While it is too early to tell exactly how implementation of the Affordable Care Act (ACA) will impact the safety net, we have many reasons to be optimistic. Public health care systems helped California take full advantage of the Medicaid expansion by leading early coverage expansion efforts to enroll more than 650,000 uninsured adults in the Low Income Health Program (LIHP), and they continue to work diligently to ensure seamless continuity of care as enrollees transition from LIHP into Medi-Cal and Covered California.

The LIHP's powerful combination of coverage and connection to a medical home prepared us well for 2014, helping mitigate pent-up demand for the Medi-Cal program. Connected to a personal primary care provider and coordinated, team-based care, enrollees received the needed care that they might have otherwise avoided. Assessing the full impact of the LIHP will take some time, but the final evaluation of its predecessor program, the Health Care Coverage Initiative, found a significant drop in costly emergency department care. These results provide evidence of public health care system success in helping patients learn to manage their chronic conditions, keeping them healthy and out of the hospital.

This success has been compounded by local delivery system innovations and improvements that are helping to ensure patients receive great care in the most appropriate setting. For example, Contra Costa Health Services (CCHS) established a Telephone Consultation Clinic, allowing advice nurses to refer patients for same-day phone consultations with a provider. From January to June 2013, nearly 4,000 patients used the service, with 75% of calls resolved without an in-person visit. As Diane, a CCHS advice nurse, shared with us, "It is very comforting to know that through this program our doctors can do something for patients without them having to come in for an appointment if it's not needed. It's a fast and convenient way to deliver appropriate care while saving in-person appointments for patients who need them."

While we have indeed made great strides, we have done so in a world that now presents many unknowns. For instance, state and federal funding is slated to decline dramatically in the next few years, based on the premise that the ACA's coverage expansion will lead to a reduction in uncompensated care. However, only with experience under our belt will we begin to see whether the funding reductions actually correspond to reduced need. What we do know is that even after full ACA implementation, millions of Californians will likely remain without coverage, and serving those individuals will continue to be a core part of the mission of public health care systems.

Thank you for your commitment to public health care systems and their patients during these exciting and turbulent times.

Yours in partnership,

Erica Murray                                  David Lown, MD

President & CEO, CAPH                Executive Director, SNI