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key takeaway

Despite being eligible, many Californians lose vital Medi-Cal coverage due to complex paperwork and difficulty reaching county offices. Streamlining the renewal process and improving accessibility are crucial to ensure everyone keeps the health insurance they need.

Continuous access to health care is necessary for everyone to be healthy and thrive. Unfortunately, paperwork challenges often prevent people from obtaining and maintaining health coverage. A clear example of this: Too many individuals continue to be disenrolled from Medi-Cal, California’s Medicaid program, due to paperwork challenges.

Last year, California began processing Medi-Cal renewals for the first time since the start of the pandemic. As a result, over 1.4 million Californians have lost Medi-Cal coverage from June 2023 to February 2024. About 9 in 10 Californians (87.4%) who lost Medi-Cal coverage during this period did so because they did not complete the renewal paperwork or had incorrect or missing information in their forms.

Completing the renewal process often involves complex paperwork and documentation requirements, which can be difficult to navigate. Additionally, many Californians have experienced extended call wait times when attempting to contact county Medi-Cal workers regarding their application.

Certain groups, including older adults and people with disabilities, are at greater risk of losing Medi-Cal coverage during the unwinding period.1Jennifer Tolbert and Meghana Ammula, 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision (Kaiser Family Foundation, June 2023). Immigrants and their family members face unique obstacles in remaining covered, such as language barriers, privacy concerns, and fear of immigration-related consequences. Many Californians who are losing Medi-Cal coverage due to paperwork challenges may still meet the eligibility criteria.2Of the redeterminations that were received and processed in February 2024, about 9% were ineligible. See California Department of Health Care Services, Medi-Cal Continuous Coverage Unwinding Dashboard (February 2024), 14.

The high disenrollment rate due to paperwork challenges underscores the need to further streamline the renewal process and alleviate the paperwork burden on beneficiaries during the unwinding period and beyond. Addressing these challenges is essential to ensure that those who are eligible for Medi-Cal continue to receive vital health coverage.

While state leaders have implemented measures to reduce barriers to accessing and maintaining Medi-Cal coverage, they can take additional steps to prevent Californians who remain eligible for Medi-Cal from losing coverage. These include:

By taking additional action, state leaders can reduce barriers and ensure that all Californians, regardless of race, age, disability, or immigration status, can access and maintain the critical health coverage they need to be healthy and thrive.

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key takeaway

California’s CalWORKs program, while crucial for low-income families with children, penalizes them financially for not meeting work requirements. This is counterproductive as sanctioned families often face the most barriers to employment.

The California Work Opportunity and Responsibility to Kids (CalWORKs) program is a critical component of California’s safety net for families with low incomes. The program helps over 650,000 children and their families, who are predominantly people of color, with modest cash grants, employment assistance, and critical supportive services. However, the program has a problematic history of prioritizing work over family well-being, exemplified by financial penalties against families and counties that don’t meet narrowly defined performance indicators.

For many families, receiving cash assistance is conditional on engaging in employment or other specified “welfare-to-work” activities intended to lead to employment, such as on-the-job training or unpaid work experience. Additionally, families must navigate through various other paperwork-related stipulations, which further exacerbate the barriers to accessing the much-needed aid. Families who do not comply with all the requirements set forth by the state can be subject to a financial sanction that reduces their monthly cash grant.

California’s sanction policy is harsher than what is required by the federal government. The punitive approach to this safety net cash assistance is counterproductive. Research shows that sanctioned recipients are often those who face the most barriers to employment, such as limited education, learning disabilities, limited work history, physical and mental health problems, and a history of domestic violence.1Rachel Kirzner, TANF Sanctions: Their Impact on Earnings, Employment, and Health (Center for Hunger-Free Communities, Drexel University, March 23, 2015). These participants are often not aware of the financial penalties or cannot fully navigate the overly burdensome processes due to limited resources and information.

As states across the country are learning that harsh sanctions do not directly lead to gainful employment and family stability, many have reduced the amount by which cash grants are cut, recognizing that pushing families deeper into poverty only further jeopardizes their well-being. California, which is often at the vanguard of providing cash and safety net support, is unfortunately trailing significantly behind.

How do CalWORKs sanctions impact California families?

CalWORKs families cannot afford to be sanctioned. These artificial barriers put families at risk of falling deeper into poverty. Briana, a Parent Voices California advocate, experienced this reality firsthand. As a mother of four living in Contra Costa County, Briana has been on and off of CalWORKs since the age of 17. Even though her CalWORKs case manager did not help her to utilize the full scope of CalWORKs services (i.e., child care, school tuition assistance), Briana received her certified nursing assistant certification (CNA) and achieved her goal of working in the medical field, which she did for several years. A CNA certification course at Contra Costa College is approximately $322 in fees and CNA students pay over $100 in books, costs that could have been covered by CalWORKs benefits and not paid through Briana’s cash aid.

