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CALIFORNIA ACEs, REPRODUCTIVE HEALTH, AND THE PATH FROM ASSESSMENT TO TREATMENT From Awareness to Action: California's Progress on ACEs, Reproductive Health, and the Next Frontier of Treatment Solutions A Two-Page Summary Prepared for the Office of the California Surgeon General By Brian Alman, PhD and Vincent J. Felitti, MD  July 2026   California has made nationally significant progress bringing Adverse Childhood Experiences (ACEs) into health care and public health. The work began with the CDC–Kaiser ACE Study, led by Vincent J. Felitti, MD, and Robert F. Anda, MD, MS, which established a graded relationship between childhood adversity and many leading causes of adult illness and premature death. California translated that science into ACEs Aware: statewide clinician training, Medi-Cal reimbursement for screening, and clinical-response guidance. As of mid-2026, clinicians have conducted nearly 5.9 million ACE screenings of more than 3 million Medi-Cal members, and over 55,000 people have completed the state's core training. Under Surgeon General Diana E. Ramos, MD, this work has increasingly connected ACEs to maternal and reproductive health — through Strong Start & Beyond and the Preconception Medical Assessment (PreMA) — recognizing that pregnancy, preconception, and postpartum care are powerful windows for interrupting the intergenerational transmission of adversity. The central finding of this report: California has built much of the foundation for the next phase, but that phase must move beyond assessment. Screening only matters when it leads to a safe conversation, a clinical response, a care plan, and follow-up. As the clinicians who have spent over three decades on the treatment side of this question — from the original ACE Study through decades of direct clinical referral and collaboration — we believe the next chapter must complete the continuum from discovery to healing. What California Has Built ● 5.9 million ACE screenings completed among 3 million+ Medi-Cal members (through June 2025); 55,250+ trained; ~25,330 certified clinicians (through March 2026). ● Medi-Cal reimbursement for qualified screening, plus statewide clinical-response guidance covering education, intervention, and follow-up. ● Dr. Ramos's integration of ACEs with maternal health, reproductive health, and equity — including Strong Start & Beyond (50% maternal mortality reduction goal) and PreMA. ● Cross-sector reach into schools and early care through trauma-informed training such as Safe Spaces. The Remaining Gap: From Referral to Reliable Help Screening without sufficient response can leave patients feeling exposed rather than helped. Real gaps remain: inconsistent post-screen clinical assessment, thin behavioral-health capacity, referral lists that don't confirm completion, and limited measurement of whether screening actually improves outcomes. A parallel risk is technology and AI tools that offer recommendations without clinical judgment, safeguards, or human follow-through. The “Now What?” Contribution Our collaboration — spanning the original ACE Study through more than thirty years of clinical referral and treatment work — has centered on the question patients ask after recognition: now that I understand what happened, what can I do? Assessment should lead to agency: a clearer understanding, and at least one practical, achievable next step, not simply a score or a referral sheet. Recommendations for the Next Phase ● Establish a California Assessment-to-Action Continuum: consent → screening → clinical assessment → education → shared care plan → immediate support → warm handoff → follow-up → outcome review. ● Launch reproductive-health demonstration sites (prenatal, postpartum, family-planning, safety-net, rural, and tribal settings) to test the full continuum. ● Build a vetted, non-exclusive menu of evidence-based treatment and support pathways, evaluated for safety, licensing, language access, and outcomes — not a single endorsed product. ● Require an immediate “first helpful step” at every visit, and fund navigation so referrals close the loop rather than ending. ● Pair ACEs with Positive Childhood Experiences, protective factors, and hope; ensure bilingual, accessible materials and inclusion of fathers and partners. ● Set responsible technology standards for any ACE-related digital or AI tool: evidence, accountability, crisis escalation, privacy, and human oversight. Conclusion California has taken a landmark body of research and built a statewide infrastructure around it. Dr. Ramos's leadership has returned that work to the place where prevention has the greatest intergenerational reach: reproductive and family health. Our shared contribution is a reminder that awareness is not the finish line — a score is not a treatment plan, and a referral is not the same as healing. California is positioned to lead again by defining what a complete response looks like: understand, assess, support, treat, follow up, and learn.

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