2026 Governors’ Health and Human Services Policy Advisors Institute

Health and human services policy advisors from states and territories across the country gathered in New Orleans for NGA's annual HHS Policy Advisors Institute. Over one and a half days, advisors shared priorities, surfaced common challenges, and learned from peers on topics ranging from healthcare affordability to child welfare, SNAP administration, and the use of AI in benefits delivery. One theme cut across every session: H.R. 1 is reshaping the financial and programmatic landscape for many HHS programs states administer.

State & Territory Introductions

Facilitated by Ryan Martin, Managing Director, NGA Center for Best Practices, and Brittney Roy-Morales, Program Director for Health, NGA Center for Best Practices

The institute opened with a round of introductions that quickly became a candid inventory of shared pressures. H.R. 1 dominated the conversation, with state after state describing the simultaneous work of implementing new Medicaid work requirements, absorbing federal funding reductions and managing an expanding SNAP administrative burden. Rural Health Transformation Program funding emerged as a second universal priority, with advisors balancing the opportunity to advance their governors' rural health priorities with the need to build durable systems rather than time-limited programs that legislatures will later be expected to sustain.

Behavioral health appeared on nearly every state's list, often at the intersection of criminal justice, youth suicide and substance use disorder. Territory representatives highlighted structural inequities unique to their situation, including Medicaid funding caps and exclusion from the Rural Health Transformation Program grant entirely. Several advisors raised SNAP payment error rates as an emerging fiscal crisis, and child welfare advisors flagged high-acuity youth cycling through emergency departments without clear pathways to appropriate care. Another common concern was the end of pandemic-era federal money, even though communities are still counting on the services it funded.

Healthcare Affordability: Policy Options for Governors

Moderated by Anna Heard, Senior Policy Analyst, NGA Center for Best Practices

Speakers: Sarah Sabshon, Deputy Chief of Staff for Policy and Cabinet Affairs, Massachusetts Governor's Office; Dr. Lindsay Weaver, State Health Commissioner, Indiana Department of Health

Healthcare affordability is really two problems at once: costs unsustainable for individual patients and costs consuming an ever-larger share of state and employer budgets. Indiana and Massachusetts have each taken distinct but complementary approaches to both.

Massachusetts Governor Maura Healey convened a Healthcare Affordability Working Group, bringing together chief hospital executives, insurers, pharmaceutical companies, businesses, and labor leaders alongside senior state policy makers. Strict confidentiality rules allow participants to speak candidly without fear of public attribution. As Sabshon noted, people need to be able to take off their institutional hats and be honest about where flexibility exists before real reform is possible. The state has also eliminated prior authorization requirements for a broad range of routine services and is capping member cost-share growth at inflation.

Indiana's approach centers on financial transparency and tying hospital tax-exempt status to community benefit and charity care. Hospitals must submit audited financials and charity care schedules with significant daily fines for late submission. Large health systems must offer direct-to-employer pricing at or below a defined percentage of Medicare, and all healthcare ownership stakes above a threshold must be disclosed. Both states emphasized that data sharing, ideally through a single database that providers and payers draw from together, will be central to sustaining this work.

Leveraging Rural Health Transformation to Sustain and Grow Overdose Prevention Efforts

Moderated by Sandra Wilkniss, Senior Director, National Academy for State Health Policy

Speakers: Nune Phillips, Senior Policy Advisor, Utah Department of Health and Human Services; Cathy Schultz, Director, Governor's Overdose Task Force, Rhode Island

Utah deliberately housed its RHTP funding under senior leadership reporting directly to the agency commissioner rather than within Medicaid, giving the program visibility and flexibility. The state's application was intentionally broad to avoid being prescriptive about community needs across a largely rural and frontier geography. Overdose prevention was already a governor's priority before RHTP funding arrived, with a standing fentanyl task force and a specific reduction goal built into the governor's strategic agenda.

