Today, Medicaid leaders are at the forefront of a dynamic health care landscape, shaping coverage and care for millions nationwide. As one of the country’s largest health coverage programs, Medicaid operates in a constant state of change, driven by shifting policies, fiscal pressures, and day-to-day operational demands. Leading in this environment requires more than technical expertise. It calls for adaptive, strategic leadership at every level.
Although today’s context is unique, this challenge is not new. More than 15 years ago, Medicaid programs entered a period of rapid policy change and expansion, introducing new coverage options while managing growing operational complexity. In response, the Center for Health Care Strategies (CHCS), with support from the Robert Wood Johnson Foundation (RWJF), began investing in Medicaid leadership development to help state and territory officials lead through change and maximize program impact.
These efforts led to the launch of the Medicaid Leadership Institute (MLI) in 2009, providing executive-level development for directors and senior teams with a focus on strategic leadership, systems thinking, and organizational effectiveness. Building on this foundation, the Medicaid Pathways Program (MPP), launched in 2020, strengthens the pipeline of senior leaders and deepens agency-wide capacity by supporting deputy directors and division heads. Together, these programs have engaged leaders across 52 states and territories — including 89 Medicaid directors and hundreds of senior leaders — fostering a national community committed to strong, effective Medicaid leadership.
“It has been a privilege to support this work and watch it grow. The leaders this program has developed are shaping the future of Medicaid in meaningful ways, and we’re excited to see what the next chapter brings for the people and communities they serve,” said Aingyea Fraser, Program Officer, Strategic Portfolios, Robert Wood Johnson Foundation.
MLI and MPP alumni often move to influential roles beyond their agencies, continuing to shape national conversations on Medicaid policy. Many progress to senior state and federal positions, bringing deep expertise in the Medicaid program and a network that spans the country. Their impact is sustained: MLI alumni remain in their director roles longer — more than twice the national average — and more than 80 percent of MPP alumni stay in public service, creating stability and enabling long-term priorities to take hold. Just as importantly, they carry what they’ve learned back to their teams, building shared language, strengthening organizational capacity, and expanding staff development opportunities. The result is a stronger, more connected Medicaid ecosystem that can better serve communities nationwide. MLI and MPP have yielded important lessons on building and sustaining effective Medicaid leadership, while establishing a strong foundation for future growth.
Insights on Medicaid Leadership Development
Over 15 years of working with Medicaid directors, deputies, and senior teams, several consistent lessons have emerged about why it’s important to invest in public sector Medicaid leaders.
- The capacity of leaders directly shapes how services are delivered and experienced. Effective leadership influences organizational culture, staff engagement, and an agency’s ability to adapt in changing environments. Medicaid leaders make daily decisions that affect how services are delivered, how communities are engaged, and strategic direction. When leaders are skilled at navigating complexity, they are better positioned to design responsive systems, build trust with communities, and drive meaningful, sustainable improvements in outcomes.
“As Medicaid leaders, we sit in a unique position to hear about the impact of the program at the individual member or provider level, while also seeing how minute operational or policy details affect the program as a whole,” said Adela Flores-Brennan, Colorado Medicaid director and MLI alumna. “As leaders, it is our imperative to take those diverse viewpoints, leverage relationships and the expertise of our teams, and tie it all together to help advance coherent, meaningful change.” - Leadership skills can be grown and nurtured over time. Leadership is not a fixed trait or title, but a practice that evolves through reflection, action, and learning from experience. It’s rooted in risk-taking and a supportive environment. Anyone can be a leader, and everyone can grow as a leader throughout their lives. New roles encourage people to learn, and new challenges support continued growth. Creating dedicated space for leadership development — outside of day-to-day operational demands — is critical. When leaders step outside of their organizational context into neutral, facilitated environments, they gain the perspective needed to lead more effectively.
“I once believed leadership belonged only to the most outspoken and extroverted people. Yet, my experiences have taught me that it is a practice built on continuous learning, adaptability, and creating opportunities for others to grow” said Collette Onyejekwe, pharmacy director for Rhode Island Medicaid and MPP alumna. “Leadership is not defined by personality or position, but rather a willingness to step outside of one’s comfort zone, embrace change, and support others. My leadership journey has shown me that the most impactful leaders are those who remain committed to learning and empower others to do the same.” - Peer networks reduce isolation and accelerate problem solving. Medicaid leaders often operate in high-pressure environments with limited opportunities for candid exchange. Peer networks create trusted spaces for sharing challenges and solutions. These relationships not only reduce isolation but also help spread effective practices across states.
“Although all Medicaid programs are different, it is helpful to talk through challenges with colleagues who have a shared understanding of the complexities of administering such a critical program,” said Ryan Van Ramshorst, chief Medicaid officer for Texas Medicaid and MPP alumnus. “Having a network of peers creates opportunities for innovation, collaboration regarding major policy initiatives, and continuous quality improvement. I feel incredibly lucky to have a trusted group of ‘phone-a-friends’ who provide support, encouragement, and guidance.” - Strong leadership pipelines are essential to program stability. Building a shared growth mentality, investing in professional development opportunities across all levels of staff, creating opportunities for delegation so work is distributed effectively, and planning for succession help ensure that organizations maintain steady direction during leadership transitions. This continuity enables long-term strategies, including policy initiatives and system-level improvements, to take hold and come to fruition over time.
“MLI reinforced the importance of creating pathways for the next generation of Medicaid leaders,” said Toby Douglas, former California Medicaid director and MLI alumnus. “I brought this lesson back to my agency and created the DHCS Academy, which provides policy training to mid-level Medicaid managers. Fifteen years later, that program has supported hundreds of DHCS staff, helping them serve members well.” - A shared leadership language strengthens the field. Common frameworks and terminology help leaders align across organizations, making collaboration more effective. Over time, this shared language builds a stronger, more connected field that can move collectively toward common goals and amplify its overall impact.
“Achieving whole-person health requires Medicaid, public health, social services, behavioral health, and every facet of the health sector work in true alignment,” said Cindy Beane, former West Virginia Medicaid director and MLI alumna. “That only happens when leaders share a common language and a common mission. When leadership is grounded in shared frameworks and understanding, it shifts from siloed systems to collective impact for the people we serve.”
Looking Forward: The National Medicaid Leadership Center
CHCS is entering a new chapter with the launch of the National Medicaid Leadership Center, alongside funding partners committed to strengthening leadership skills across Medicaid. As the nation’s primary hub for developing Medicaid leaders, the Leadership Center strengthens the pipeline of skilled professionals and builds the collective capacity of Medicaid agencies to lead system transformation, sustain policy innovation, and steward public resources responsibly.
This moment is especially timely. States and territories are navigating significant policy and operational shifts, and the need for skilled leaders who can guide agencies through change is critical. The future of Medicaid depends, in no small part, on the people leading it. Sustained investment in leadership development strengthens programs’ ability to adapt, deliver results, and better serve communities. The launch of the Leadership Center reflects a continued commitment to building the leadership needed not just for today’s challenges, but also for what lies ahead.
