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Health Department outlines Medi‑Cal 2020 waiver: $6.2B federal funds, tighter metrics and revenue risks
Summary
Deputy director Colleen Chawla briefed the commission on the Medi‑Cal 2020 waiver (effective Jan. 1, 2016–Dec. 31, 2020). She described core components (PRIME, Global Payment Program, Whole Person Care, Dental Transformation), noted a smaller federal pool than the prior waiver and flagged implementation and measurement challenges that could reduce local drawdown of federal funds.
Colleen Chawla, deputy director for policy and planning at the San Francisco Department of Public Health, provided the commission with an extensive overview of California’s Medi‑Cal 2020 demonstration waiver and its implications for San Francisco’s safety‑net health system.
Chawla said Medi‑Cal 2020 began retroactively on January 1, 2016, and runs through December 31, 2020. She said the state estimates roughly $6.2 billion in federal funding in the waiver (about $12 billion when state matches are included) and explained the waiver’s major components: PRIME (Public Hospital Redesign and Incentives in Medi‑Cal), a Global Payment Program to combine disproportionate‑share and safety‑net pools into a bundled approach, Whole Person Care county‑led pilots (competitive awards funded at approximately $1.5 billion over five years), and a Dental Transformation Initiative (about $400 million over five years) for children on Medi‑Cal.
Chawla explained that PRIME replaces the prior DSRIP program and requires participating public hospitals to complete nine projects across three domains and meet performance metrics to earn incentive funding. She warned the commission that PRIME metrics would be harder to achieve than under the prior waiver and that the total federal pool under Medi‑Cal 2020 is smaller statewide than the prior waiver (Chawla cited roughly $6.2B federal vs. ~$8B under the last waiver), which creates revenue risk for the Department.
The presentation covered the global payment program’s emphasis on incentivizing outpatient, preventive and primary care over inpatient volume; the need to set hospitals’ point thresholds using historic and projected uninsured‑service data; and uncertainty about how much of the global payment pool will be allocated in years 2–5 pending the uncompensated‑care assessments. Chawla said DPH has been engaged in waiver design, worked with the California Association of Public Hospitals and Health Systems, and formed an internal implementation team spanning the network, hospital, finance and policy staff.
Commissioners raised questions about the magnitude of the revenue changes, how metrics will align with existing quality measures, and reporting and governance structures for tracking PRIME and global payment measures. Chawla and staff offered to return with follow‑up reports and suggested checking back in roughly a quarter after attachments and STCs (special terms and conditions) are finalized (staff cited April 1 as the expected time for final STCs and proposed a Commission follow‑up in May).
