Jen Strohecker, PharmD, Utah Medicaid director, offers advice to Medicaid leaders looking to initiate and/or expand efforts to advance health equity in the communities they serve.

Over the last three decades, Utah has experienced a significant demographic shift. In 1990, less than 10 percent of the population identified as non-white. By 2022, that percentage had more than doubled to 23 percent, and is on track to be above 30 percent by 2040. For Utah Medicaid, this increase in diversity across the state has highlighted the imperative to focus on health equity and better address the needs of historically marginalized populations.

Utah’s Medicaid team, under the leadership of Jennifer Strohecker, has been increasingly focused on efforts to improve health equity over the past few years. A pharmacist by training, Jen served as the director of pharmacy for the Utah Department of Health and Human Services (formerly Utah Department of Health) from 2018 until assuming the role of Medicaid director in 2022. Since then, she has led efforts to integrate health equity into both the vision and day-to-day operations of Utah’s Medicaid program.   

Below, Jen shares lessons for Medicaid leaders seeking to advance health equity work. She reflects on how leaders can guide and empower staff to further the cultural and operational change necessary to advance health equity.

Establish Vision and Commitment

In Jen’s experience, creating the vision is the easy part. When she began her tenure as Medicaid director, the Utah Department of Health and Human Services had just updated its vision statement to reflect a health equity priority. She was also participating as a Fellow in the Medicaid Leadership Institute and used the experience to articulate her own leadership values and alignment with health. Together, she and the Medicaid team were able to clarify their vision, articulating that Utah Medicaid “will address health equity and health outcomes through a focus on member experience and improved access and use of preventative services.” To maintain this commitment, Jen and her team needed to incorporate health equity into policy and operations without losing focus on competing priorities. They embedded the organization’s commitment to health equity into strategic plans, division goals, and initiatives.

An “aha” moment came in the form of a framework offered by the Governor’s Senior Advisor on Equity and Opportunity and Director of the Utah Division of Multicultural Affairs, which offers the advice that organizations approach equity by being “data-informed, opportunity driven, and customer-centered.” This framework supports Utah Medicaid’s action-focused approach to health equity that provides a sustainable long-term vision.

Becoming more customer centric reinforces the commitment to health equity because it helps the Medicaid team see programs through the eyes of members and their lived experience. Jen sought to reflect this commitment to Medicaid member engagement during staff meetings, trainings, and external engagements. “It can be easy to say that Medicaid pays for a service, so we’re all set,” Jen said “However, focusing on health equity requires understanding the challenges and barriers, and how a person’s lived experience may prevent them from accessing valuable health care.”

Utah is working to bring the member voice ever closer to the decision-making process. Jen is emphatic that she and her team hear directly from members, explaining, “We build systems and programs, but if we’re not thoughtful, they may be isolated from how the member journey plays out in the real world.”

This includes member survey and satisfaction data, but it also includes giving members space to tell their stories. Recently, Jen invited a member to join a monthly Medicaid team meeting to share her story about engaging with the Medicaid program — both the struggles and the benefits it provided. She also brings her eligibility team members out to community events, both so that the public can get real-time support, but also so that the team is connected to the questions, concerns, and perspectives of members and prospective members.

Jen leans on her own personal experience as well.  As a pharmacist, she notes, you need to be thinking, “What is the question a person is too afraid to ask? Or maybe they couldn’t read the materials and I’m using words that are too clinical. As a result, they don’t make the connection that there might be an important issue that they need to discuss with you.” It’s only when you find a way to give someone the space and ability to raise that question or concern that you’ve truly begun to meet their needs. 

“Our Medicaid agency team has the interest and passion,” Jen explains. “Our staff want to do this work because they care about the people we serve.” From Jen’s point of view, it’s really a matter of creating the space for growth in perspective and giving people the tools to create change. As a leadership skill, creating space means giving people the chance to reflect, exchange ideas, and develop trust as a team. This can look like open discussion time in meetings, community listening sessions, team building, and identifying other ways to slow down and show up authentically. While the leader may ultimately be accountable for setting the vision and reinforcing the commitment, successful transformation relies on teamwork, including shared commitment and contributions to the vision.

Break Down Silos

While Jen looks ahead to where she’d like the Medicaid program to go, she also gives credit to Utah for having a nearly 20-year history of investing in health equity. The Utah Office of Health Equity (OHE), first established in 2004, is an invaluable resource and partner to the Medicaid division, and there have been focused efforts to break down silos and create collaboration between the two entities. This was aided by a larger restructuring when, in 2022, the Department of Health merged with the Department of Human Services, supporting greater facilitation of umbrella agencies like OHE and Medicaid. Combining OHE’s expertise and the Medicaid program’s reach, their partnership is having an impact beyond what either entity could achieve on its own. This partnership is critical for advancing Jen’s vision to improve health equity. Most recently, OHE supported Medicaid with a series of assessments and coaching wherein OHE worked with one Medicaid team (e.g., Medicaid policy team) at a time. This included an assessment of how the team incorporates best practices in supporting health equity and serves as a starting point to inform ongoing coaching and support.

