What Will It Take to Transform California’s Early Identification and Intervention System?

California’s Medi-Cal and Early Start programs are required to ensure infants and toddlers with developmental delays and disabilities and their families receive the support they need, when they need it. The two programs sit in different state agencies, and families experience delays when these programs are not coordinated efficiently. For a child under 3, this can mean missed therapy or services during a developmental window when every month counts. What results is inequitable access to services that eligible children and families are legally entitled to, with a disproportionate impact on families with low-income. More than half of California’s young children have Medi-Cal health coverage, yet they represent just 8% of children in Early Start. The barriers are well known, as are many of the solutions, but closing this gap will require state leadership to prioritize young children and transform these programs into a system every family can count on.

Developmental milestones are often described in months, reflecting just how fast our youngest grow and learn during their first three years of life. By 9 months, most babies are able to sit up without support. By 15 months, most toddlers can take a few steps on their own. Progress in a particular skill, or the first sign of it, can seem to happen overnight, which is why some families and providers take a “wait and see” approach when a milestone has not appeared. But it also means that if a delay is identified, there is a valuable window in which getting support can have an outsized impact, and the goal of early intervention is to work within this window to promote healthy growth and development.

An estimated 1 in 6 children ages 3 through 17, or about 17%, have one or more developmental disabilities, indicating that the number of children who could benefit from early intervention is likely much higher than the current reach. Early Start, the state’s early intervention program overseen by the Department of Developmental Services (DDS), serves 7.8% of all California children under 3 over the course of a year, just above the national median of 7.5%. Children are eligible for Early Start if they have a developmental delay, a disability, or have established risk for delay or disability. There is no available data on how many children who are eligible or in need of early intervention are actually served, but research suggests many eligible children are not being reached and that access is not evenly distributed, including for children with Medi-Cal.

Medi-Cal, administered by the California Department of Health Care Services (DHCS), plays a significant role given it provides healthcare coverage to over half of California’s birth to age 5 population and is mandated to conduct routine developmental and autism screenings and provide all medically necessary treatment. Screenings completed during well-child visits often serve as a critical entry point for identifying potential delays and initiating referrals to early intervention, although families can also self-refer to Early Start or be referred by a community provider. The developmental screening rate for children under age 3 with Medi-Cal coverage has risen to almost 50%, but this still leaves half of the population without sufficient screening in their first three years of life.

Screening is often the first step in a complicated process that families must navigate to receive services. If the screening results in a referral to Early Start, the process to determine eligibility for early intervention services is coordinated by regional centers each serving its own region, which do not map cleanly onto county lines. Each of the 21 regional centers has its own process to determine eligibility, creating inconsistency and uncertainty about what families can expect and experience. Federal law specifies when certain steps must occur, but scheduling and logistical challenges can stretch the process beyond the mandated 45-day timeline. Because there is currently no online system for families to check the referral status and no mechanism for the referring pediatrician to close the loop and confirm that the child has received services, families have little visibility into where they stand. This also makes it difficult for others to support families in figuring this out.

Once a family moves through the intake process and their child is determined eligible for services, confusion over who pays for services becomes another hurdle. Regional centers are legally the payers of last resort. What this means is once eligibility is determined and a plan for early intervention services is made, families must first try to obtain services through other programs such as Medi-Cal or private insurance. Medi-Cal services are mostly delivered through managed care plans that are organized at the county level, introducing another layer of variation on top of the regional center system families are already navigating.

It is not always clear which system should pay for and provide a given service, and the process of determining what services are “medically necessary” for an individual child varies across different plans and providers. This gray area is confusing and can lead to families experiencing delays or wrongly denied care. In theory, the regional center should step in and cover services while a family waits for insurance approvals, but in practice, this back-and-forth can slow down a child’s access to care. Payment aside, the two systems also differ in how services are delivered. Early Start is required to provide services in natural environments (everyday, familiar settings like the home), while Medi-Cal services are often delivered in medical or clinical settings. Early Start assessments also sometimes recommend services at a frequency beyond what Medi-Cal managed care plans allow.

Families overwhelmingly value what Early Start offers their children. But a process that feels clear upfront can quickly become confusing as families interact with multiple programs and providers along the way. These challenges are not new, yet they have been met with a persistent lack of attention and urgency. The systemic solutions are multifaceted and require cross-department coordination, and, as with all prevention and early intervention work, the more acute needs of people already in the system tend to feel more pressing to administrators and policymakers. But when we defer the work of defining and clarifying responsibilities, delays that could have been addressed with a few months of early support instead follow children into preschool and kindergarten, where the same needs require more intensive and costly interventions.

Neither program can meet its obligation to these children and families alone. DDS acknowledges that "where someone lives, and which regional center serves that area, should not make a difference in someone’s eligibility." A family's managed care plan should also not affect the family's experience or the support their child receives. DHCS and DDS must take joint action to align Medi-Cal and Early Start where responsibilities intersect, beginning with the forthcoming project to standardize intake processes. Beyond systems alignment, the state will also need to address the shortages of service coordinators and direct service providers who help coordinate and deliver services, potentially leveraging existing local infrastructure and a growing community health worker workforce for navigation support. Doing so will ensure families encounter a process and system that meets them with clarity, consistency, and adequate support at every step, rather than one that leaves them to piece it together alone.