Overview of the State

California is the largest state by population size and the third largest state by land area, behind Texas and Alaska, in the nation.[1],[2] California is bordered by Oregon to the north, Mexico to the south, Nevada and Arizona to the east, and the Pacific Ocean to the west. It is divided into 58 counties ranging in size from under 50 square miles in San Francisco to over 20,000 square miles in San Bernardino.[3] These counties – along with three designated cities, Berkeley, Long Beach, and Pasadena – make up the 61 local health jurisdictions (LHJs) in the state. Given the vast size of California, the distance that some individuals, especially those living in rural counties, must travel to receive health care services can be a significant challenge.

Population

In 2021, an estimated 39.9 million people reside in California. The state’s population is projected to increase to 41.8 million by 2030. About 36% of all counties are expected to experience a population increase of 5% or more, and 12% of all counties are expected to experience an increase of 10% or more. By 2030, 11 counties will have a population size of over one million residents. Los Angeles will be home to 25% of the state’s population.[4]

Residents who identify as Hispanic account for 45.6% of the state’s population. This is followed by residents who identify as White (31.9%), Asian (12.3%), and Black (6.0%). Residents who identified as multi-racial account for just 3.2% of California’s population.[5]

Immigration

In 2019, the most recent year of data, California was home to more than 11 million immigrants. The largest numbers of immigrants come from Mexico, followed by China and the Philippines. In five counties (Santa Clara, San Mateo, Los Angeles, San Francisco, and Alameda), foreign-born residents account for over 30.0% of the population. An estimated 2.4 to 2.6 million undocumented immigrants reside in the state. From 2010 to 2019, the number of undocumented immigrants in the state declined from 2.9 million to 2.3 million.[6] The size of the undocumented population ranges from about 1,500 in Humboldt County, to 9,000 in San Luis Obispo County, and 248,000 in Orange County.[7]

Languages Spoken

The 2019 American Community survey estimates approximately 16.5 million residents aged five and over speak a language other than English at home.[8] This represents an 8% increase since 2010 and a 232% increase since 1980.[9] Based on a special tabulation by the U.S. Census, more than 200 languages are spoken at home in California. About twenty percent of residents who speak languages other than English at home do not speak English well or do not speak English at all,[10] underscoring the need for linguistically appropriate health services and outreach.

Economy

In 2019, the California economy remained the largest in the country, accounting for $3.1 trillion dollars or 14.6% of the nation’s gross domestic product. The state’s economic output in 2019 was the fifth largest in the world.[11] It has grown by an average of nearly 3% per year since 2010.[12]

There are still great disparities in wealth distribution between households in California.[13] The median net worth of college-educated Black residents is about $68,200 compared with a median net worth of $397,100 for college-educated White residents.[14] Before the COVID-19 pandemic began in early 2020, families with incomes at or above the 90th percentile earned 9.8 times more than those with incomes at or below the 10th percentile, and recent recessions have only widened economic inequality as recovery has been slower to reach the lower end of the income spectrum.[15]

Poverty

In 2019, the American Community Survey estimated that 4.5 million residents were living below the federal poverty level. This represents nearly 11.8% of the state’s population. Several population subgroups experience poverty at higher rates. A greater proportion of residents who identified as Black (19.0%) or Hispanic (15.0%) live in poverty than residents who identified as Asian (9.0%) or White (10.8%). At the same time, a greater proportion of children under the age of 18 years (15.6%) live in poverty than adults aged 18 to 34 years (12.8%) or adults aged 35 to 64 years (9.4%).[16] At the local level, the poverty rate in 12 counties is at least five percentage points greater than the state average.[17]

The California Poverty Measure is an index which expands conventional poverty measures by accounting for costs associated with living expenditures and family resources.[18] Based on this index, about 17.8% of residents are estimated to live in poverty, 4.9% of which live in deep poverty. Poverty remains higher among children, seniors, Latinos, and less-educated adults and 50% percent of all infants rely on the WIC nutrition program.