While experiencing postpartum depression following the births of her son and daughter, Briana went back on CalWORKs assistance to help make ends meet. During this time, Briana was sanctioned several times for reasons such as:

  • Not having an up-to-date immunization card;
  • Not having one of her children’s birth certificates on file; 
  • Not turning in a check stub (despite the stub already being in the CalWORKs system); 
  • As well as other reasons unknown to Briana.

These sanctions cost Briana hundreds of dollars, as highlighted in the preceding chart. With the $242 recouped from sanctions, every month, Briana could have paid for:

  • Six days of groceries for her family;
  • Three-quarters of her monthly utility bill;
  • 48 gallons of gas; or
  • Funds to support rent and car payments.

Briana’s sanctions coupled with remaining cash aid paying for her CNA certification exacerbated her financial insecurity. At the time that Briana shared her story at a March 2024 Assembly hearing, she was $300 short on her rent and car payment and had $0 left on her EBT card.

Briana’s story is just one example of how CalWORKs sanctions perpetuate the cycle of poverty and are rooted in a racist and sexist history popularized by figures like then California Governor Ronald Reagan that punished Black and other mothers of color, in particular. In the words of Briana: “Our future generations, our grandkids, somebody down the line is gonna need help. And I just want it to be easier for them. We need to defend these programs against cuts, get rid of these unnecessary sanctions, and reimagine CalWORKs into a program that opens those doors to help us get to where we want to go.”

How can policymakers ensure families in need have access to CalWORKs?

The governor’s commitment, outlined in his January budget proposal, to apply to a federal pilot aiming to center family well-being over work requirements offers California a great opportunity to reevaluate its sanction policy. Policymakers can make a significant difference in CalWORKs families’ lives, like Briana’s, by eliminating non-federally required sanctions and minimizing the amount sanctioned families lose each month. Additionally, policymakers should continue investing in CalWORKs and protect the program from harmful cuts. CalWORKs should center the well-being of families by removing barriers instead of amplifying them.

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key takeaway

While domestic and sexual violence disproportionately affects women, transgender, non-binary, and women of color, prevention programs that address root causes like gender and racial inequities can significantly improve safety for all Californians.

All Californians should be able to live in safe environments, free from violence and fear. However, millions of Californians experience domestic and sexual violence every year and women, transgender, non-binary, and women of color are most likely to experience these types of violence.

Domestic and sexual violence prevention programs are proven ways to stop violence from occurring in the first place. Prevention programs take a proactive approach and seek to shift culture on racial and gender inequities. Examples of prevention work include educating people on healthy relationships, increasing economic security for families, and reducing systems and beliefs that can lead to violence. These programs have been shown to:

  • Improve the safety of school and community spaces,
  • Lead to significant community and structural changes,
  • Lead to sexual violence prevention being added to school district budgets,
  • Make physical spaces safer in order to reduce vulnerability to sexual violence,
  • Increase student conversations about sexual violence as a problem,
  • Reduce dating abuse, and
  • Result in substantial cost savings due to reductions in sexual violence-related costs.

How does California support domestic and sexual violence prevention?

Since 2018, California has provided small, one-time grants for prevention programs. The California Governor’s Office of Emergency Services (Cal OES) administers multiple grants with this one-time funding to support prevention efforts. There are also some federal funds available for prevention, but the large majority of federal funding for addressing domestic and sexual violence is for intervention only, and in fact, is prohibited from being used for prevention efforts. Despite domestic and sexual violence prevention’s proven effectiveness, state funding is relatively new and has been sporadic.

What organizations have received state prevention funding?

Many organizations across the state have received state funding in the form of Cal OES prevention grants. These grants are focused on supporting community-based organizations in the implementation of domestic and sexual violence prevention and education initiatives, especially those that focus on serving communities that are disproportionately impacted. Examples of organizations that have been able to increase their prevention efforts because of the state funding are described below.

ACKNOWLEDGEMENT

Special thank you to Korean American Family Services, Project Sister Family Services, and Rainbow Services for providing the information included in these examples.

How has state prevention funding impacted what services organizations can provide?

Dedicated prevention funding has a meaningful impact on communities. Perspectives from these organizations demonstrate how funding has supported the services that can be provided.

What would happen without ongoing domestic violence prevention funding?

Each organization recognized that their important work, which supports survivors and helps prevent domestic violence, is at the peril of sporadic state funding. Organizations describe how without these grants, they would not have any prevention funding to continue sustaining these programs.

  • Both Project Sister and Rainbow Services explained how they are not able to do more ongoing prevention education due to a lack of ongoing funding, and that the sustainability of current programs relies on the state’s grants.
  • KFAM shared that the only prevention funding they have is from the Cal OES grants. Although there is much more funding provided for intervention efforts, prevention grants allowed them to be more creative with programs to prevent violence in the first place, rather than only supporting survivors afterward.

