In recent years, policy analysts have paid much attention to the precarious state and uncertain future of local public health departments and so-called safety net providers, usually treating each separately. This paper explores the ways in which these systems are converging, are adapting to a changing health marketplace, and are interacting with new private sector competitors and partners. Although threatened by policy, competitive, and financial forces, many of these local organizations are adapting successfully. An agenda for transforming these entities is described; the agenda emphasizes leadership, democratization, and partnerships with communities.