Food Insecurity

Food insecurity is defined as a household-level economic and social condition of limited or uncertain access to adequate food.[19] Food insecurity can have devastating effects on pregnant women and young children. Women experiencing food insecurity during pregnancy are more likely to experience birth complications than women who are food-secure. In children, inadequate nutrition can permanently alter brain development, affecting life-long learning, social interactions, and productivity.[20]

In 2017, an analysis using data from the U.S. Department of Agriculture revealed that 4.3 million Californians experienced food insecurity, 1.6 million of whom were children. Counties with the highest rates of child food insecurity include Fresno (25%) and Merced (24%).[21] While recent figures show that the prevalence of household food insecurity in 2020 has decreased by four percentage points since 2010,[22] it is anticipated that stagnation in the downward trend is due to the COVID-19 public health emergency and lingering economic crisis. In line with their status as the two most populous states, California would see the largest increase in the number of people experiencing food insecurity (+760,070) and Texas would see the largest total number of people experiencing food insecurity (4.8 million).21

Age Distribution

Between 2014 and 2019, the state’s proportion of children (ages 5-19) and young children (under age 5) has stayed relatively stable. In 2019, 7.5 million Californians (19.1%) were aged 5-19, and 2.4 million (6.1%) were children under the age of five.[23] In 2014, about 7.7 million Californians (19.9%) were between the ages of 5-19 and 2.5 million (6.5%) were under five years old.[24]

As of 2021, an estimated 7.8 million women of reproductive age (15 to 44 years) reside in the state. This number is projected to increase slightly to 7.9 million by 2030, marking a significant decline in previous predicted population growth estimates.[25]

Education

In the 2019-2020 school year, there are over 1,000 public school districts located throughout the state serving a total of 6.2 million students.[26] Approximately 45% of public-school students are in elementary school (Grades 1-6) and 35.1% are in high school (Grades 9-12). There are 23 campuses belonging to the California State University system and 10 campuses belonging to the University of California system.[27],[28] There are 116 campuses belonging to the California Community College system.[29] Collectively, these systems teach about 2.7 million college-age students each year.

In the 2019-2020 school year, California ranked 47th in the percentage of students served under the Individuals with Disabilities Education Act (12.0%) but continues to serve the largest number of children. This number has increased by 16% from about 645,000 in 2000-01, to about 788,000 in 2019-20. California served approximately 10.3% of all children (ages 0-21) in the nation covered by the Individuals with Disabilities Education Act.[30]

Ecology

California is very geographically diverse, with many different climates and native plants and animals unique to the state. This geographic diversity lends itself to a host of natural assets – including mountains, lakes, coastal areas, deserts, and ideal agricultural conditions, as well as to a range of natural disasters – including wildfires, floods, and earthquakes. California’s ecology and the increasing frequency of climate-related natural disasters are directly influenced by climate change.[31] Half of the most destructive wildfires in the state’s history have occurred since 2015.[32] Wildfires increase air pollution in surrounding areas and can affect regional air quality. The effects of smoke from wildfires can range from eye and respiratory tract irritation to more serious disorders, including reduced lung function, bronchitis, exacerbation of asthma and heart failure, and premature death.[33]

Housing

California has one of the most severe shortages in affordable housing across the county. By Q4 2021, the median price of a single-family home in California was 2.2 times greater than the median U.S. home price. Only 25% of all households in the state could afford to purchase a house, although this differs by county.[34] The California Department of Housing and Community Development projects that there will continue to be severe housing issues. From 2015 to 2025, about 1.8 million new housing units will be needed to meet the projected growth in the number of households. The demand for housing will be compounded by both the expected growth in the state population and the expected growth in the size of individual households.[35]

According to a congressional report by the U.S. Department of Housing and Urban Development, as of January 2021, California had an estimated 161,500 persons experiencing homelessness on any given day. This represents an increase of 6.8% from 2019. About 15% of all homeless people were families with children. California accounted for 56% of all unsheltered homeless unaccompanied youth across the United States.[36] LGBT youth are significantly overrepresented in homeless populations compared with the general U.S. population, being twice as likely to experience homelessness in their lifetime compared to non-LGBT peers.[37]

