California’s 58 counties sit at the heart of the state’s healthcare system, delivering public health services, providing mental health and substance use care, and serving as the safety net for residents with low incomes and those who are uninsured.
Two new reports from the California Health Care Foundation (CHCF), authored by Sellers Dorsey Senior Strategic Advisor, Meredith Wurden, Director Alexandra Kanemaru, and Consultant Manager, Olivia Brown tell a comprehensive story about how counties administer, finance, and deliver care for millions of Californians.
Together, these reports provide an updated, practical look at how county systems function, how they have evolved over the last 10 years, and why counties are indispensable to California’s efforts to improve access, quality, and outcomes across health, behavioral health, and public health.
Counties Are the Backbone of California’s Safety Net
California’s counties play a uniquely expansive role in administering and delivering health services. They administer Medi-Cal (California’s Medicaid program) eligibility and specialty services, operate or partner with safety net providers, manage public health programs, and oversee specialty behavioral health systems for mental health and substance use disorder (SUD) care.
Counties serve as providers of last resort for vulnerable Californians. Over time, primarily due to coverage expansions under the Affordable Care Act (ACA) and Medi-Cal, counties have had a reduced role in filling coverage gaps, prompting them to reshape their programs and increasingly focus on supporting the Medi-Cal delivery system. However, recent federal and state policy changes are requiring counties to reexamine their roles and programs.
Medi-Cal Transformation Has Deepened County Responsibilities
Medi-Cal is the dominant health coverage program in California, covering nearly 15 million members, approximately 95% of which are enrolled in managed care. Counties are deeply embedded in this system, whether through County Organized Health Systems, public healthcare systems, county behavioral health plans, or as providers of Enhanced Care Management and Community Supports under CalAIM.
Recent initiatives, including CalAIM and BH-CONNECT, have expanded expectations for coordination, data reporting, quality oversight, and cross-system collaboration. Counties are responsible for implementing many of these reforms on the ground while balancing local needs, state mandates, and federal requirements.
Behavioral Health Is a Core County Function
Behavioral health is one of the most complex areas of county responsibility. Counties administer Medi-Cal specialty mental health and SUD services, oversee non-Medi-Cal safety net programs, and increasingly play a role in addressing homelessness, justice involvement, and crisis response.
The COVID-19 pandemic underscored long-standing gaps in behavioral health capacity and service needs. In response, California has invested more than $15B in behavioral health initiatives broadly distributed across multiple delivery systems that have included counties.
The passage of Proposition 1 in 2024 marked a turning point and included replacing the Mental Health Services Act with the Behavioral Health Services Act which requires counties to implement evidence-based practices, dedicate funding to housing, and operate under heightened state oversight.
Public Health: Critical and Evolving
Counties are also the frontline of California’s public health system, responsible for disease prevention, emergency preparedness, access initiatives, and community-wide interventions. While recent investments strengthened local public health infrastructure significant risks to funding remain.
The Future of Public Health Initiative aims to modernize public health systems, but counties continue to face workforce shortages, funding instability, and increasing expectations to respond to both acute crises and long-term population health challenges.
Funding Complexity Shapes County Decision-Making
Across health care, behavioral health, and public health, counties operate within a fragmented funding landscape that includes federal funds, state General Fund dollars, realignment revenues, voter-approved sources, and other funds. While these funding streams can allow counties to leverage dollars creatively, they are also subject to limitations and, for certain sources, are particularly vulnerable to economic volatility that complicate long-term planning.
Counties must continuously reassess priorities, align funding with community needs, and demonstrate accountability, often while managing multiple reforms simultaneously.
Why These Reports Matter
Together, these reports provide a clear, accessible foundation for policymakers, advocates, health plans, providers, and community partners seeking to understand how California’s county health systems work, and why they matter.
As California continues to pursue ambitious reforms, counties will remain central to whether those efforts translate into real, measurable improvements in access and care.
Explore how California’s county health, behavioral health, and public health systems work, and how they have developed to deliver on their evolving roles over the last decade.