Rhode Island's Cathy Schultz described a governance model built around genuine community power-sharing. Each task force work group has a stipend supported community co-chair with equal decision-making authority, ensuring that people with lived experience shape decisions rather than simply inform them. Rhode Island has surpassed its fatal overdose reduction goal, a result Schultz attributed to this whole-of-government approach and the depth of community trust it has built over time.

Both speakers acknowledged significant headwinds. Harm reduction investments are being routed through opioid settlement dollars rather than federal channels, as recent executive orders have made those channels unreliable. Attendees also raised the emerging gap around stimulant use disorder, where opioid-era infrastructure offers no direct parallel, and the primary evidence-based treatment approach remains in regulatory limbo within RHTP.

Strengthening State and Territory Child Care Systems

Moderated by Marie Giandomenico, Director, Social Finance

Speakers: Elena Trueworthy, Commissioner, Office of Early Childhood, Connecticut; Kristen Dudanowicz, Director of Systems and Policy Planning, Office of Early Childhood, Connecticut; Leah Van Kirk, Health Care Policy Advisor, Commissioner's Office, Alaska Department of Health

The childcare session opened with the observation that the childcare system was straining across all levels. Parents cannot afford or access care, providers cannot retain workers and a large share of the early childhood workforce is considering leaving the field entirely.

Connecticut has pursued a structural solution through a long-term Early Childhood Education Endowment, a trust fund seeded with significant state dollars and replenished annually by any unbudgeted budget surplus. A defined share of new spaces must serve infants and toddlers, correcting the tendency of childcare investment to concentrate on preschool-age children. A standalone Office of Early Childhood housing all birth-to-five services has been essential to the model's success, as has a Blue Ribbon Panel process that built broad stakeholder buy-in and legislative champions who now sit on the endowment's advisory board.

Alaska incorporated childcare directly into its Rural Health Transformation plan, grounded in the recognition that rural health infrastructure cannot be built if healthcare workers cannot find or afford care for their children. A governor-convened task force produced recommendations after extensive listening sessions with providers, parents, businesses, and tribal communities, leading to regulatory reforms, expanded administrator qualifications, and a tribal licensing exemption. Both states offered the same caution: resist the pressure to spend quickly. Build the system infrastructure first, then let spending follow a coherent plan.

Strengthening Rural Health Infrastructure Across the Lifespan

Moderated by Asia Riviere, Senior Policy Analyst, Health, NGA Center for Best Practices

Speakers: Meghna Patel, Deputy Secretary of Health and Human Services Policy and Planning, Pennsylvania; Leah Van Kirk, Health Care Policy Advisor, Commissioner's Office, Alaska Department of Health

Alaska and Pennsylvania face the same underlying problem from opposite geographic directions: when health infrastructure erodes in rural communities, the communities themselves erode with it.

In Alaska, the vast majority of communities have no road connections, broadband is severely limited and most regions face health professional shortages. Alaska's RHTP strategy is built around community health aides, people already living in rural communities certified as Medicaid-recognized providers, with telehealth layering specialist access on top. Alaska is also pursuing a traditional healing waiver model, recognizing that Western care models often do not connect culturally with Alaska Native communities, which keeps utilization low regardless of what services are nominally available.

Pennsylvania's challenge is structural. A large share of rural hospitals have closed their labor and delivery units over recent years, driving young families out of communities and further depopulating rural areas. Pennsylvania piloted a global budget model for rural hospitals through the CMS Innovation Center, providing stable monthly revenue independent of patient volume, which prevented closures and stabilized communities during the pandemic. Pennsylvania Governor Josh Shapiro has since launched a broader rural health initiative with health, human services, economic development, and agriculture secretaries at the table, reflecting the understanding that rural hospital viability is inseparable from broader community health.

