Lessons from the field: expanding health insurance coverage one county at a time

From 2004 to 2007 the California HealthCare Foundation's Step by Step: Local Coverage Expansion initiative supported insurance coverage expansions for uninsured children and adults in thirty California counties. In this paper we descbribe the initiative and its achievements as well as challenges for grantees. Also, we discuss the implications of the initiative's outcomes for expanding coverage locally and more broadly. Implementing new insurance programs is possible in the most difficult settings. Although there are real challenges to sustaining these expansions and limits to what they can accomplish in the face of major unmet needs, they may lay useful groundwork for broader expansions later.