Population Health Division Cuts Staff as Medi-Cal Threats Mount

San Francisco's Population Health Division is absorbing vacancies and grant losses by shrinking and consolidating its operations staff. Its leader told the Health Commission on Oct. 5, 2026, that the work will slow with fewer people. The informational reports landed alongside new Medi-Cal funding threats, an 8% drop in HIV diagnoses and a stubborn detox bottleneck that health officials blame on state rules, not beds.

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• Population Health Division cuts 5.5 operations FTE in a restructure driven by unfilled vacancies
• Commissioners press for answers on Medi-Cal provider fee risk as federal HR 1 cuts take hold
• New HIV diagnoses fall 8% to 136 in 2025, but rise among Latinx residents
• Over 40% of detox seekers miss same- or next-day care, which DPH ties to state licensure limits
• DPH now counts stimulant deaths separately from opioid overdoses, citing heart disease findings
• City Option outreach cuts accounts facing escheatment 43%, returning more health dollars to workers

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Doing More With Less at Population Health

The basics: The Population Health Division runs San Francisco's disease surveillance, public health lab, emergency preparedness and community health planning. It has a budget of about $149M and 454 full-time-equivalent positions (FTE) in fiscal year 2026-27.

Why it matters: This was the meeting's longest discussion, at roughly 52 minutes. It showed how hiring limits and grant uncertainty are forcing trade-offs inside the department's core public health arm.

Where things stand: Dr. Susan Philip, Health Officer and Director of the Population Health Division, said the Operations, People and Infrastructure branch had 39.5 FTE in March 2026. By June, its new structure "actually represents a decrease of 5.5 FTE," with work spread across other branches.

Daisy Aguayo, Deputy Director of Operations, People and Infrastructure, said the driver was simple: "we are unable to fill vacant positions." Vice President Jurado asked whether frontline staff had input. Aguayo said conversations with staff began before a plan existed. She said four areas saw decreased support and that a plan-do-study-act approach will be used to adjust the changes. Some projects, front desk coverage and procurement support have slowed. Commissioner Guillermo voiced support for the approach.

Philip also pointed to bright spots. Public health lab billing grew from $20,000 in revenue in fiscal year 2021 to over $2M beginning in fiscal year 2025. She also highlighted staff safety initiatives, the Community Health Improvement Plan and a UCSF-backed Healthy Neighborhoods Initiative.

The Medi-Cal cloud: Earlier in the meeting, Guillermo flagged a looming state threat to the Medi-Cal provider fee. "I'm concerned about the Medi-Cal waiver issue that is going to impact the provider fee that will have even more devastating effect on our funding issues," said Commissioner Guillermo, who asked for an update at coming meetings.

Director of Health Tsai said the federal statute HR 1 reduces certain payments, that people are being removed from Medi-Cal and that state financing approaches are at risk. "We're going to continue to provide care irrespective of reimbursement," said Tsai.

Health Commission President Greene asked Philip, "Do you anticipate getting some very valuable data that then you can't operationalize because of funding?" Philip said she is planning as though no new resources will arrive. "The steady work of improving health and improving the data is going to take longer with fewer people doing it," she said.

Reaching Asian American communities: Commissioner Chow asked what the division is doing for San Francisco's large Asian American population on Medi-Cal retention. He urged the use of trusted spokespeople, ethnic media, radio, video and press events. Navina Baba, Deputy Director, said DPH held a summer convening of about 20 organizations, including the Chinatown Community Development Center and the AAPI Council. She said the Human Services Agency leads Medi-Cal retention messaging and that "there's a lot of distrust of government," which makes community messengers essential. Guillermo said the "different cultural and linguistic and immigrant experiences across all the different diverse Asian American Pacific Islander communities is something that cannot be discounted." Greene endorsed follow-up.

Decisions and stakeholder impacts: No vote was taken. The people who feel the cuts first are division staff absorbing extra work and residents who rely on slower data and outreach. Community-based organizations are becoming the de facto front line for keeping immigrant families enrolled in Medi-Cal.

What's next: Commissioners requested a Medi-Cal funding update and more explicit AAPI outreach at future meetings.

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HIV Gains Hold, but Detox Access Lags

Why it matters: Prevention funding restored through budget add-backs preserved HIV progress. Meanwhile, delays in getting into detox leave medically complex patients waiting.

Where things stand: Tsai presented the 2025 HIV Epidemiological Report. "We had 8% fewer new HIV diagnoses, so 136 in 2025," he said. Diagnoses declined across several populations but rose among Latinx residents. Tsai credited budget add-backs for restoring HIV prevention cuts.

This year's treatment-on-demand report measured timeliness for the first time. Close to 80% of people seeking treatment got same- or next-day care. Detox was the exception: "Over 40% of the time someone that raised their hand for detox … were not able to get same or next day treatment," said Tsai.