According to another report funded by the U.S. Department of Health and Human Services, about 30% of youth who leave home in California are “on the street” based on data collected from crisis-related calls and other communications to the National Runaway Safeline. This includes children who were forced to leave their home by a parent-guardian, children who were considered to have run away, and children who were homeless because their family are also homeless.[38],[39]

Health Insurance

In 2019, about three million residents – or 7.7% of the state population – did not have health insurance coverage.[40] This includes about 328,400 children aged 0 to 18 years and 788,300 adults with dependent children.[41],[42] The population groups with the highest rates of uninsured status include residents who identified as Hispanic (12.7%) and non-elderly adults (10.9%).[43] According to the California Department of Public Health (CDPH)/Maternal, Child and Adolescent Health (MCAH) Division’s Maternal and Infant Health Assessment survey, 10.8% of women who had recently given birth were uninsured in the month before pregnancy, and another 7.7% of pregnant women were uninsured in the months after pregnancy in 2016-2018.[44] As part of the American Rescue Act Plan (ARPA), effective April 1, 2022, an individual eligible for pregnancy and postpartum care services under Medi-Cal or the Medi-Cal Access Program (MCAP) is entitled to 365 days (12 months) of postpartum care coverage. Further, California has also expanded full-scope Medi-Cal eligibility to low-income adults 50 years of age or older, regardless of immigration status.

As of August 2021, there are about 14.2 million Medicaid-certified eligible persons in the state. This includes 5.5 million children between the ages of 0 and 20 years. Most of the eligible persons (83.4%) are served under California’s managed care program.[45] Survey data from the California Health Interview Survey reports that 35.9% of infants and children (ages 0-18) were on Medicaid in 2020.[46]

The Patient Protection and Affordable Care Act has reduced the number of uninsured residents in the state. Overall, the rate of uninsured non-elderly persons decreased from 15.2% in 2013 to 6.8% in 2019.[47] During the COVID-19 pandemic beginning in early 2020, a combination of pre-pandemic state and federal policies that expanded health insurance coverage, along with quick action by policymakers to bolster those policies with additional crisis stopgaps, helped protect coverage for many Californians during the pandemic and helped keep levels of uninsured individuals from increasing.[48]

Substance Use

In 2021, California had slightly higher rates of non-medical drug use among its population of adult women when compared to the national average (10.3% versus 10.1%).[49] In 2016-2018, 4.7% of women who had recently given birth reported cannabis use during pregnancy and 7.5% reported drinking alcohol during the third trimester of pregnancy.[50] The National Survey on Drug Use and Health data show that the rate of illicit drug use among California adolescents (12-17) was among the lowest in the nation in 2019-2020, with 2.6-4.1% of the adolescent population being dependent on or having abused illicit drugs or alcohol in the past year.[51]

In 2021, tobacco use among women in California ranked second lowest in the nation at 7.4%.51 The rate of tobacco smoking among pregnant women in California is low, with 2.5% of women who had recently given birth reporting tobacco smoking during the third trimester of pregnancy in 2016-2018.52 Additionally, in 2021, tobacco use among adolescents (age 12-17) was the second lowest nationally in California at 2.6%, second only to Hawaii.[52] 

Government Structure

California’s governmental structure is composed of three branches: the legislative, the executive, and the judicial. The executive branch is responsible for administering and enforcing the laws of California. The executive branch houses more than 100 offices, agencies, and departments. One of these agencies is the California Health and Human Services Agency. This agency contains 17 individual departments/offices, including the California Department of Public Health (CDPH). Public Health and Health Care Services are separate departments in the California Health and  Human Services Agency. CDPH is divided into Centers much like the CDC and the Maternal, Child and Adolescent Health Division is in the Center for Family Health along with two other Divisions: Genetic Disease Screening Program and the state Women, Infant and Children (WIC) program.
 

That state’s governmental structure is also divided into counties. For the purposes of administering CDPH/MCAH programs, the California Health and Safety Code goes further to divide the government structure by county health departments or smaller local health departments, collectively referred to as local health jurisdictions (LHJs).[53] In California, 58county health departments and 3 LHJs directly administer CDPH/MCAH programs within their regions.

