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With steady jobs, plentiful insurance coverage, and high levels of payment reform and clinical integration, California’s capital has long been a reliable market for stakeholders. But radical change is looming with the Dignity-CHI merger cleared to go. Health systems now face the entry of a powerhouse conglomerate that threatens to steamroll them. Insurance carriers are in a similar position as Dignity has an established health plan that will undoubtedly see a boost in enrollment. Sutter Health, Kaiser Permanente and UC Davis Health, Anthem, and Centene must devise shrewd strategic maneuvers to persevere in this changing market.