By Christian Sandrock, M.D., M.P.H.

With the advent of the federal Affordable Care Act, extended health insurance coverage is expected to reach more than 32 million Americans in 2014. While many states are resisting the law in federal courts based on constitutional grounds, California is front and center in its acceptance. Implementation is under way statewide, with more than 3 million newly covered individuals expected by 2014.

In these early phases of implementation, California was granted a five-year, $8 billion Medi-Cal demonstration waiver to expand coverage to millions of Californians. Under this waiver, expanded coverage of the uninsured is being performed on a county-by-county basis to low-income, childless adults — a group not previously covered under Medi-Cal.

Yet, with this expanded coverage comes increased demands on our medical and public health system, from primary care physicians to public hospitals that support California’s lowest-income and highest-need individuals. To ensure improved access to care and better population health under the new law, local and state health departments will play a vital role in the law’s implementation.

The first step in this process has been to bring all local health care providers to the table — a process that did not have the same urgency in the past. The countywide health care delivery system is vast, from local hospitals, community clinics and long-term care facilities to mental health providers and specialty care centers.

Yolo County can coordinate the needs of these groups to ensure equal, high-quality access across the county. Often, providers may be competing groups in the community, so cost transparency and fairness becomes an issue. Thus, to achieve the best outcomes, the new system must ensure equitable, low-cost and fair distribution of these newly insured among the providers in the county while not providing an undue advantage to one provider over the other.

The second step is to provide adequate health care access. Thousands of newly insured individuals in Yolo County may now enter an overwhelmed system, particularly for primary care physicians. In addition, this access must be in both rural and urban areas, often in the lowest-income regions of the county where access is most difficult.

To be successful, Yolo County must make new alliances with medical schools and residency programs throughout the state, ensuring a potential new stream of both primary care physicians along with highly needed sub-specialties. This bridge is new territory for many local health departments but critical for providing long-term success of the Affordable Care Act.

Finally, the system must ensure comprehensive care delivery. Many of the newly insured within the Medi-Cal system will have multiple diagnoses such as substance abuse, mental health disorders and multiple chronic illnesses. Ensuring access to mental health, social service and other social support can best occur at the county level, as providers and local clinics and hospitals do not have the resources and connections to bridge these services. Thus, comprehensive coordination of these difficult cases is needed to bring all agencies in Yolo County together to provide adequate and high quality health care delivery.

The Affordability Care Act will challenge local health departments, particularly in the smaller and more rural counties, to build a system of health care delivery with all providers. With the demonstration waiver’s implementation at the county level, this challenge will require delving into previously uncharted waters, from the primary care provider shortage to the competitive nature of private and public health care delivery.

— Christian Sandrock, M.D., M.P.H., is Yolo County’s health officer. This column is published monthly.

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