L.A. Care entered the exchanges with a clear vision of its target audience: lower-income families transitioning between Medicaid and the general insurance market when they earned more than the Medicaid-eligibility cutoff (138 percent of the federal poverty line).

The pitch was that L.A. Care could provide continuity of care to people who moved back and forth across that divide: They could keep their same doctors when fluctuations in their income tipped them from Medicaid into the exchanges, or vice versa. “That was why we did it—for continuity,” Baackes said. “The thinking was people who may cross the line and earn a buck more than 138 percent, they’d lose medical eligibility, and if [they] were in the exchange, they could stay with L.A. Care, be eligible for a significant subsidy, and they’d still have access to care.”

As a public plan serving a predominantly low-income population, L.A. Care has developed an unusually holistic approach to health insurance. It has opened six family-resource centers, including the one in Lynwood, and plans to open eight more by the end of 2020. Each center offers dozens of classes each week to promote healthier living—from meditation and stretching to early literacy and domestic-violence counseling. Margaret Coins, who directs the Lynwood Center, told me that more than 800 people pass through it each week. “I have families who have been coming here since day one,” said Coins, who has worked at the Lynwood facility since it first opened in 2009.

L.A. Care is now moving toward more comprehensive services. It wants to coordinate more closely with other social-service agencies to ensure that customers are enrolling in benefits that they’re eligible for, from housing assistance to food stamps. It is training a corps of “community health workers” who will coordinate care for the minority of plan members with the most complex medical needs (the people who also generate the most expenses for any health insurer).

L.A. Care also interacts with medical providers in an unconventional way. Rather than paying providers for each visit or procedure (what’s known as fee-for-service), it offers them a fixed sum to cover all the health-care needs of each patient. That reduces the incentive for providers to maximize visits from patients and instead, as Baackes put it, encourages them to ask, “What’s the most efficient way to ensure they get the highest quality?”

For all these reasons, outside observers generally praise L.A. Care as a worthy model. Laurel Lucia, the health-care program director at UC Berkeley’s Labor Center, said the plan has demonstrated that a public option can effectively coexist and compete with private insurers. But, like Wright, she notes that the plan’s effect on medical costs has been evolutionary, not revolutionary. Not until this year was L.A. Care offering the lowest premiums on the ACA exchanges in L.A. County, and Baackes said another plan may be slightly less expensive next year.