An evaluation of San Mateo County’s comprehensive health system redesign initiative finds notable improvements in access to high quality patient care for formerly uninsured adults. For example, the percent of such individuals having a usual source of care rose from 42.5 to 91.2 percent with the initiative. The initiative met with success despite mounting fiscal challenges associated with the economic recession and state budget crisis threatening the county’s ability to support these innovations. The county’s efforts offer lessons for local and national policymakers, program administrators, and providers about how progress is possible despite severe financial obstacles.