Issue 1 -

The Issue -

Medicaid is woven into the fabric of states’ health care systems and economies: it covers one in five Americans; is the single largest insurer in every state; and is the largest source of funding for mental health, substance use disorder (SUD), long-term care, and maternity services. Medicaid is also a critical engine in state economies and a significant item in their budgets. Given Medicaid’s importance, new state officials will want to evaluate the program, disentangling fact from fiction, identifying challenges and opportunities, and tackling pressing program priorities. This brief highlights priority issues for consideration and potential action.

The Structure of the Medicaid Agency -

The Medicaid Director is charged with stewardship of the Medicaid program. Where the agency and its leadership “sit” within state government enables or impedes the authority of the Medicaid Director to make critical decisions about program strategy, services, and budget. For example, while Medicaid is the primary funder of behavioral health and longterm-care services—and enrollees requiring these services are among the program’s most complex—in some states, responsibility for delivery system and payment policy for these services is vested with agencies that are outside of the purview of the Medicaid Director. States are increasingly questioning the rationale of this fragmented structure, and consolidating authority for all physical health, behavioral health, and long-term-care services under the Medicaid Director. New state officials should evaluate the structure of the Medicaid Agency and consider changes to strengthen the Medicaid Director’s ability to run the program effectively.