Systems of Care

The California Department of Health Care Access and Information reports that an estimated 19 million residents live in locations designated as underserved areas due to health care provider shortages. As of September 2021, this includes 7.8 million Californians living in areas with too few primary care providers, 11.5 million living in areas with too few mental health providers, and 2 million living in areas with too few dental health providers.[54]

In 2021, there were approximately 8,200 licensed healthcare facilities in the state. These facilities include 524 general acute care hospitals, 2,122 clinics, and 1,368 long-term care facilities. The 10 largest acute-care hospitals are located in the following eight counties: Fresno, Los Angeles, Orange, San Diego, San Francisco, Santa Clara, Sonoma, and Tulare. Each of these facilities has a capacity of more than 600 beds.[55]

According to the Children’s Hospital Association, there are 21 children’s hospitals located throughout California.[56] These hospitals are located within 10 counties across the state. Although most counties do not have a designated children’s hospital to provide pediatric care, many counties have arrangements to refer pediatric clients to the nearest children’s hospitals in the region.

According to the March of Dimes, seven counties are designated as having no/low access to maternity care, with these counties having only one hospital each which serves their entire county’s population.[57] This is particularly consequential for pregnant women, given a recent finding that traveling more than 50 miles to prenatal care is associated with increased likelihood of high blood pressure during pregnancy. [58]

The connections between transportation and public health are numerous and varied, touching on physical activity, walkability and safe streets, injury, air quality, and differential access to services including health care. For example, the Los Angeles Mommy and Baby Study determined that poor geographic accessibility to care was associated with travel burdens for pregnant women.[59]

In California, access issues can be complicated given the geographic diversity and distribution of providers. These factors present a number of unique challenges to implementing local MCAH programs, particularly among those located in rural areas where program administrators might face issues related to staff recruitment, provider shortages, long distances to conduct home visits, and other region-specific challenges.

California has both benefited and is challenged by its size, its varied climate and geography, and the diversity of its people. It’s a vibrant and attractive place to live but experiences serious disparities in wealth, health and opportunity.  Diseases of despair exist amongst rich cultural communities creating juxtapositions of both hardship and hope.  CDPH/MCAH focuses on upstream approaches to foster individual and community capacity through resiliency, empowerment, autonomy, diversity, equity and inclusion for all.

[1] U.S. Bureau of the Census. ACS Demographic and Housing Estimates, 2013-2017 American Community Survey 5-Year Estimates. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_17_5YR_DP05&src=pt. Accessed January 4, 2019.

[2] U.S. Bureau of the Census. GCT-PH1. Population Housing Units, Area, and Density: 2010: United States – States: and Puerto Rico 2010 Census Summary File 1. https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?src=bkmk. Accessed January 4, 2019.

[3] California State Association of Counties. Square Mileage by County. http://www.counties.org/pod/square-mileage-county. Accessed January 4, 2019.

[4] California Department of Finance. P-1 County Population Projections 2010-2060, Total Population by County. http://www.dof.ca.gov/Forecasting/Demographics/Projections/. Published July 2021. Accessed February 15, 2022.

[5] California Department of Finance. P-1 County Population Projections 2010-2060, Total Population by Race/Ethnicity. http://www.dof.ca.gov/Forecasting/Demographics/Projections/. Published July 2021. Accessed February 15, 2022.

[6] Johnson, H., Alesi-Perez C., Cuellar-Mejia M.,. Immigrants in California. Public Policy Institute of California. https://www.ppic.org/wp-content/uploads/jtf-immigrants-in-california.pdf. Published March 2021. Accessed February 15, 2022.

[7] Hayes, J., & Hill, L. Undocumented Immigrants in California. Public Policy Institute of California Website. https://www.ppic.org/content/pubs/jtf/JTF_UndocumentedImmigrantsJTF.pdf. Published March 2017. Accessed January 4, 2019.

[8] U.S. Bureau of the Census. S1603. Characteristics of People by Language Spoken at Home. 2019 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=S1603&table=S1603&tid=ACSST1Y2018.S1603&lastDisplayedRow=19&hidePreview=true&g=0400000US06. Accessed February 15, 2022.

