CHCF: California and Its Counties Under the ACA: A Leadership Framework

Deborah Reidy Kelch

California’s state-county partnership for health care is shifting under the ACA. This framework provides policymakers and stakeholders a way to understand the changes. 

As California moves to implement the ACA, it is making major health program, policy, and fiscal changes that will transform the way the state and its 58 counties share responsibilities for the health of Californians.

To help policymakers and stakeholders better understand the state-county partnership and prepare for the changes, this issue brief provides a leadership framework to assess the potential impacts of shifting responsibility. The framework identifies some of the tradeoffs that result depending on whether counties or the state take the lead in a particular health program or initiative. In the past, where the state has taken the lead, there has generally been greater operational consistency across programs. Alternatively, where counties have assumed lead responsibility, the level and type of services that county residents receive reflect the diversity of California counties in resources, capacity, and political orientation.

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