Domestic and sexual violence prevention efforts take time. These programs work on shifting culture, which takes long-term planning and commitment. However, as the organizations in the examples all noted, organizations doing this critical work cannot commit to long term programming without permanent, ongoing funding. The governor’s proposed 2024-25 budget does not include any additional funding for domestic violence prevention, which puts these programs providing critical domestic violence prevention services at risk for termination.

No Californian should live in fear over their safety. In order to adequately protect Californians from domestic and sexual violence, the state should provide ongoing, sustained funding for prevention programs that can help stop the violence before it starts.

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key takeaway

California has a significant unmet need for affordable child care, with only a fraction of eligible children receiving subsidized care. The state needs to make significant and sustainable investments in expanding subsidized child care options, particularly for infants and toddlers.

Affordable child care is critical for supporting California’s families to grow and thrive. Within California’s mixed delivery system, the California Department of Social Services (CDSS) provides child care programs at low- to no-cost for families with low incomes. For far too long, the demand for subsidized child care has outpaced supply. Specifically:

  • In 2015, 85% of children eligible for subsidized child care did not receive services.
  • In 2017, 89% of children eligible for subsidized child care did not receive services.

An analysis of 2022 data shows an unfortunate continuation of this trend, underscoring the need for a larger supply of subsidized child care spaces in California. 

Child Care and Development Transition

This analysis only includes child care programs within CDSS. The 2020-21 Budget Act transferred the child care and development programs from the California Department of Education (CDE) to CDSS. This transfer was intended to support a more integrated and coordinated system of care that could more effectively serve children, families, and the workforce. Thus, as of July 1, 2021, CDE only maintained oversight of two early learning programs: 1) The California State Preschool Program (CSPP); and 2) Transitional Kindergarten (TK) — both of which are now a part of CDE’s “Universal Pre-K” system. Previous Budget Center analyses of unmet need included CSPP. However, given the transition of programs from CDE to CDSS and related changes to eligibility requirements and other aspects of these programs, this analysis does not include CSPP. A forthcoming publication will explore eligibility and enrollment specific to CSPP. 

What is the unmet need for child care?

In 2022, only one in nine of California’s children eligible for child care actually received services. The number of children eligible for subsidized child care has grown from 1,479,000 in 2015 to 2,161,000 in 2022. While the number of new subsidized child care spaces has increased — notably, 146,000 new spaces were added since 2021-22 — the number of new slots has not kept pace with the growing demand. The chart below provides a visual of the unmet need for child care in California.

What are the implications of failing to meet California’s child care needs?

Families of color in California have historically been denied access to key services and opportunities. These inequities continue to negatively impact Californians of color as recent analyses have shown that poverty rates nearly doubled for Black and Latinx adults in California from 2021 to 2022. Moreover, Californians of color are more likely to struggle with paying for basic expenses.

The chart below shows that children of color are disproportionately eligible for subsidized child care. As the supply of subsidized child care continues to far outpace demand, families of color are most impacted by this insufficient supply. Therefore, the lack of subsidized child care continues to exacerbate the historical and unjust inequities that impact Californians of color.

CDSS’s child care and development programs serve ages zero to twelve. Within this age range, the cost of providing care is the highest for infants and toddlers; yet, providers that serve infants and toddlers typically make less money. Given this context, as well as the potential impacts of TK expansion on the mixed delivery system, there is concern around a diminishing supply of infant and toddler care options.

The chart below shows that across all age groups, only a fraction of those eligible for care are actually enrolled. However, children ages 0-2 are the only age group that is solely served by CDSS’s child care programs (other age groups have access to programs hosted by CDE). Thus, the unmet need for child care is particularly acute for infants and toddlers and failure to expand subsidized child care may disproportionately impact this age group. While school-age children have access to alternatives, it's important to note that the unmet needs stretch beyond infants and toddlers.

How can policymakers address the unmet need for child care?

While the supply of subsidized child care has increased since the dramatic cuts made during the Great Recession, California is still a long ways away from meeting families’ child care needs. Specifically, to help address the unmet need for child care, the 2021-22 enacted budget set a goal of adding 200,000 new child care slots. While 146,000 of these slots have been funded, slot expansion has been delayed for the last two fiscal years. The governor maintains his commitment to fund all 200,000 slots by 2026-27; however, the timeline for funding the remaining 54,000 slots by the deadline remains unclear.

The administration can increase the number of new slots in the 2024-25 budget to make immediate and needed progress on addressing the unmet need for child care. The unmet need for child care in California is an issue that requires state leaders' attention regardless of the cyclical ups and downs of the state budget. State leaders should make significant and sustainable investments in increasing access to affordable child care that meets families’ needs. Failure to do so keeps thousands of families — mainly families of color — on child care waiting lists, hampering their economic mobility and ability to find nurturing care for their children.

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