[9] Zeigler K, Camarota SA. 67.3 Million in the United States Spoke a Foreign Language at Home in 2018. Center for Immigrant Studies. https://cis.org/Report/673-Million-United-States-Spoke-Foreign-Language-Home-2018. Published October 29, 2019. Accessed February 15, 2022.

[10] U.S. Bureau of the Census. B16004. Age by Language Spoken at Home by Ability to Speak English for the Population 5 Years and Over, 2018 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=b16004&lastDisplayedRow=31&table=B16004&tid=ACSDT1Y2018.B16004&hidePreview=false&g=0400000US06&y=2018. Accessed November 13, 2019.

[11] California Department of Finance. Gross State Product, Comparison to other Major Countries. http://www.dof.ca.gov/Forecasting/Economics/Indicators/Gross_State_Product/. Accessed February 15, 2022.

[12] California Department of Finance. Gross State Product, Gross State Product in California. http://www.dof.ca.gov/Forecasting/Economics/Indicators/Gross_State_Product/. Accessed February 15, 2022.

[13] Bohn, S., & Danielson, C. Income inequality and the Safety Net in California. Public Policy Institute of California Website. https://www.ppic.org/content/pubs/report/R_516SBR.pdf. Published May 2016. Accessed January 4, 2019.

[14] California Budget and Policy Center. The Racial Wealth Gap: What California Can Do About a Long-Standing Obstacle to Shared Prosperity? California Budget and Policy Center. https://calbudgetcenter.org/wp-content/uploads/2018/12/Report_The-Racial-Wealth-Gap_12.2018.pdf. Published December 2018. Accessed February 15, 2022.

[15] Public Policy Institute of California. California’s Future. Public Policy Institute of California. https://www.ppic.org/wp-content/uploads/californias-future-january-2019.pdf. Published January 2021. Accessed February 15, 2022.

[16] U.S. Bureau of the Census. S1701. Poverty Status in the Past 12 Months. 2019 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=S1701A%3A%20POVERTY%20STATUS%20IN%20THE%20PAST%2012%20MONTHS&moe=false. Accessed February 15, 2022.

[17] U.S. Bureau of the Census. S1701. Poverty Status in the Past 12 Months. 2018 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=S1701A%3A%20POVERTY%20STATUS%20IN%20THE%20PAST%2012%20MONTHS&moe=false. Accessed February 15, 2022.

[18] Stanford Center on Poverty and Inequality. California Poverty Measure. https://inequality.stanford.edu/publications/research-reports/california-poverty-measure. Accessed February 15, 2022.

[19] U.S. Department of Agriculture, Economic Research Service. Definitions of Food Security. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx. Published September 2021. Accessed February 16, 2022.

[20] Gunderson, C., A. Dewey, M. Kato, A. Crumbaugh & M. Strayer. Map the Meal Gap 2019: A Report on County and Congressional District Food Insecurity in the United States in 2017. Feeding America, 2019. https://www.feedingamerica.org/sites/default/files/2019-05/2017-map-the-meal-gap-full.pdf

[21] Feeding America. Map the Meal Gap 2019: Overall and Child Food Insecurity by County in 2017. https://public.tableau.com/profile/feeding.america.research#!/vizhome/2017StateWorkbook-Public_15568266651950/CountyDetailDataPublic. Accessed February 16, 2022.

[22] Coleman-Jensen, A, Rabbitt MP, Gregory C, and Singh A. 2021. Household Food Security in the United States in 2020. U.S. Department of Agriculture, Economic Research Service. https://www.ers.usda.gov/webdocs/publications/102076/err-298.pdf?v=7842.1. Published September 2021. Accessed February 16, 2022.

[23] U.S. Bureau of the Census. CP05. Comparative Demographic Estimates. 2019 American Community Survey 1-Year Estimates.

[24] U.S. Bureau of the Census. CP05. Comparative Demographic Estimates. 2013 American Community Survey 1-Year Estimates.