He said bed supply is not the problem. "On average, for example, HealthRight 360 has 10 empty withdrawal management beds on any given day," he said. Tsai cited state licensure rules as the main barrier. He said DPH is seeking waivers and will procure a 16-bed dual-diagnosis residential unit.

The other side: Amelia Harmon, a District 9 resident, said the treatment data reflects a year when peer counselors were on street crisis teams. She said peer-gathered data on medically fragile people denied detox is "not collected within the current SFFD metrics." Commissioner Chow asked how DPH street teams coordinate when the fire department lacks a peer. Tsai said peers are embedded in DPH street teams and contracts, that "peers continue to be a very, very important piece," and that DPH is available to partner. He noted the fire department has pivoted its own model.

Decisions and stakeholder impacts: DPH is shifting vaccination capacity toward homebound seniors. Vice President Jurado asked, "Is there a chance we could partner in some way with Meals on Wheels since we're talking about the same population," and staff said they would follow up.

What's next: Harmon asked DPH to address the peer data at an upcoming hearing on citywide drug markets.

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Rethinking How Meth Deaths Are Counted

Why it matters: How deaths are counted, and which outcomes regulators accept, shape which methamphetamine treatments get developed and funded.

Where things stand: Dr. Philip Coffin, presenting for the Center on Substance Use and Health, said addiction care nationally "basically still addresses methamphetamine use like throwing spaghetti at the wall." He outlined four strategies: assessment, general prevention, use reduction and toxicity prevention.

His team studied 100 stimulant-attributed deaths and found 93% had significant cardiovascular disease before death, a pattern resembling chronic illness. As a result, DPH now reports opioid overdose deaths and stimulant-attributable deaths separately. Coffin also reported two related findings. Some 42% of opioid overdoses that paramedics responded to involved people who denied intentional opioid use. And 40% of fentanyl decedents lacked evidence of regular use.

Current trials include GLP medications and extended-release naltrexone. A PrEP adherence study produced a five-fold increase in adherence.

The other side: Commissioners questioned whether reduced use, rather than abstinence, should be the goal, and asked about effects on executive function. "Or are we then actually looking at what is an acceptable level of methamphetamine, just like an acceptable level of caffeine?" asked Commissioner Chow. Coffin pointed to the FDA as a model, noting it "recently … changed their approval metrics for alcohol use disorder medications" to measure reduced use.

What's next: If the FDA adopts reduction-based measures for methamphetamine, San Francisco's research could help set national treatment standards.

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Workers Reclaim More City Option Health Dollars

The basics: Under the Healthcare Security and Healthy Airport ordinances, some employers pay into City Option medical reimbursement accounts for workers. Accounts left inactive for three years are subject to escheatment, meaning the unclaimed money reverts to the city's General Fund.

Why it matters: These employer contributions belong to workers. Outreach is returning more of that money to them rather than to city coffers.

Where things stand: Stella Chow, Director of the Office of Managed Care, said employers reported that 95% of their 2024 health spending went to insurance and 5% to City Option. Historic account use has hovered around 34%. Using a 2023 snapshot ahead of the first escheatment in May 2026, outreach cut the number of accounts subject to escheatment 43%, from 242,000 to 138,000. The dollar amount at stake fell 60%, from $507M to $201M.

Challenges included outdated addresses, data mismatches, cases involving deceased employees and strained staff.

Decisions and stakeholder impacts: Low-wage workers gain directly from the outreach, while the General Fund receives less in unclaimed funds. "The key here was to get the employees to make use of the funds, and clearly this has been done in a very wonderful manner," said Commissioner Chow.

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• Turf heat: Bob Hall of Keep Crocker Real reported artificial turf readings of 142 degrees at Franklin Park and 155 degrees at Crocker Amazon. He asked the commission to issue heat guidance, but it could not act because the item was not on the agenda.
• Contracts: The Finance and Planning Committee reviewed seven contract amendments and two new contracts. These included a $1M annual Smith and Nephew robotic orthopedics consumables deal and a 47% HealthRight 360 reduction. Commissioner Salgado questioned the cost.
• ZSFG oversight: Commissioner Chow reported that hospital vacancies have risen beyond 5% and that sexual assault allegations are up. The commission approved the consent calendar, including ZSFG policies, by voice vote; no tally was announced.
• Ebola preparedness: DPH has monitored travelers returning from Uganda since May 2026 and issued health advisories May 20 and June 9. It held an Aug. 18 hospital tabletop exercise with more than 60 participants.
• Procedural: The Sept. 21, 2026 minutes passed by voice vote. The commission met in closed session on Laguna Honda credentialing; no outcome was reported.

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Looking ahead: Watch for the Medi-Cal provider fee update Commissioner Guillermo requested, staff follow-up on a possible Meals on Wheels vaccination partnership and expanded AAPI outreach plans.