Charting a Path in Changing Times

The Greek philosopher Heraclitus sought to identify the First Cause for the creation of the world. From this work comes his famous quote, “change is the only constant.”  There has been plenty of leadership change in Medicaid lately, with large-scale changes in member enrollment on the horizon.  Its enough to make people wonder if we have ever seen anything like it.  Short answer? We have.

The reality is that Medicaid is constant change. The federal-state program balances common expectations of a national entitlement program with flexibilities that enable states to reflect needs and priorities. Particularly in 2023 there are several factors – unwinding, the end of the federal public health emergency, the economy – that could affect coverage and financing under Medicaid. Seeking order and some perspective, we turned to Dave Richard, the former Deputy Secretary of Medicaid in North Carolina.  He offered insight specifically for new Medicaid Directors and the stakeholders who champion their success.

First, a reality check.  You can’t manage change by yourself. The Medicaid Director needs to listen to and spend time with internal and external stakeholders. In particular, engaging stakeholders outside of the agency helps the leader gain insight and allies. Dave jokes, “When I came into Medicaid, I thought I knew a lot. It turns out I knew nothing. The external stakeholders helped me navigate the areas of the program that were new to me and showed just how vested they were in Medicaid functioning at its best.”

Second, some advice. Stepping into leadership means building awareness and competency in multiple areas, simultaneously. NAMD’s New Medicaid Director Roadmap articulates this first phase of assessment across seven domains of leadership.  Dave distills it into three:

• Know your leadership style. Dave cautions that imposter syndrome is real, and his best advice is you can only be yourself.  A new leader is effective when they know what they are good at and where they need others’ strengths.
• Lead up. Dave reflects on the good fortune and hidden benefit of serving four different secretaries during his tenure.  Onboarding and elevating “uppers” help a director fine-tune focus, direction and priorities. With each secretary or cabinet-level change, comes adaptations in collaboration and communication styles.
• Map stakeholders. A new Medicaid Director needs to understand stakeholders who will be most influential. For Dave, that meant getting out of the office, getting on the road, and meeting providers and patient groups at the point of service. Inevitably, the Medicaid Director will wind up making decisions about the program based on their understanding.  To have a complete understanding of the program, it is critical to spend time looking at the program from other people’s point of view.

Third, a leadership lesson. Leaders new to Medicaid need dedicated thinking time. During years of COVID and now unwinding, the Medicaid program is fueled by volume, process, and the “grind”. For Dave exploration, research, and staying open to ideas created space for personal and program growth. Elevated thinking contributes to personal satisfaction and momentum in a program where it is easy to lose ground among competing timelines.

Lastly, Dave encourages Medicaid’s allies to be supportive in extraordinary times. The confluence of unwinding, budgeting and other significant state priorities sets a complicated table. The Medicaid agency is on a precipice – having planned and re-tooled they are anxious to see how unwinding plans play out. Allies of Medicaid should understand it’s unlikely the Medicaid director knows everything about every scenario – many policy issues require translation, and the agency is filled with policy specialists to help find answers. Stakeholders should also understand that Medicaid staff are working hard, and their time is especially important now.  State staff are likely spread thin, forced to prioritize, and bounded by time and capacity realities. It is a good time to remind ourselves and our stakeholders that change is constant and we are navigating it together.