Children with special health care needs (CSHCN) have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and require health and related services of a type or amount beyond that required by children generally. On kidsdata.org, indicators related to access to services for CSHCN include:

• Access to usual sources of preventive and sick care
• Access to a variety of services, including medical, mental, dental, and specialty care, as well as school-based services

Nearly 1.4 million California children, and more than 15 million children nationwide, have or are at increased risk for a chronic health condition—physical, developmental, mental, or behavioral—and require care and related services of a type or amount beyond that required by children generally (1). As advances in technology and medicine continue to improve and extend the lives of children with special health care needs (CSHCN), these numbers are expected to grow (2). Over the next decade, for instance, it is estimated that the number of children with medically complex conditions will double (3).

When compared with children who do not have special health care needs, CSHCN are more likely to be limited in their ability to function and participate in daily activities, and to experience social, academic, and other life challenges that can complicate their medical care (2, 4, 5). As a result, CSHCN often rely on a range of services from multiple sectors, and their parents and family members often face higher caregiving burdens and experience more stress and difficulties with employment and finances when compared with other families (6).

Obtaining timely, appropriate, and affordable care is a major problem for many CSHCN families (4, 5). Statewide and nationally, around 9 in 10 CSHCN do not receive care in a well-functioning system of services—one meeting federal standards for receipt of care within a medical home, preventive services, adequate health insurance, access to needed care, and family engagement (7). Major barriers to care, especially in California, include a fragmented system of services and an inadequate, shrinking workforce of pediatric subspecialists (2, 3, 4, 5). Beyond service system barriers, social factors and practices—such as poverty and discrimination (e.g., on the basis of race/ethnicity or ability)—influence access to care, and, as a result, health outcomes. For example, CSHCN of color and those in low-income families are more likely to have unmet health needs and limited access to high-quality care when compared with their more affluent and white peers (8).

In 2022, an estimated 82% of children with special health care needs (CSHCN) ages 0-17 in California had received a preventive health check-up in the previous year, while 91% of CSHCN ages 1-17 had seen a dentist or other oral health professional in the previous year—this compared with 68% and 83%, respectively, for California children without special health care needs. In addition, a larger share of California CSHCN ages 0-17 (80%) had a usual source of sick care—a doctor's office or health care setting other than a hospital emergency room—in 2022 than their non-CSHCN peers (69%).

Still, the estimated share of California CSHCN with unmet health care needs, among those needing care in the previous year, was nearly four times higher (8%) than the corresponding share of non-CSHCN in California with health care needs in the previous year (2%).

Across CSHCN subgroups, there is variation in access to services by income, race/ethnicity, and type of health insurance coverage. California and U.S. CSHCN covered by public health insurance only, for example, are less likely to receive preventive care or to have a usual source of sick care than their counterparts covered by private insurance only.

Statewide and nationally, more than 30% of CSHCN ages 0-17 who needed health care referrals in the previous year had difficulties getting or were not able to get the referrals they needed, according to 2022 estimates. Among CSHCN ages 3-17 with one or more provider-diagnosed behavioral or mental health conditions—attention deficit disorder (ADD) or attention-deficit/hyperactivity disorder (ADHD), anxiety problems, behavioral or conduct problems, or depression—more than 60% received treatment or counseling in the previous year.

Children with special health care needs (CSHCN), like all young people, need ready access to appropriate physical and mental health care, educational opportunities, and, sometimes, social services and other support (1). CSHCN, especially those with more complex conditions, frequently encounter obstacles to obtaining timely access to pediatric subspecialty providers and receiving comprehensive, coordinated, high-quality health care (1, 2). They also are more likely than children without special needs to experience psychosocial problems, difficulties with school, and other life challenges (1). Their families, too, often face significant caregiving burdens and economic, employment, and personal stress in excess of families without CSHCN (1, 3). While most CSHCN do not receive all aspects of quality health care, inequities in access to care and other resources are especially pronounced for children of color and low-income children (4).

Systems serving CSHCN can be strengthened through comprehensive, equity-focused programs and policies at the local, state, and national levels. Frameworks such as the national Blueprint for Change aim to improve service access and financing, reduce disparities, and enhance the lives of children and families (1, 4). Achieving equity in access to care and health outcomes for CSHCN requires addressing the root causes of disparities, such as poverty and discrimination, and overcoming cross-sector challenges involving resources and financing, system coordination, and workforce development and training (4).

Strategies to promote equitable access to care for CSHCN and their families should address:

• Equity-focused systems change: Leaders recommend a paradigm shift towards systems that are simplified, centered on equity, proactive instead of reactive, and based on needs rather than diagnoses, eligibility thresholds, insurance authorization, or other factors. Removing administrative barriers, aligning eligibility processes, and supporting families in navigating services can streamline access to care and prioritize the needs of CSHCN and their families (1, 2, 5).
• Comprehensive and consistent health care coverage: CSHCN need comprehensive insurance that provides adequate coverage for medical and mental health care, access to specialty care providers, care coordination and integration, and long-term supportive services (1, 2). These children also need consistent coverage, without gaps that can cause delays in needed care. Appropriate reimbursement, especially by Medicaid (Medi-Cal), is critical to ensuring that high-quality services are available from an adequate network of providers (2, 4, 6).
• Early and frequent screening: Regular screenings for special health care needs beginning early in a child's life have the potential to reduce long-term consequences of some chronic conditions, highlighting the urgency for equitable access to early identification and intervention services (7).
• Family-centered care: CSHCN tend to have better health outcomes when they receive family-centered care—from providers who engage with families, include them as partners in decision-making, and prioritize their needs, values, and goals (1, 8). Concerted efforts are needed to address family-centered care disparities for CSHCN, particularly by family socioeconomic status (1, 8).
• High quality, well coordinated, integrated services: CSHCN benefit from evidence-based health care services provided in the context of a medical home, which assures high quality, well-coordinated care, including integrated physical, oral, mental, and behavioral health care and collaboration across community, school, and home-based support services (2, 5). Delivery of this type of care is uneven, and often is connected to insurance reimbursement policies (4).
• Place-based care: Telehealth and other innovative methods of care—such as co-management (in which subspecialists and other providers actively coordinate)—can increase access to services for CSHCN families facing geographic or other barriers (2, 4, 5).
• Educational inclusion: Providing CSHCN with access to high-quality support services at school and ensuring their full inclusion with other children in general education settings is critical to their development and can maximize their social and academic outcomes (9).
• Adequate subspecialty workforce: CSHCN with complex conditions need access to pediatric subspecialty providers who are able to focus on specific health care needs. The shortage of pediatric subspecialists warrants revamped recruitment and retention efforts, along with increased collaboration between specialty and primary care providers (2, 6).
• Cultural responsiveness: A health care workforce that reflects the cultural and linguistic diversity of CSHCN could help reduce disparities and improve health outcomes (1, 2). All sectors serving CSHCN, including medical subspecialties, should have a diverse workforce trained on culturally responsive practices (4).
• Continuity across service sectors: CSHCN often must move across service sectors, such as from the pediatric to adult health care system as they age. Continuity and support across systems and sectors should be prioritized, along with minimizing new hurdles to accessing services (4).
• Robust investments in financing reform: A complicated web of service systems with dueling eligibility criteria and confusing payment policies can result in delayed or denied services for CSHCN and financial hardship for families (1). Current financing systems disincentivize equity, promote fragmentation, and impede reform (4, 5). Public investments are needed to transform financing models in ways that support integrated, comprehensive care, minimize hardship for families, and address structural discrimination (1, 4). This includes adequate state and federal funding for public systems serving CSHCN (2, 6).