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Health care policy happens at many levels, but health care delivery: just one. Policy is made at the federal, state and local levels—but delivery is at the local level: in organized systems of care or with individual or teams of practitioners working with patients and families.

There must be a nexus between policy and practice in order for policy related to medical care to have any real impact on the health of individuals and populations. Though there is some recognition of the importance of the nexus (see the formation of clinical translational research entities—CTSAs—at many universities), policy makers often overlook this important step. To make true change in the way care is delivered in America, this translation of policy to local level implementation must be explicit.

The coverage provisions of the Affordable Care Act (ACA) offer great examples of the importance of this connection, and how the centrality of the local role has been overlooked. The ACA relies heavily on Medicaid and health insurance exchanges to expand health coverage. We know from Massachusetts’ experience that when coverage was expanded, many people tried to find a practitioner to treat them and could not. This meant that those with newly acquired coverage were more likely to get care in the emergency department or other facility settings: high cost and ineffective approaches to primary care.

Where is planning occurring in the rest of the country to prepare for 2014 and avoid what happened in Massachusetts? There does not seem to be a coordinated strategy in any states or with the federal government to address this important issue—but we have a great example right here in Washtenaw County.

In the early fall of 2010, the former CEO of the St. Joseph Mercy Health System in Ann Arbor, Robert Laverty, started talking to a number of community leaders about coming together to identify ways to improve care for the poor in Washtenaw County today (Medicaid recipients and the uninsured), and to begin planning for health care reform long before 2014. He got commitments from the CEOs of the two major health systems in the community to co-sponsor this effort, and enlisted other community leaders to chair and facilitate the work. Ultimately, 40 individuals got involved—on a voluntary basis—representing providers, safety net organizations, the Department of Human Services, county employees, public health, patients and their advocates, and the like. The group worked for 6 months focusing on how to improve care—here and now—as well as to plan for the future.

The first step the group took was to document the current state of affairs and what care in Washtenaw County might look like in the future. For example, the group noted that there were approximately 6,400 people currently eligible for Medicaid but not enrolled and 50,000 uninsured in Washtenaw County. By 2014, an additional 25,000 individuals were expected to be eligible with most (but not all) of the uninsured expected to enroll in private coverage with the help of subsidies.

While there are many primary care providers active today in Washtenaw County, the group estimated that the expansion of coverage would increase demand for primary care services by something like an additional 54,000 visits and more than 33,000 of the uninsured appear not to be connected to primary care at this time.

These numbers should be startling and galvanizing: and they have been in Washtenaw County. The groups are now working together on the strategies needed to fill these gaps and more (dental, mental health, and substance abuse treatment were also areas of focus for the group, along with ways to simplify and improve the Medicaid enrollment process). Working together, the health systems and safety net providers are looking at how to restructure what already exists and bring more capacity to the community to be prepared for the expected increase in demand.

This is where the nexus between policy and practice happen. Washtenaw County is off to a great start in preparing for 2014. How many other communities can say the same?