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Reflections from Matt Salo

A blog with reflections from NAMD’s founding Executive Director, Matt Salo.

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Medicaid provides health insurance coverage and access to vital services for millions of people and is a critical component of the country’s health care system.

As Matt Salo, the founding Executive Director of the National Associator of Medicaid Directors prepares to leave his post, Gretchen Hammer, former Medicaid Director in Colorado and current consultant for NAMD, sat down with him to ask him a few questions about his time working with Medicaid and at NAMD. You can listen to the full podcast here as well as read Matt’s reflections on the COVID19 pandemic here.

Matt, you have been NAMD’s first executive director and have been credited with creating a vibrant and vital association for Medicaid leaders. Can you help listeners understand why an association of Medicaid leaders is so important and what the unique attributes or challenges are that Medicaid leaders face that requires this kind of support?

Medicaid is not only the most important health care or social program in the country, it is arguably the most complicated program in the country. Given the complexity and importance of the mission, the key thing that a strong association can do for Medicaid leaders across the country is first of all to bring them together and give them a community where they can learn from one another. The second thing is to bring them together to be able to have a voice in national conversations.

Whether we’re dealing with federal partners in congress, the administration, or other stakeholders, it is so important for the voice of the Medicaid leader to be elevated so they can have an impactful meaningful voice in conversations that impact this country that impact the program and that impact the people we serve.

That is what we’ve tried to do over the past decade or so at NAMD. Create an organization that first and foremost creates this fraternity/sorority of Medicaid directors who have a shoulder to lean on and a peer-to-peer network where they can learn and avoid easily avoidable pitfalls, and learn tips and tricks from one another.

Finally, in the past several years we’ve really had the opportunity to lean into leadership development. We asked ourselves how can we at the association level strengthen and support state Medicaid agency leaders? Thus far, we’ve offered leadership 101 types of supports as well as applied Medicaid leadership concepts to be able to take this program and achieve what we know we can achieve.

As we look at the Medicaid program and the role it plays in the health care system and in providing access to vital services, what do you think has evolved the most during your tenure as Executive Director of NAMD?

So, I think the answer to that question is complicated, in that the program has been undergoing steady but also significant growth and changes throughout its almost 60-year history. I mean, the Medicaid program was created essentially as an afterthought to Medicare, but now it is a much larger, but also much more meaningful, program.

When this country faces a crisis, whether that be natural such as a hurricane or man-made such as 9/11 or pandemic related, Medicaid has stepped up to provide the insurance and assurance that millions of Americans physical mental, behavioral, and yes even fiscal health will be supported and strengthened through a time of crisis. Medicaid has stepped up and, in many ways, become more visible, in part because of its growth. Medicaid pretty soon will be covering almost 1 in 4 Americans.

For too long in this country, people have been able to dismiss Medicaid as a “low-income” program or “poverty” program, and not fully appreciate it because they think it benefits someone else. But what we’ve really learned in the past decade is that Medicaid is all around us. Medicaid is us. Medicaid is the backbone of our country. The greater appreciation of that (reality) we see from citizens and from policy makers at the state, federal, and local levels, the more important and more vital conversations are to ensuring the lifelong stability and support for the Medicaid program.

As you look ahead to the future what do you see as the ideal type of leader Medicaid programs are going to need at the federal and state level? What will those leaders be focused on as they look ahead into the future?

So, I think the future is going to be determined by a number of very important questions.

I think we are at an inflection point where Medicaid is playing such an outsized role in so many areas of the U.S. health care system. One of the questions will be, can it continue to grow? Can it continue to take on more and more of the challenge and the complexity and expense of the health care system for more and more Americans?

Another question is, will it continue to provide the types of cutting edge, groundbreaking services that Medicaid has really leaned into as of late. We have talked a lot in recent years of the social drivers of health. Things like housing, food security, trying to prevent trauma and adverse childhood events. These are the kinds of things Medicaid is embracing as a way of saying, “Here are things that are going to have meaningful impacts on people’s lives but have never really been part of a traditional health insurance or medical insurance model.” Medicaid is going to have to think very,very carefully about how far down that road it can go.

Similarly, Medicaid is going to have to think about how much of the nation’s Long Term Services and Supports (LTSS) burden it can carry. Right now, Medicaid is taking on the burden of being the nation’s LTSS system, which has a lot of downsides. Especially because Medicaid is still, at its core, a low income, means-tested program.  So, this means for many people, by the time American citizens are receiving robust LTSS they either will have had to impoverish themselves first to get those or impoverish themselves and give up estates to estate recovery afterwards.

At the federal level, I think the main question is do we want Medicaid to continue to operate the way it has ever since 1965, which is as a program that has a federal framework but is very much driven by decisions that are socially, culturally, and financially relevant at the state and local level. That does lead to differences across states in the program. Many people, myself included, would say that is a strength in the program. That is a feature not a bug. But, a question that is going to come up pretty frequently as people look across the states and say this state does X and that state doesn’t. Is that fair? Should we change that? That to me is going to be one of those future conversations the program is going to have to grapple with.

As you prepare to leave your post as the founding executive director. What do you wish that people knew more about in terms of the leaders that lead these Medicaid programs in the states and Territories?

I’ve not only had the privilege of a lifetime running this association, but I have spent my entire career, more than 25 years, working with state health Medicaid officials.

The one thing that has kept me glued to my seat the entire time has been the awe in which I have always been around these leaders and the way that they so seamlessly combine passion and compassion along with pragmatism and practicality. The Medicaid program is the perfect example of a program where you don’t just get to decide. You don’t get to wave a magic wand and say I’m fixing the health care system and it’s going to be perfect tomorrow. You deal with the reality of how the world exists, with politics as they exist, and the health care system as it exists.

The Medicaid directors that I have known for decades have all had that incredible commitment to running this program and improving the program. Taking a health care system in this country that doesn’t always know how to deal with medically complex individuals and derive improved value and greater outcomes out of it. That kind of leadership has always struck me, and I think that is one takeaway I would want people to have.

Medicaid also is a series of tradeoffs. Every decision you make there is going to be someone saying, “Oh, I wouldn’t have done that” or “Shouldn’t you have gone further?” There are no easy decisions in Medicaid. You have to very delicately balance politics, the health care system, finances, and (the) reality of balanced budgets.  You also have to balance many, many stakeholders, all of whom have very legitimate needs and very legitimate claims for more resources and more investments. Every day brings a new difficult decision.

I would want people to walk away saying I understand the nature of this job a little better. I appreciate the hard work that Medicaid Directors are putting in, in a very imperfect world, to try to create a better health care system for the people we serve.

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