Dear Director Lightbourne and Chief Deputy Director Cooper: 

Our organizations are writing to urge the Department to hold Medi-Cal plans accountable for improving care for California’s kids. Medi-Cal is the cornerstone of health care for California’s children – half of the state’s children rely on Medi-Cal to meet their health care needs, three-quarters of whom are children of color. Medi-Cal managed care plans’ poor performance in delivering preventive and other care for children is well-documented. The deficiencies in the Medi-Cal managed care program contribute to health disparities for children across the state that can last a lifetime.  

In 2019, in response to a scathing state audit report showing how few Medi-Cal children received preventive care, the Newsom Administration announced major changes to the way Medi-Cal health plans would be held accountable for caring for children. This May, the Governor asserted that the new state contracts with Medi-Cal managed care plans would be “big and bold.” Even with the 2019 changes, the newly proposed draft contract is not bold or strong enough to ensure accountability for children’s health. The State should favor and award contracts to health plans with a proven track record of exceptional performance and commitment to children’s health and quality improvement.  

These draft contracts represent a once-in-a childhood opportunity for the Department of Health Care Services (DHCS) to prioritize kids. The Medi-Cal contracts should establish accountability and payment mechanisms across the range of children’s health care services that are: centered on equity; rooted in youth and parent/caregiver voice; and firmly held to high standards that drive improvement in child health outcomes. 

Unfortunately, the draft documents released for public comment fall far short of what is needed to make improvements for children’s health. The drafts fail to directly address the issue of low preventive care utilization for children, which has fallen even lower since the public health emergency. While we appreciate the greater focus on health equity and population health, these draft contract documents do not match the Administration’s rhetoric around children’s health care.  

The State should establish contracts that hold managed care plans accountable for kids receiving critical, cost-effective preventive services, getting better care coordination, and ultimately realizing better health outcomes. For a generation of children growing up with Medi-Cal, these contracts as drafted would lock in low health plan performance expectations, do little to incentivize improvements in the quality of care, and waste valuable state resources by paying plans even when children cannot get their most basic health care needs met. Instead, the State should lay out a robust vision and set a north star for improving quality of care for kids, reducing health disparities for children and youth, and responsible fiscal stewardship of valuable health care dollars.  

Specifically, we share the following feedback and remedies on the draft documents, as requested by DHCS. We suggest that the State should:  

• Establish requirements that all children have a pediatric medical home that provides and coordinates access to high-quality health care. Medi-Cal contracts with health plans are worth roughly $5 billion annually for children’s health care, and they will be worth even more as new requirements and incentives are implemented. Therefore, the contracts need to do a better job defining the expectations for coordinating children’s health care and how plans will be held accountable. For example, the contract language in Exhibit A, Attachment III should more clearly reflect the Administration’s stated intention to hold health plans accountable to benchmarks on the Children’s Preventive Services Report measures. The contract also needs to better define the requirement that health plans maintain a Medical Home for children (Section 4.3.2), explain how health plans will prove they are providing Basic Care Management (including all wellness and preventive services and screenings) to all children (Section 4.3.5), coordinating care for all services for children under 21 (Section 5.3.4), and meeting the requirement that a Dental Liaison help facilitate children’s dental care (Section 4.3.14).  

• Establish a Quality Improvement Program with financial accountability when health plan performance is among the worst in the country. These drafts envision that payment rates would be developed the same way they always have been, untethered to plan performance and kids’ health outcomes. But this procurement needs new strategies to improve the stubbornly low performance among Medi-Cal managed care plans. We strongly recommend that the State rewrite Section 1.5 of Exhibit B to make the rate development process a central driver of quality improvement and impose financial withholds for plans that perform in the bottom half of health plans nationwide for children’s preventive services. In Section 2.2.9.A. of Exhibit A, Attachment III, the draft contract should be updated to reflect the current policy that all plans are expected to perform at least at the upper half (or 50th percentile) of plans nationwide and that anything less will have consequences and sanctions. In addition, DHCS could reward health plans for improved performance by explicitly naming children’s services as an area for additional payments/incentives in Section 1.8 of Exhibit B.  

• Better address child health equity through greater community engagement. The state’s data has shown that Black, American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, and children living in households that speak a language other than English are even less likely to receive crucial preventive services to which they are entitled. Much more needs to be done to address disparities among  LGBTQ+ Medi-Cal members. Communities can and should help guide health equity goals and activities, so there should be greater opportunities to bring in Medi-Cal members and other community stakeholders. For example, “youth” themselves as Medi-Cal members should be represented in plan advisory committees and other areas with member representation (in Section 1.1.10). Community engagement should further be strengthened through more representation of child and youth populations in the membership of Community Advisory Committees (in Section 5.2.11.C), and the addition of consumer participation and transparency for the new Quality Improvement and Health Equity Committee (QIHEC) requirement (in Section 2.2) of Exhibit A, Attachment III.  

• Issue new drafts for public review that incorporate policy proposals that will have positive impacts on the health of pregnant individuals, babies, and children, such as reimbursement for community health workers, expanded access to dyadic care, and a new doula care benefit to promote birth equity. Along those lines, the State should require health plans to describe how they will better provide comprehensive, wraparound health care and coordinate services for these populations, including leveraging voluntary evidence-based home visiting programs to serve pregnant and parenting foster youth, pregnant and parenting families participating in both Medi-Cal and CalWORKS, and other families who could benefit. The contracts must also describe how care management will be coordinated and enhanced for children with classic California Children’s Services (CCS) coverage as well as those CCS-eligible children receiving services through a Whole Child Model (WCM) program that the state pays plans separate rates for according to Section 1.3 of Exhibit B.   

The Medi-Cal managed care program must be held accountable for truly ensuring that every enrolled child receives appropriate physical, behavioral, and oral health care at the right time in the right place. California’s increasing investment in Medi-Cal managed care must work for kids and families covered by Medi-Cal, not just health plans.  

We respectfully urge you to adopt our recommendations in the next iteration of these draft contracts and seize the opportunity to improve the managed care program for children.  

Sincerely, 
The Children’s Movement