State Spotlights: Case Studies on SNAP Administration

Moderated by Rhonda Jackson, Director, No Kid Hungry Louisiana

Speakers: Katie DeMuth, Chief of Staff, Oklahoma Department of Human Services; Deborah Doyle, Program Integrity Director, Washington Department of Social and Health Services

H.R. 1 makes the largest cuts to SNAP in the program's history, with two changes falling directly on states. Administrative cost-sharing shifts significantly toward states in the near term, and states with payment error rates above a defined threshold will soon be required to pay a share of benefit costs, with exposure that could reach hundreds of millions of dollars annually for states with high rates.

Oklahoma's Katie DeMuth was emphatic: payment error rate is not fraud. The large majority of errors are caused by clients failing to report changes in household circumstances, and conflating the two undermines the client engagement strategies that actually bring rates down. Through pre-certification case review, structured new hire training, and quality dashboards for supervisors, Oklahoma has cut its estimated error rate roughly in half over the past year, achieving that result with no new funding

Washington's Deborah Doyle offered a structural lesson: embed quality control (QC) data into regular cross-agency review meetings rather than treating it as a siloed compliance function. Washington had built that infrastructure before H.R. 1 passed, which meant the state could model scenarios quickly once the law was enacted. That modeling showed that the difference between acting immediately with a manual workaround versus waiting for an automated system fix could mean a many-fold difference in error rate exposure, directly changing the decisions that were made. Both speakers called for delayed and uniform implementation that credits states for progress already underway.

Leveraging Technology and AI for Health and Human Services

Moderated by Tia Corbett, Senior Cooperative Portfolio Manager, National Association of State Procurement Officers

Speakers: Camille Conaway, Executive Director, Office of Economic Independence, Louisiana Department of Health; Patrick O'Malley, Chief Portfolio Officer, MD Benefits, Maryland

Maryland has spent years building an enterprise shared platform housing multiple benefit programs under a unified eligibility system. A single application developed with user experience expertise allows residents to screen and apply for multiple benefits at once, with measurable increases in digital application rates since launch. Maryland is deploying AI to automate routine tasks and free workers for cases requiring human judgment. O'Malley's central caution: AI is not free, not a universal solution and every implementation requires a human in the loop.

Louisiana's One Door initiative consolidates multiple benefit programs under one agency, with Conaway holding a joint appointment bridging health and labor, a structural fix to a coordination problem that task forces have historically failed to solve. Louisiana is building toward a closed-loop referral system connecting Medicaid work requirement compliance directly to job training enrollment and using a self-sufficiency scoring model to identify the most work-ready individuals within a very large caseload. Both states emphasized the same point: technology is only as good as the change management around it, and federal program silos with conflicting design requirements remain a significant barrier to the no-wrong-door experience both states are pursuing.

Improving Child Welfare Outcomes and Strengthening Child and Family Well-Being

Moderated by Dimple Patel, Director of State Public Policy, Casey Family Programs Speakers: Dr. Alyssa Bish, Director, Division of Children and Family Services, Nebraska Department of Health and Human Services; Connelly-Anne Ragley, Chief External Affairs Officer, South Carolina Department of Social Services; Tana Senn, Secretary, Washington Department of Children, Youth, and Families

The child welfare session surfaced both progress and persistent frustration. Nebraska described joining ACF's Home for Every Child initiative, which replaced burdensome multi-page compliance plans. Bish noted honest baseline-setting using data will drive conversations with judges and stakeholders that vague compliance language never could.

South Carolina adopted separate kinship licensure standards, eliminating barriers for relatives and fictive kin while maintaining safety checks, and has seen kinship placement rates rise dramatically as a result. Ragley was candid about the political friction: traditional foster care providers have financial interests that align against kinship expansion, and states should be prepared to name that opposition.

Washington described two ongoing challenges rooted in federal policy constraints. The FFPSA requirement to build an entirely new child welfare IT system before drawing down funds has significantly delayed implementation, and the evidence-based program clearinghouse lacks culturally relevant options for tribal and diverse communities. Washington is actively advocating for federal flexibility on both fronts, including the ability to count domestic violence services and other proven interventions toward FFPSA eligibility.

