The People Behind the Medicaid Transformation and What They Need from Us Now

Reflections from the 2026 National Association of Medicaid Directors Conference

By Janine Savage, Principal, Value-Based Care Solutions for States and Payers

At the recent National Association of Medicaid Directors (NAMD) Fall Conference, I heard an unexpected conversation in an elevator that has stayed with me. Several of us wearing NAMD conference badges stepped into an elevator, along with a gentleman who was not attending the conference. He looked at our badges, and, with a curious look on his face, asked, “What’s NAMD??” Someone explained that it was the National Association of Medicaid Directors, and another person offered a quick explanation about the organization and its members.

When the elevator reached my floor, I stepped out… and so did this gentleman. As we began walking down the same hallway, I felt compelled to add something to the explanation. I told him that the people attending this conference do extremely important work, that they help determine the healthcare that’s available to some of our country’s most vulnerable people, they earn far less than they could be making in the private sector, and they choose to do this work because they believe so strongly in it. He stopped, looked at me, and said, “I had no idea. Thank you so much for sharing that with me.”  

It was a brief encounter, but it captured something I believe is too often missing from conversations about Medicaid policy and transformation: behind every Medicaid policy and program are people who have committed their professional lives to making healthcare work better for those who depend on it.And right now, they are being called upon to fulfill that mission under what are arguably the most challenging circumstances of their careers.

People and Purpose: The Foundation of Medicaid Transformation

I have spent my entire career in healthcare, beginning as a registered nurse and later working across operations, compliance, healthcare technology, and value-based care. Today I specialize in Medicaid policy, working closely with state Medicaid agencies and the partners supporting their efforts to improve healthcare quality, access, and outcomes.

That experience has given me tremendous respect for the people who lead and operate state Medicaid programs. They work at the intersection of healthcare delivery, public policy, finance, technology, regulation, and human need. They must balance the interests of Medicaid members, providers, managed care organizations, state leadership, federal agencies, and taxpayers, and often when those interests are not fully aligned or politicized.

Their decisions affect whether individuals have access to health insurance and essential healthcare services, providers have the resources to deliver those services, and public investments produce meaningful improvement in health and well-being.

This is difficult work under the best of circumstances, but now, it is taking place amid extraordinary change and uncertainty. At NAMD, the intensity of the challenges facing state Medicaid agencies was unmistakable, including federal policy changes, mounting fiscal pressures, Medicaid financing restrictions, new administrative requirements, and evolving expectations for quality and accountability.

Yet the underlying mission has not changed. State Medicaid leaders still want to expand access to appropriate care, improve healthcare quality, strengthen outcomes, and ensure the responsible use of public resources. The question for those of us who work alongside them is now how we can do more than adapt our solutions to changing policies; how can we best support these dedicated public servants in fulfilling their mission to improve the lives of the people they serve?

Sustaining Progress When the Financial Landscape Is Changing

One of the most consequential issues discussed at NAMD was the changing financial environment for Medicaid. States are confronting new federal restrictions affecting Medicaid financing and state-directed payments, alongside broader pressures on state budgets and healthcare delivery systems.

State directed payments (SDPs) have become an important mechanism for supporting provider reimbursement and advancing delivery-system and payment reform initiatives. Changes to the availability and limits of these arrangements create difficult questions about the sustainability of programs that states have invested years in developing. How do states improve quality when the financial structures supporting their initiatives change? How do they preserve provider engagement and meaningful performance incentives when resources become more constrained? And how do they protect the objectives of Medicaid transformation while adapting to new federal requirements? These questions do not have simple answers.

In my work, designing and operationalizing statewide value-based payment programs, I have seen firsthand the complexity of moving from a policy objective to a functioning program. Successful policy implementation requires much more than just designing a payment methodology. It requires clinical and policy expertise, reliable data, clear performance expectations, provider participation, technical infrastructure, sound governance, and ongoing program administration.

It also requires the ability to adapt. As states evaluate the future of their payment reform initiatives, sustainability is essential to initial program design, not just as an afterthought when funding is threatened. Sustainability means identifying what is working, understanding what is not, and developing viable approaches to preserve the outcomes and improvements that matter.

Measuring What Matters and Making Those Measures Matter

Another significant theme I ran into at NAMD was the growing emphasis on outcomes-based accountability. The Centers for Medicare and Medicaid Services (CMS) has launched its Investing in Health Outcomes initiative, calling for greater emphasis on meaningful health outcomes, fewer duplicative reporting requirements, more timely digital quality measurement, and stronger alignment between financial accountability and results.

Healthcare quality measurement will ultimately help us understand whether people are indeed receiving better care and experiencing better health, and it’s essential to bending the cost curve on healthcare spending by reducing waste. But translating that objective into effective value-based payment programs requires careful consideration.

