Today’s Medicaid programs face a rapidly evolving landscape characterized by substantial budget constraints, frequent state-level leadership changes, and the operational challenges of rolling out new eligibility and work-requirement policies. There is also an increased emphasis on reducing fraud, waste, and abuse, all while aiming for long-term program sustainability. Concurrently, states are pursuing key initiatives including improvements to behavioral health systems, maternal health programs, payment and delivery system reforms, and efforts to transform rural health services.

Earlier this month, the Center for Health Care Strategies (CHCS) hosted a panel to provide insights into how Medicaid leaders are navigating today’s changing environment.

Allison Hamblin, President and CEO at CHCS, opened the session by asking the panelists to share one thing they wish people understood about the realities of running a Medicaid program.

Melisa Byrd, Senior Deputy Director and Medicaid Director at the Department of Health Care Finance in the District of Columbia and former NAMD board president, shared that ongoing changes in Medicaid are one of the challenges. One of the newer challenges, she noted, is the interrelatedness of the Medicaid program. “If we make a change here to Medicaid, what does that do to our overall system within the district? A small change in Medicaid can take out hundreds of millions of dollars out of your healthcare system.”

Jami Snyder, President and CEO with JSN Strategies, former Arizona and Texas Medicaid director, and former NAMD board president, added that in Arizona, there was a need for outside partners to accomplish the program's goals. “It didn't make sense to do it alone, and we had system partners that could bring that expertise and, more importantly, resources to the table.”

Stuart Portman, Executive Director of the Division of Medical Assistance Plans with the Georgia Department of Community Health and NAMD board president, remarked that the operational side is increasingly dominated by contract- and procurement-related discussions. He emphasized that implementing important ideas shouldn’t take multiple years.

“Medicaid means a lot of different things to a lot of different people across the country,” Mark Larson, Senior Vice President, Leadership and Capacity Building at CHCS and former Vermont Medicaid director, noted. “For some, it's how do we create continuity of care to create greater population health. For others, it's a social welfare program that should be limited and for certain people.”

To the question of how to promote innovation and creativity among teams, Snyder responded: “Make sure that your team knows it's okay to challenge longstanding assumptions.” You want to bring in those folks that are on the ground, whether they're doing eligibility work or contract monitoring work, and really tap into their sense of creativity, Snyder added. “I think the other piece of the equation in terms of creativity and innovation is bringing in your system partners early.” Additionally, she said, oftentimes the most impactful changes are incremental in nature.

“There is no Medicaid without politics, Portman added, “and I think a lot of people think that things would be easier without the politics, but Medicaid doesn't exist in a world devoid of politics….In that political back and forth, you can get some real creativity.” “There is a partnership angle both within the state and also with the federal government,” Portman said in relation to engaging in conversation with CMS.

Regarding which emerging issues or opportunities will most shape Medicaid priorities, Byrd mentioned the H.R. 1 act. “We're going to be implementing that for several years.” Additionally, she said there are profound changes to Medicaid financing, legislation, provider taxes, and 1115 waiver administration.

“I think when you get more in that five-year window,” Portman said, “I will just note there's a lot of discussion in healthcare broadly about trying to shift from paying for volume to having a more value-based system.”

“I think one of the challenges that we'll face in the next five years, speaking as a former state legislator,” Larson said, “is the volatility in state revenues, which will put an ongoing pressure on the resources that we have, not just to keep operations going, but to drive some of those innovations.”

“This time really requires leaders to think about transformational change that will ultimately ensure the sustainability of programs,” Snyder added.

Regarding advice for incoming directors, Snyder noted that it’s important to build relationships with partners at CMS, state legislators, community stakeholders, health plans, and providers. Also, she said, lean on your peers in other states.