The Supreme Court decision that kept Obamacare intact made one major change to the legislation: the Medicaid expansion became optional. But California, one of the states leading on reforms, started the expansion of the state Medicaid program—known as Medi-Cal— three years ago. The early expansion in California and other states was intended to show the benefits and pitfalls of reforms before they were rolled out nationwide and to provide models for success.

So far, the early roll out has done both, highlighting the good and the bad of coming reform. Some counties, for instance, opted out of the reforms because they could not afford the additional costs they would incur, even with the additional funds.

Federal funds covered half of the cost of the expansion, called Low Income Health Programs. That money allowed 50 of California’s 58 counties to develop creative enrollment methods, plug gaps in care, improve communication and treat patient populations as a whole.

California counties have been the health-care provider of last resort for low-income adults since the early 1990s. Counties devised different ways of providing for the poor, from offering the bare minimum to providing more comprehensive benefits through county and community health clinics.

The majority of counties opted to take advantage of the federal funds in advance of the ACA. Sixteen are coordinating their own Low Income Health Program and 34 rural and small counties are grouped together in the California Medical Service Program.

Counties with more robust health-care benefits were better prepared to pivot to a Low Income Health Program, but some still limited the expansion of benefits to the poor because of cost concerns.

San Francisco, for instance, decided to expand benefits to people making 25 percent of the poverty line, the lowest income threshold in the state. That’s in part because the city already provides a primary care medical home to low-income residents through their health benefits program, Healthy San Francisco, with fewer restrictions than the Low Income Health Program.

Those who qualify for the Low Income Health Program, known as SF PATH, will receive the additional benefits of non-emergency medical transportation and emergency coverage outside of the county.

Los Angeles, in contrast, saw the Low Income Health Program as an opportunity to drastically expand enrollment and experiment with new enrollment methods. At last check, they’d enrolled 257,009 people in their Low Income Health Program, known as Healthy Way LA. They set their income cap at 138 percent of the federal poverty level, the same as Medi-Cal. Before the expansion, the county’s medically indigent program had at most 60,000 enrollees.

“The county Department of Health Services took the position that even though it would be a high share of costs borne by the county, it was important to have an uncapped program,” said Amy Luftig Viste, Director of Community Partner Programs, Department of Health Services. “Eventually, when these patients become 100 percent federally funded in 2014, we will already have them in the program.”

Their goal is to enroll 300,000 by the time the transition to Medi-Cal happens. The most recent estimate from UCLA and UC Berkley found that there are 390,000 potential Healthy Way LA enrollees.

They’ve partnered with three established non-profit groups to proactively go into communities and hold enrollment and education events at churches and schools. The best way to reach people is by using trusted people and institutions in communities to spread the word about the program, Viste said.

“We’ve also confirmed that people are utterly concerned about the Affordable Care Act,” she added.

Other counties have used the Low Income Health Program to improve care management.

Alameda County has used the extra funds to expand access, improve quality and integrate behavioral health with their medical coverage. They looked at their patient population as a whole and started more comprehensive management of chronic conditions like diabetes and hypertension.

The change has made a difference to patients like Salvador Gomez. The 62-year-old retired maintenance worker and his wife Maria signed up for the Low Income Health Program known as HealthPac through the LifeLong Medical Care community clinic in Berkeley.

Gomez was diagnosed as pre-diabetic three years ago. At first it was difficult for him to make the lifestyle changes necessary to improve his health. Eventually he and his wife went from eating pork and fried food to a diet of fish and chicken and increased their exercise. He works with his medical team including a nutritionist at LifeLong to maintain his health.

“I try to do whatever they told me because I want to live, I don’t want to die,” Gomez said. “And if I don’t do something (they tell me), I feel it.”

Through this kind of proactive care, clinics hope to improve the overall health of their patient base and reduce the amount of more complicated and expensive treatment.

Alameda has now enrolled more than 40,000 people in the Low Income Health Program under their already existing HealthPac program. By examining their system comprehensively, the program has made multiple minor changes that make a big difference, according to Rachael Metz, policy director for the Health Care Services Agency.

For example, if a client needed durable medical equipment such as an oxygen tank, they once went to the county hospital and waited in the overcrowded emergency room until someone was available to issue it to them. Now their primary care provider sends a form to the hospital to authorize the tank, a process that sidesteps the ER.

“It sounds minor, but it makes a difference,” Metz said. “It’s good for the patient and good for the ER.”

San Mateo County also used the federal matching funds to improve communication and coordination between behavioral health and medical care, merging the once separate departments of behavioral health. Now patients can be seen by a medical doctor in three of their behavioral health clinics instead of having to go to a medical clinic. Care teams also coordinate their efforts to align patient’s medication and treatment plans.

“It’s a population who’s access to care is often fragmented,”said Srija Srinivasan, County Health System Director of Strategic Operations. “We want to make it as unified as possible.”

Frenso County’s Medically Indigent Services program mostly covers uninsured adult and juvenile inmates and undocumented residents for emergency specialty care and hospitalization. They are one of eight counties that opted out of the Low Income Health Program because they were not sure they could cover the additional costs.

“We have a very high poverty rate and a high unemployment rate, and we are not a high revenue county,” David Luchini, Assistant Director of the Fresno County Department of Public Health said. “So we can’t take as many risks.”

If they had opted to develop a Low-Income Health Program they would have had to establish primary care medical homes for those who qualified. Because the Medi-Cal expansion will take effect nationally in 2014, the county decided to wait until state program expands and the federal government covers all the costs.

Once the reforms take effect in January there will still be large numbers of uninsured. Undocumented immigrants and legal permanent residents who’ve been here less than five years will be excluded from any of the new benefits. Others still won’t find the options on state insurance exchanges affordable, or won’t realize that benefits are available to them.

After reform, counties still must cover the remaining uninsured with at least hospitalization.