Judy Silber

For La Clínica de la Raza, long a source of care for a diverse Oakland community, the ACA has increased the clinic's share of insured patients. But financial pressures are still a constant reality, and the problem will worsen dramatically if federal funding isn't renewed.

Sign-ups for insurance on the federal and state health exchanges end in less than a month, and the state's push to enroll more Latinos appears to be paying off. Meanwhile, safety net providers such as Clinica Sierra Vista are focused on both signing up and retaining patients.

As a federal "funding bump" expires, the payments California doctors receive for seeing Medicaid patients are dramatically decreasing. At the same time, the state is imposing a 10 percent fee cut that was approved in 2011 but is just now taking effect.

As the pool of uninsured shrinks, public hospital systems must increasingly compete for newly insured patients. “We're forcing public hospitals to compete in one of the most competitive industries that has ever existed in the economy,” said one county health director.

With Obamacare's second season of open enrollment underway, advocates remain focused on signing up the remaining uninsured. In California, the uninsured rate is projected to drop to 6 percent by 2019. But getting it much lower will require creative new strategies.

After a resounding defeat Tuesday, backers of Prop. 45 vow to press on with efforts to give California's insurance commissioner greater regulatory authority over insurance rates. Meanwhile, one prominent health policy expert said the failed measure was "a huge threat to health reform in the state."

Prop. 45 would grant California’s insurance commissioner the ability to approve or reject health insurance rate increases. While voter support soared over the summer, approval has fallen since then, as the insurance industry invests heavily in defeating the measure.

In California, millions have been added to the Medicaid ranks. But even the state's most forward-thinking counties are struggling to provide timely health care access to all of these new patients.

In its first year on California's state health exchange, Kaiser trailed three other major insurers in market share. As the second open enrollment period fast approaches, Kaiser is trying to better reach Latinos by beefing up Spanish language outreach, call operators and online services.

A recent policy brief found that public health programs must expand their reach if they're to increase the number of people who receive preventive care. But reaching those who don't routinely seek care means meeting people where they are — culturally, linguistically and geographically.