[25] California Department of Finance. P-1 State Population Projections, 2010-2060, Total Population by Sex and Age Group. http://www.dof.ca.gov/Forecasting/Demographics/Projections/. Published July 2021. Accessed February 16, 2022.

[26] California Department of Education. Fingertip Facts on Education in California. https://www.cde.ca.gov/ds/sd/cb/ceffingertipfacts.asp. Accessed February 16, 2022.

[27] California State University. Fact Book 2019. https://www2.calstate.edu/csu-system/about-the-csu/facts-about-the-csu/Documents/facts2020.pdf. Accessed February 16, 2022.

[28] University of California. UC System. https://www.universityofcalifornia.edu/uc-system. Accessed February 16, 2022.

[29] California Community Colleges. Key Facts. https://www.cccco.edu/About-Us/Key-Facts. Accessed February 16, 2022.

[30] National Center for Education Statistics. Digest of Education Statistics, Table 204.70. Number and Percent of Children under Individuals with Disabilities Education Act (IDEA), Part B, by Age and State or Jurisdiction: Selected Years, 1990-91 through 2019-20. https://nces.ed.gov/programs/digest/d20/tables/dt20_204.70.asp?current=yes. Accessed February 16, 2022.

[31] Office of Environmental Health Hazard Assessment, California Environmental Protection Agency. Indicators of Climate Change in California. https://oehha.ca.gov/media/downloads/climate-change/report/2018caindicatorsreportmay2018.pdf. Published May 2018. Accessed January 8, 2020.

[32] Governor Newsom Strike Force. Wildfires and Climate Change: California’s Energy Future. https://www.gov.ca.gov/wp-content/uploads/2019/04/Wildfires-and-Climate-Change-California%E2%80%99s-Energy-Future.pdf. Published April 2019. Accessed January 2, 2020.

[33] Environmental Protection Agency. Wildland Fire Research: Health Affects Research. https://www.epa.gov/air-research/wildland-fire-research-health-effects-research#:~:text=Wildfires%20increase%20air%20pollution%20in,heart%20failure%2C%20and%20premature%20death. Accessed March 15, 2022.

[34] California Association of Realtors. Housing Affordability Index – Traditional, Q4-2021. https://www.car.org/marketdata/data/haitraditional. Accessed February 16, 2022.

[35] California Department of Housing and Community Development. California’s Housing Future: Challenges and Opportunities Final Statewide Housing Assessment 2025. http://www.hcd.ca.gov/policy-research/plans-reports/docs/SHA_Final_Combined.pdf. Published February 2018. Accessed February 16, 2022.

[36] U.S. Department of Housing and Urban Development, Office of Community Planning and Development. The 2020 Annual Homeless Assessment Report to Congress: Part 1: Point-in-Time Estimates of Homelessness. https://www.huduser.gov/portal/sites/default/files/pdf/2020-AHAR-Part-1.pdf. Published January 2021. Accessed February 16, 2022.

[37] UCLA School of Law Williams Insititute. Homelessness among LGBT Adults in the US. https://williamsinstitute.law.ucla.edu/publications/lgbt-homelessness-us/. Accessed March 15, 2022.

[38] National Runaway Safeline. Crisis Connection Content Data Report for Calendar Year 2017. https://www.1800runaway.org/runaway-statistics/crisis-hotline-online-services-statistics/. Accessed December 4, 2019.

[39] National Runaway Safeline. National Trends on Youth in Crisis in the United States: An Analysis of Trends in Crisis Connections to the National Runaway Safeline over the past decade (2007-2017). https://www.1800runaway.org/wp-content/uploads/2018/11/NRS-2018-Trend-Report_Final.pdf. Published 2018. Accessed December 4, 2019.

[40] U.S. Bureau of the Census. S2701. Selected Characteristics of Health Insurance Coverage in the Past 12 Months. 2019 American Community Survey 1-Year Estimates. https://data.census.gov/cedsci/table?q=uninsured. Accessed February 16, 2022.

[41] Henry J. Kaiser Family Foundation. Health Insurance Coverage of Children 0-18. https://www.kff.org/state-category/health-coverage-uninsured/?state=CA. Accessed February 16, 2022.

