This report presents early findings of an evaluation of San Mateo County's Health System Redesign and Adult Coverage Initiative (ACE), an effort to improve effectiveness, efficiency, and care coordination among uninsured and underserved adults in the county. Enrollment in the ACE program has exceeded expectations, yet sustained financing for the program has yet to be identified. We have observed reforms in scheduling, team-based care, and the implementation of electronic medical records. However, we found significant barriers to access for primary care and specialty appointments. This analysis is the first of several ongoing evaluation reports by the Urban Institute and UCSF.