Health Access Priorities for California’s Waiver Renewal

Health Access is pleased to present a new white paper, Medi-Cal Reform 2.0: Health Access Priorities for California’s Next Medicaid Waiver, as a discussion draft. We invite all stakeholders, especially our allied consumer and community advocates, to look it over and submit any comments to In your feedback, please indicate whether we can include your comments on a moderated discussion board.

With much deliberation and engagement of expertise from across the state, the Medi-Cal waiver renewal stakeholder process is in full swing. What comes out of these barrage of meetings will be important for the next critical phase: preparation of the draft application by the Department of Health Care Services (which administers Medi-Cal and oversees waiver initiatives) with additional opportunities for consumer advocates and others to weigh in.

The state hopes to submit its initial application sometime in late February or early March of this year. After that we expect vigorous back-and-forth negotiation with CMS on the different points of the proposal, in particular the financing assumptions behind the state’s waiver request.

In multiple workgroups (Health Access California served on three of them, joined by other allies like California Pan-Ethnic Health Network, SEIU, Congress of California Seniors, Western Center on Law and Poverty, and others), DHCS put forward concepts in an attempt to formulate a rough consensus on their major waiver ‘asks.’ In the world of waivers (watch for highlights in a coming blog), it’s expected that states will ask for as much flexibility as possible in terms of how federal Medi-Cal financing should be used to meet the state’s ambitious Medi-Cal and health system reform goals. The goal is a renewed waiver to begin as soon as the current waiver expires in late October of this year.

From the Executive Summary…

The coming renewal of California’s section 1115 Research and Demonstration Medicaid waiver and Delivery System Reform Incentive Program (DSRIP) presents a critical opportunity to build on the state’s success in implementing health reform and to tackle longstanding issues in the state’s health care safety net.

Health Access seeks a new “Bridge to Reform 2.0” Medicaid waiver (and DSRIP 2.0) which supports our safety net; improves care and provides a medical home for Medi-Cal enrollees and the remaining uninsured; and moves California toward the “quadruple aim” of better care, better health, lower cost and reduced disparities, through both delivery system reform and population health approaches that integrate health care with other human services and community supports. Health Access supports the following vision and goals for Medi-Cal Reform 2.0:

    Past waivers have focused on yielding needed resources for public hospitals and the safety-net, and this priority is as urgent as ever. In light of California’s success with Medi-Cal enrollment, the safety net needs the capacity to address the pent-up demand for care presented by new Medi-Cal enrollees, even as it continues to serve the remaining uninsured. A critical part of the Bridge to Reform waiver, the DSRIP program brings additional resources to the safety net with funding levels tied to outcomes on delivery system reforms designed to make the safety net more efficient and effective so they can serve millions more.
    Our health care system works better when everyone—both Medi-Cal enrollees and the remaining uninsured—has access to coordinated care in a primary care setting. President Obama recently gave relief from deportation to hundreds of thousands of California immigrants. To help California provide comprehensive managed care for the remaining uninsured (and others the state may determine eligible over the course of the waiver), the federal government should share savings with the state from reduced utilization of emergency care and related services financed through Restricted-Scope Medi-Cal. A complementary goal would be to restructure the Disproportionate Share Hospital (DSH) and Safety Net Care Pool funding to provide more comprehensive primary and preventive care to the remaining uninsured.
    The Medi-Cal Reform 2.0 waiver should embrace the ‘quadruple aim’ and keep the patient at the center of efforts to improve care, reduce costs, improve health and reduce disparities. A major source of financing for the safety-net, and the health system as a whole, a Medi-Cal waiver should provide health care delivery systems with sufficient resources and direction to focus on patient-centered goals—using a shared savings structure, and through related payment, transparency, and policy mechanisms. DSRIP 2.0 should prioritize key health goals already vetted from the Let’s Get Healthy California Task Force report. Such changes should protect consumers and our health system, as they improve care, outcomes, and equity. Patients benefit from care transformations when their social circumstances—transportation needs, access to healthy food, decent housing and safe neighborhoods—are taken into account. DSRIP initiatives, too, need to build on proven medical home models and stretch beyond clinical walls to engage the community supports and resources to improve outcomes for patients, starting with Medi-Cal enrollees and the remaining uninsured. Finally, building on stakeholder consensus (not to mention CMS expectations) that DSRIP 2.0 should have a stronger emphasis on measurable outcomes, all metrics and analytics tied to clinical and population health outcomes should be stratified by race/ethnicity, primary language, income, gender, sexual orientation, and gender identity.  Likewise, transparency and reporting mechanisms like dashboards should be accountable and accessible to the communities with the most to gain from delivery system reforms.
    The premise of ”whole person care” is that health care is most effective when it engages services and supports across the silos of health, housing, corrections, and more. At a minimum such “horizontal integration” innovations should include integration of physical health with behavioral health, (mental health and substance abuse); ‘whole person’ care for those most in need, including those post-incarceration and those with seriously behavioral health issues; and coordination of long term services and supports for seniors and persons with disabilities as well as the “dual-eligibles” (those enrolled in Medicare and Medi-Cal). Counties should have additional incentives to develop innovative connections between health care and housing, health care and corrections, and other population health approaches.

For those less familiar with Medi-Cal and waivers, this paper starts with a quick background of the waiver process and the results and lessons learned from the last waiver, before detailing how the new waiver can meet these four general goals.

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