[42] Henry J. Kaiser Family Foundation. Health Insurance Coverage of Adults with Dependent Children. https://www.kff.org/state-category/health-coverage-uninsured/?state=CA. Accessed February 16, 2022.

[43] U.S. Bureau of the Census. S2702. Selected Characteristics of the Uninsured in the United States, 2019 American Community Survey 1-Year Estimates. California. https://data.census.gov/cedsci/table?q=S2702&table=S2702&tid=ACSST1Y2018.S2702&lastDisplayedRow=26&hidePreview=true&g=0400000US06&y=2018. Accessed February 16, 2022.

[44] MIHA Data Snapshots, California: Health Indicators from the 2016-2018 Maternal and Infant Health Assessment (MIHA) Survey. Sacramento: California Department of Public Health, Maternal, Child and Adolescent Health Division; 2022.. Assessed March 14,2022.

[45] California Department of Health Care Services. Medi-Cal Monthly Eligible Fast Facts: Characteristics of the Medi-Cal population as captured by the Medi-Cal Eligibility Data System. https://www.dhcs.ca.gov/dataandstats/statistics/Documents/FastFacts-August2021.pdf. Published November 2021. Accessed February 16, 2022.

[46] AskChis. Covered by Medi-Cal, by year. http://ask.chis.ucla.edu/AskCHIS/tools/_layouts/AskChisTool/home.aspx#/results. Accessed February 16, 2022.

[47] U.S. Bureau of the Census. S2702. Selected Characteristics of the Uninsured in the United States, 2019 American Community Survey 1-Year Estimates. California. https://data.census.gov/cedsci/table?tid=ACSST1Y2013.S2702. Accessed February 16, 2022.

[48] California Health Care Foundation. Coverage During a Crisis: Insured Rate for Californians Hits Historic High in First Year of COVID-19 Pandemic. https://www.chcf.org/publication/coverage-during-crisis-insured-rate-historic-high-first-year-covid-19-pandemic/#:~:text=Key%20Findings,subgroups%20from%202019%20to%202020. Accessed February 16, 2022.

[49] America's Health Rankings annual report: Non-medical Drug Use – Past Year. 2021. AmericasHealthRankings.org, Accessed March 11, 2021.

[50] MIHA Data Snapshots, California: Health Indicators from the 2016-2018 Maternal and Infant Health Assessment (MIHA) Survey. Sacramento: California Department of Public Health, Maternal, Child and Adolescent Health Division; 2022.

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[53] California Health and Safety Code. Division 106. Personal Health Care (Including Maternal, Child, and Adolescent) Part 2. Maternal, Child, and Adolescent Health [123225-124250]. http://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=HSC&division=106.&title=&part=2.&chapter=3.&article=6. Accessed January 2, 2019.

[54] Kaiser Family Foundation. Providers & Service Use Indicators, Health Professional Shortage Areas. State Category | Health Professional Shortage Areas | KFF. Accessed February 16, 2022.

[55] California Department of Health Care Access and Information. Facility Finder. https://oshpd.ca.gov/facility-finder. Published June 30, 2018. Accessed February 16, 2022.

[56] Children’s Hospital Association. Children’s Hospital Directory. https://www.childrenshospitals.org/Directories/Hospital-Directory. Accessed February 16, 2022.

[57] March of Dimes. Nowhere to Go: Maternal Care Deserts Across the U.S. https://www.marchofdimes.org/materials/2020-Maternity-Care-Report-eng.pdf. Published 2021. Accessed February 16, 2022.

[58] Shi, L, MacLeod KE, Zhang D, Wang F, Chao MS. Travel distance to prenatal care and high blood pressure during pregnancy. Hypertension in Pregnancy. 2017, 36(1):70-76.

[59] Lu Shi, Kara E. MacLeod, Donglan Zhang, Fan Wang & Margaret Shin Chao (2017) Travel distance to prenatal care and high blood pressure during pregnancy, Hypertension in Pregnancy, 36:1, 70-76, DOI: 10.1080/10641955.2016.1239733.