After a series of expansions over the past decade, Medi-Cal provides health insurance coverage for about one-third of California’s population. While the federal government supplies about 70% of program funding and the state determines aspects like the scope of benefits and payment rates, county governments are vital partners for administering the program and for organizing and delivering health services. But the resources available to counties for health programs, along with their responsibilities for providing and funding services, have also shifted over this time.

In several counties, more than half of residents are Medi-Cal enrollees. Medi-Cal provides health insurance for the majority of residents in Colusa, Tehama, and Lake Counties in the Far North, in several counties in the San Joaquin Valley, and in Imperial County at the southern border.

Counties manage Medi-Cal enrollment. County social service agencies handle enrollment and case management services including eligibility determinations and annual renewals. Since May 2023, county agencies have restarted eligibility checks for the 15+ million enrollees who remained in the program since annual eligibility determinations were put on hold during the pandemic.

Counties provide behavioral health services to Medi-Cal enrollees. Counties provide specialty mental health services to Medi-Cal enrollees with serious mental health needs, such as psychiatric hospitalization, residential treatment, crisis intervention, case management, medication support, and therapy. Counties also provide treatment for substance use disorders (SUD) for Medi-Cal enrollees, which may involve outpatient treatment, medication-assisted treatment, withdrawal management, and residential and recovery services.

Under the CalAIM initiative, Medi-Cal is working to better integrate physical and behavioral health services and provide social supports like housing assistance for people with serious mental health conditions—underscoring the importance of county behavioral health systems.

Some large counties operate public hospital systems. Twelve large urban counties operate public hospital systems that include major medical centers and outpatient clinics. County hospitals serve high volumes of Medi-Cal patients and are important access points, especially for inpatient and specialty care. Public hospital systems also help train physicians and operate high-level trauma centers.

Some counties operate Medi-Cal managed care plans. More than 90% of Medi-Cal enrollees belong to managed care plans that organize and pay for members’ health care services. California has four types of Medi-Cal managed care plans; counties operate one such plan—County Operated Health Systems (COHS)—in collaboration with local providers and community groups. Six COHS plans serve Medi-Cal enrollees across 22 counties, including many rural counties in the Northern region and Central Coast.

Beyond their direct role in the Medi-Cal program, counties also operate public health departments that focus on population-based health including prevention measures, infectious disease control, and emergency preparedness which also support community health and well-being.

Ensuring counties have adequate resources to support the Medi-Cal services they provide is vital to the program overall and also the success of initiatives like CalAIM. All counties have endured longstanding challenges, including provider capacity and workforce shortages—especially in the area of behavioral health. Smaller, rural counties face additional hurdles related to the large, geographically isolated areas they serve and even greater barriers to recruiting physicians and other health care providers. Multiple federal, state, and local funding streams support the health services that fall to counties. Federal Medicaid dollars, state sales tax and vehicle license fees, county funds, and an additional 1% personal income tax on high-income earners all contribute.

Major policy changes have shifted some financing and responsibilities borne by counties for health-related programs. For example, the state provides less funding to counties since the Medi-Cal expansion because far fewer uninsured people now qualify for county indigent care services. At the same time, counties have received additional funding for public mental health services in the wake of public safety realignment—and if voters approve the governor’s proposed changes to the Mental Health Services Act on the March ballot,  more changes could be on the horizon