunity to Improve how Medi-Cal Serves Young Children

The Department of Health Care Services recently requested stakeholder input on upcoming changes to Medi-Cal managed care plan contracts. Based on research done by the First 5 Center and input from a number of stakeholders, including the First 5 network, the First 5 Association submitted a response to the Department with recommendations designed to improve health outcomes for children and provide care with a whole-child, whole-family approach. The following provides an overview of the Association's response.

The First 5 Association of California appreciates the opportunity to provide input to the Department of Health Care Services on its procurement process for managed care plans to serve the Medi-Cal population. We see this as a critical opportunity to fulfill Governor Newsom’s vision of a California For All. The Medi-Cal program serves 64% of California’s children ages 0 to 5, three-quarters of whom are children of color. Because of the rapid health and development that occurs during the first five years of life, and the high rates of adversity and trauma faced by too many California families, the health care delivery system represents a tremendously powerful tool to promote positive trajectories for lifetime health among all of our children, and to begin to reverse some historical and current systemic forces that harm children of color.

However, over the last several years it has become increasingly clear that too many young children are not being adequately or appropriately served by Medi-Cal. Many children enrolled in Medi-Cal do not receive basic primary care or referrals to needed services. By most measures, California is missing critical opportunities to improve the life-long outcomes of its children. For example, the American Academy of Pediatrics recommends all children be screened three times before age three with a validated screening tool to identify developmental delays and social-emotional challenges requiring follow up, yet only 26% of children in California receive such screenings. Children living in households with low income and children of color are less likely to receive developmental screening than more affluent, white children. With almost 90 percent of young children enrolled in Medi-Cal in managed care plans, the Department must increase accountability and requirements to meet quality measures for performance on child outcomes to change these trends and ensure that our youngest at-risk children receive timely help and support to prevent longer term challenges.

California is home to over nine million children, of whom three in four are children of color, and half have at least one parent who is an immigrant. Overall, children of color endure higher rates of low birth weight, asthma, hospitalizations, homelessness, racism, and poverty -- all of which have devastating impacts on health. Women of color, particularly Black mothers, also face the significant adverse effects of structural racism. Even as California’s rate of maternal mortality has dropped overall, for example, three times as many Black women still die during, or in the period following, childbirth as women of all other races. The inequitable health outcomes that have plagued families of color and their communities are rooted in oppression from racist or xenophobic systems, laws and policies that are a part of our state’s history. We can only move forward to achieving a “California for All” if equity and a whole-family approach is woven through the systems that touch the lives of children. These principles lay the foundation for a collective health and well-being equity framework that centers young children from marginalized communities.

We recommend that the Department structure requirements and incentives for health plans in recognition that a child lives and develops within the context of her family and community. Children’s optimal development requires secure attachment with adults, stability, and loving interactions. These ingredients for children to reach their full potential are found within families that themselves are supported by the community and environment around them. Research also shows that investing in the first five years of life produces positive returns over a child’s lifetime in the form of decreased medical and mental health costs, greater educational achievement, higher likelihood of employment, and lower likelihood of incarceration. Health systems should proactively nurture healthy relationships and resilience of young children and their families, and identify and address developmental, social-emotional, behavioral and other related issues at the earliest stages, before they spiral into long-term, high-cost conditions into adolescence and adulthood.

The earliest years of a child’s life present an urgent opportunity to set up healthy development, given the rate of brain development that occurs during those years. It is also a window of opportunity for the parents, as they are open to advice, coaching and behavior change following the birth of a baby. For these reasons, the Department and health plans should view infants and toddlers as a special population, with targeted strategies to best serve them. The recommended schedule of 12 well-child visits before a child’s third birthday provides a platform to deliver positive, prevention-focused touchpoints, and these should be the focal point of a whole-child and whole-family approach to set children and families up for success.

Because social-emotional factors greatly contribute to children’s health, it is critical that children are routed to timely and appropriate interventions so social-emotional problems do not adversely impact their functioning, development and school readiness. Risk of poor outcomes, and not a specific diagnosis, should drive referrals to services, both inside and outside of the clinical setting.

For these reasons, the First 5 Association’s priorities for new managed care contracts include:

1) Financial incentives and accountability measures, including a performance bonus incentive, to increase well-child visit utilization, as well as recommended screenings and referrals.

2) Specific health equity plans to address inequities and disparities, which should include specific data reporting requirements related to race, ethnicity and age group; access to community health workers, doulas and promotoras to offer culturally-relevant care, including home visiting; and specific plans for reducing birth outcome disparities that disproportionately affect Black families.

3) Financial incentives for practices that provide holistic services as a standard of care to strengthen the relationship between child and caregiver within the pediatric primary care setting, including behavioral health services and closed-loop referrals to community-based and clinical supports.