Medicaid and OHE recently completed work with the member call center team, where call data, scripts and guides, and call recordings were reviewed to gain insights about where opportunities existed to engage and meet member needs more effectively. As a result, the call center team modified their call center scripts, but more importantly, the team is now more attuned to understanding the barriers a member may need support in navigating, above and beyond the question they may be immediately asking.

Jen notes that the two teams that have gone through the assessment and coaching so far feel empowered to do their work differently. They are investing in process improvement and building continuous quality improvement into their teams’ strategic planning efforts. And the work continues, with the Eligibility team up next.

OHE, with its history of partnering with communities, has also helped Jen and her team to build trusted partnerships outside of state government. The Medicaid team has been able to build key relationships with community health worker organizations and refugee resettlement programs because of their partnerships with OHE, and they in turn help build trust with communities and members themselves.

Get (Super) Tactical

Setting vision, establishing commitment and relationship-building with internal and external partners are critical, but there are also the nuts and bolts of operationalizing change. Once it was clear that Medicaid staff were starting to prioritize health equity, it was time to put that focus into action. Jen and the Utah Medicaid team prioritized two key areas: getting timely accurate demographic data and mapping out data processes.  

Limitations on data sharing often impede opportunities to identify and address disparities. For example, Utah’s Medicaid application is required to have racial and ethnic data as optional fields, which means data are not always provided. Similarly, OHE has collected a wealth of data on health disparities over the last 20 years, but OHE data are not connected to Medicaid data.

Recently, one large Utah Medicaid managed care organization (MCO)¹ went through the NCQA Health Equity accreditation. This created an opportunity for the Medicaid team to understand the best practices the MCO had been implementing, particularly to capture more data.

As a result, Utah updated all their MCO contracts to require that MCOs share demographic data with the state on a monthly basis. The state also built quality metrics and payments into their contracts to incentivize MCOs to proactively interview members to capture additional demographic data. This accountability also served as a mechanism to reinforce the Division’s ongoing commitment to health equity. While the agency is currently using a manual process to integrate the collected demographic data with eligibility and enrollment information, it represents a key first step to having timely and actionable data.

But demographic data is only part of the story.  Jen also emphasizes the need to understand how people are — or aren’t — able to navigate the system they encounter.  Where is someone likely to get stuck?  As Jen phrases it, “Where is the path too winding and difficult, and we need to straighten and smooth it out?” Process mapping provides a way to clearly identify gaps and opportunities, especially when the mapping is informed by a member’s perspective. For example, Jen shared how her team received feedback from members that eligibility forms and notices are challenging to understand and interpret. In response, they partnered with OHE to address this feedback and as a result, the Eligibility Notice Improvement project started with the goal of enhancing clarity, accessibly, and compliance. Through this project, her team is implementing enhancements to Medicaid forms and notices. They’re focused on assessing the cultural, linguistic, and accessibility needs of members, and creating easily comprehensible materials in accessible formats and members’ preferred languages. They are also establishing a formal process to ensure written materials in members’ languages are high-quality and accurate — they want to avoid relying on machine translation tools like Google Translate.

Leadership Takeaways

Focusing on health equity and health outcomes and incorporating them into the culture and policy making of a Medicaid agency takes time, effort, and intention. The experiences of Jen and her team at Utah Medicaid illustrates key considerations for Medicaid leaders at all levels to reflect on as they undertake their own health equity journey.  

• Establish vision and commitment. As a leader, developing a vision for and commitment to health equity is an important opportunity to effect change and bring in the voices and experiences of staff and the communities served.  How are you bringing lived experience into the policy development process, including the lived experience of the members, your teams, and your own? How can you make equity conversations real and tangible? How can you create space for staff, members, and stakeholders to bring their energy and ideas? How can you reinforce this commitment among competing priorities?
• Break down silos. Identifying the potential internal and external partners who are already engaged in health equity work (or who may have a key piece of the puzzle, e.g., data access) will bring additional energy and expertise, and help you maintain momentum. You probably have more people to draw on than you expect. How can a focus on equity work foster new partners and, if not break down silos, build bridges across them? Does your state have a resource like Utah’s Office of Health Equity that can help guide and support your team? Are there partners that you work with who have trusted community relationships?
• Get (super) tactical. Much of Medicaid’s work is about embedding values and policy goals into the nitty gritty of everyday processes. What tools and resources do you have to operationalize your commitment? What information or data do you need that you don’t have? Does it exist in different places? How are you creating visibility into places where people fall through the cracks in the system? What steps can you take to shore up those areas?

Additional Resources

The Center for Health Care Strategies offers a variety of resources on health equity tailored for public sector agencies. Select resources and projects include:

• It’s All About Relationships: Driving Health Equity by Prioritizing Connections
• Maintaining Momentum to Advance Health Equity in Adverse Environments
• Becoming a More Inclusive Leader
• The Equity Changemakers Institute

1. Managed care organizations are referred to as Accountable Care Organizations in Utah, which is distinct from the Center for Medicare and Medicaid Services’ definition of accountable care.