The "safety net" refers loosely to the health care services available to the most economically and socially vulnerable populations in California, as many as one-third of residents, who are either uninsured (and low income) or covered by Medi-Cal or other public programs, such as Healthy Families.

But the term "safety net" also refers to a diverse combination of health care providers, including community clinics (federally qualified health centers and other community-based organizations that predominantly serve lower-income populations), public hospitals, academic health centers, and mainstream nonprofit and for-profit hospitals and physicians who take care of these patients. The safety net is tied together by a complex weave of federal, state, local and charitable funding.

Just like all of American health care, the safety net is not a system. It is a collection of extremely dedicated, hardworking people doing the very best they can for the populations they serve, in institutions that are not coordinated to optimize the health and health care of the populations they serve.

It's time to prepare for the newly insured - and those left behind under reform. Estimates suggest that more than 8 million Californians may be uninsured today, and health care reform, once fully implemented in 2014, may provide coverage for the majority of those currently uninsured. But some Californians will still fall through the cracks, whether through homelessness, mental illness, undocumented-immigrant status or choice.

Here are the next items on the state's checklist:

New demands on care delivery. The expansion in coverage envisioned in the bill will likely increase the demand for services across health care. Many of the currently uninsured will have an insurance card in 2014 - half of the newly covered with a Medi-Cal card and half with subsidized insurance purchased through the California Health Benefit Exchange. All California health care stakeholders need to identify how to cope with the new demands that this expansion in coverage will bring. For safety net providers, there will be challenges and opportunities in competing for these newly covered Californians, while still keeping open doors for those that are left behind.

New models of care delivery. The growth in coverage, the major and ongoing shift toward chronic care needs, and the lack of adequate primary care delivery resources make transforming the way health care is delivered an imperative. Leaders in the safety net should - and will - be on the front lines of innovating for higher quality and lower costs for their patients.

New ways to be accountable. Throughout all of health care, payers and providers are being asked to demonstrate higher performance through ubiquitous and non-negotiable measurement of performance. This broader trend will continue, and safety net stakeholders must decide how to embrace and customize this trend for their own institutions and the patients they serve.

This is the next big challenge for the country's largest, most diverse state. The most vulnerable Californians will be counting on us to seize the opportunity and to create the best possible future.