California has one sub-specialty pediatrician for every 5,464 children, making it difficult for children with special needs to see an endocrinologist, cardiologist or other medical specialist.

While there’s no ideal ratio—the American Academy of Pediatrics says multiple factors dictate the appropriate figure such as the number of insured and uninsured children, disease burden of the community and presence of academic medical centers—California’s ratio is strikingly low in comparison to other states.

In fact, California’s kids experience more problems obtaining sub-specialized pediatric care than children in any other state, a new UCLA Center for Health Policy Research study has found.

The reasons are multidimensional and so are the recommendations to close the access gap, says Daphna Gans, lead author and research scientist at the center.

“They vary from workforce supply to the different characteristics of the children, such as racial and economic status,” she explained.

The study “Assuring Children’s Access to Pediatric Sub-specialty Care in California,” funded by the Lucile Packard Foundation for Children’s Health,* found persistent disparities to pediatric sub-specialty care by type of insurance coverage, geographic location, language spoken at home and race and ethnicity.

For some of these children, the consequences of such barriers can result in delayed medical care, which ultimate translates to higher medical costs.

(Related: Special needs children struggle to obtain quality health care.)

Some key findings:

• Children with Medi-Cal coverage often receive longer waiting times to see a sub-specialist because of the unwillingness of providers to participate in such program due to low payments, excessive paperwork and payment delays.

• Uninsured children face the most acute access problems. Uninsured children with special care needs in the state are four times more likely to have unmet health care needs.

• The majority of pediatric sub-specialty care is provided at large academic centers typically found in metropolitan areas, leaving many children residing outside such geographic regions with access hurdles. Northern and Sierra counties, which include Shasta, Humboldt and Butte, have a higher sub-specialist-to-children ratio. The Greater Bay Area has the lowest.

• Lack of diversity in pediatric sub-specialty workforce, including those who can communicate with limited-English patients and their families, can also decrease access to sub-specialty pediatric care. The vast majority (64 percent) of children with special care needs are youngsters of color.

California is in the middle of demographic shifts. Hispanics already constitute the majority of school-aged children. Initiatives to diversify the health professional pipeline have been in the works for some time, and some are having some measures of success.

More women going into sub-specialty pediatrics, said Gans.

“Some of the recommendations that we talked were specifically to try to create more diversification of that particular pediatric sub-specialty group,” she said.

An ongoing debate among educators and some in the profession is how to improve workforce incentives, particularly those in the form of loan repayment programs.

Sub-specialty pediatricians must complete three years of general comprehensive pediatrics training after they complete medical school. Those wishing to obtain sub-specialty certification must add three years or more beyond general pediatric training to become certified in developmental-behavioral, cardiology, endocrinology, rheumatology or other specialized training.

Depending on their sub-specialty and type of program, they can spend anywhere from three-to-four additional years beyond general pediatric training, according to American Board of Pediatrics guidelines.

That can translate to delaying entering the workforce. Earlier this year, a group of major health care associations told Congress that any cuts to such loan repayment programs could have an adverse impact.

“Financial concerns, such as debt loan, are a significant factor and a deterrent influencing career choice away from pediatric sub-specialty,” said a letter sent to Congress earlier this year on behalf of some of the largest medical associations in the nation.

“The concern that we see particularly among people in pediatric sub-specialty has become very difficult to get the training, stay in school for so long, then come out making less money than other specialties,” Gans said. “That will continue to jeopardize children’s access to the critical health care services.”

*The Lucile Packard Foundation for Children’s Health is a financial sponsor of calhealthreport.org.