It’s often said that you cannot manage what you do not measure. Outcome measures are essential, but not every outcome measure is equally appropriate for every provider, population, or payment arrangement. Measures must be clinically meaningful, statistically reliable, supported by available data, and reasonably attributable to the providers being held accountable.

Process and structural measures also have an important role in designing this program, particularly when they reflect evidence-based practices or capabilities necessary to improve outcomes. But focusing on individual measures does not, by itself, improve healthcare quality or mean you have an effective measurement approach.

So what does “effective” look like? It depends on where you sit. For state Medicaid leaders, it means being able to connect quality strategy to program design, performance expectations, provider incentives, and credible evaluation of results. For providers, it means understanding expectations, having confidence in how performance is measured, and receiving information they can use to improve care. For Medicaid members, it should ultimately mean better healthcare experiences and outcomes. The real opportunity is to build measurement frameworks that support better decisions and continuous improvement.

Program Integrity Is Fundamental to Public Trust

Program integrity deserves particular attention as Medicaid programs face increasing financial scrutiny. Traditionally, discussions of Medicaid program integrity often focus on preventing, detecting, and addressing fraud, waste, and abuse. These functions remain critically important, so I was glad to see it highlighted as an important topic at NAMD. But I believe program integrity must also be understood more broadly as a foundational element of program design and administration.

Consider a statewide value-based payment program. Are provider eligibility criteria clear and applied consistently? Are member attribution and utilization data valid and reliable? Are quality measures calculated according to appropriate specifications? Are payment methodologies transparent and implemented as intended? Can the state validate and defend the resulting payments? These are not simply technical or administrative details. They are essential to the integrity, fairness, and credibility of the program.

This is why program integrity cannot be an afterthought; it must be built into the design, data, processes, controls, and governance of Medicaid payment initiatives from the beginning. It is also inseparable from public trust. State Medicaid agencies have a responsibility to demonstrate that public resources are used appropriately and produce the intended results. Their partners share a responsibility to provide the expertise, transparency, and accountability necessary to support that stewardship. At a time when every dollar faces increasing scrutiny, strong program integrity and meaningful quality improvement should reinforce one another, not compete for attention.

Technology and AI: Tools That Must Serve the Mission

Technology modernization and artificial intelligence (AI) were also prominent themes at NAMD. There is enormous potential for technology to help state Medicaid agencies improve efficiency, integrate information, reduce administrative burden, strengthen oversight, and make better-informed decisions. AI’s capabilities offer new ways to analyze complex data, identify anomalies, streamline workflows, and help agency teams focus their expertise where it can have the greatest impact.

But technology is not an end in and of itself. Effective Medicaid transformation begins with a clear understanding of the problem we are trying to solve and the outcomes we hope to achieve. Reliable data, sound methodology, appropriate governance, interoperability, security, and human oversight remain essential. AI does not eliminate those requirements; in many respects, it makes them even more important. Technology should be evaluated not only on what it can automate, but on how it helps the people responsible for administering these extraordinarily complex programs.

What State Medicaid Leaders Need from Us Now

The issues spotlighted at NAMD are interconnected and interdependent. Financial sustainability cannot be separated from payment reform. Payment reform cannot be separated from quality measurement. Quality measurement depends on reliable data and effective technology. And every one of these activities must be supported by program integrity, transparency, and accountability.

State Medicaid leaders do not have the luxury of treating these as isolated challenges. Neither should the organizations that support them. Whether we are technology companies, consultants, healthcare providers, managed care organizations, or other partners in the Medicaid ecosystem, we have an obligation to bring more than products, policy interpretations, and recommendations to the table. We need to bring practical expertise, a willingness to collaborate, and a commitment to successful implementation – not simply deliver strategy recommendations.

We need to understand the operational realities state agencies face, including limited resources, competing priorities, demanding timelines, and changing federal requirements. We need to help states make informed decisions, anticipate unintended consequences, implement workable solutions, and demonstrate results. Andwe need to recognize that the success of our work is ultimately measured not by the sophistication of a methodology or technology platform, but by the difference it makes for the people Medicaid serves.

Remember Why the Work Matters

I keep thinking about that brief conversation in the elevator. The gentleman who asked about NAMD did not know what the acronym meant. Honestly, he probably had little reason to think about Medicaid administration or the people responsible for it. But when I described the commitment and importance of the work, he understood.

In healthcare, we spend a great deal of time discussing policies, regulations, reimbursement, quality measures, technologies, and transformation strategies. Those conversations are necessary, and they are also complex, consequential, and sometimes contentious. But we cannot allow the complexity or the contentiousness to obscure the purpose.

The people leading Medicaid programs are making difficult decisions in an environment of profound change. They are navigating challenges that will affect healthcare access, delivery, and outcomes for millions of Americans. They deserve our respect, our partnership, and our best work.

Behind every Medicaid transformation initiative are people who believe healthcare can be better and who have chosen to dedicate their careers to making that happen. As their partners, our responsibility is to help them succeed.