Casey Family Programs closed the session with a reminder that prevention and serving families before children enter care remains the highest-leverage strategy available, and the current federal plan update cycle is an opening to act on that.

Leveraging MLTSS Partnerships to Strengthen the Direct Care Workforce

Moderated by Nicole Howell, Director, Direct Care Workforce Development, National Council on Aging

Speakers: Tina Barrett, Assistant Director, Intellectual and Development Disabilities, North Carolina Department of Health and Human Services; Anna Lea Cothron, System Transformation Director, TennCare, Tennessee

The direct care workforce session took up a challenge that sits at the intersection of healthcare and economics. Demand is growing rapidly as the population ages, yet many direct care workers live at or near poverty, and the field faces severe recruitment and retention challenges with no straightforward fix.

North Carolina and Tennessee both pointed to managed care organization contracts as one of the most effective levers available to states. Embedding workforce requirements directly into MCO contracts creates accountability and a continuous feedback loop that voluntary approaches cannot replicate. Barrett described the importance of a comprehensive wage and rate analysis as a necessary first step - covering all direct care worker types across all settings and benchmarking pay against community-level living wages - before any meaningful reimbursement reform can follow.

Tennessee's Cothron focused on the credentialing infrastructure needed to professionalize the field. The current model, in which training certificates are owned by the agency rather than the worker, undermines workforce mobility and dignity. Portable, individually-owned credentials that workers can carry from employer to employer, structured as stackable credentials that ladder into community college associate's and bachelor's degrees, build genuine career pathways. Both states noted that incentivizing credentialing for both the worker and the provider agency helps sustain workforce development initiatives after dedicated funding runs out. Realistic job previews, whether video-based or otherwise, were also highlighted as a practical tool that meaningfully reduces early attrition by ensuring workers understand the demands of the role before they enter it.

Discussion on Supporting Youth with High-Acuity Mental Health Needs

Moderated by Jess Kirchner, Senior Policy Analyst, Children & Families, NGA Center for Best Practices

Speaker: Bridget Harrison, Deputy Director, Department of Medicaid, Ohio

Ohio's Bridget Harrison discussed the small but resource-intensive population of youth with complex behavioral health needs who are simultaneously served by multiple systems and historically passed between them without any single system taking ownership. Harrison's framing was direct: building a genuine system of care requires treating these as "our kids" collectively rather than sorting them by agency jurisdiction.

Medicaid, Harrison argued, is underutilized as both a funding source and a convener in this space. It can bring healthcare quality improvement practices and care coordination disciplines to child welfare, juvenile justice, and developmental disabilities in ways those systems have not historically had access to. States with newer programs should plan for slow enrollment ramps early on and build automatic eligibility pathways, such as enrollment triggered by a behavioral health inpatient episode, to reach scale over time.

Participants identified the middle of the continuum as the most urgent gap: intensive in-home and community-based services that can prevent step-up to residential or institutional care, and support step-down after a higher level of care, are what the system most lacks. The session also warned about compounding policy changes, when juvenile justice reform and child welfare disproportionality initiatives affect the same population simultaneously, the unintended consequences can work against each other and must be actively mapped and managed. The transition from youth-serving to adult systems was named an emerging crisis, with young people who received rich, coordinated care in youth-focused programs often facing a steep cliff when they age out. Workforce cross-training spanning both developmental disabilities and behavioral health was identified as a foundational gap, as co-occurring needs are common but the workforce remains largely siloed.

Strategic Communications for Health and Human Services

Speakers: Megan Sigesmund, Vice President, Strategic Partnerships and External Engagement and Hannah Strashun, Vice President, Group Campaign Director, at the Ad Council.

The closing session offered a practitioner's view of what makes public health communications campaigns actually work. The central argument was that communications is most effective when treated as the "air game" that amplifies on-the-ground programmatic work - a complement to systems change, not a substitute for it.

Effective campaigns are built from audience research rather than expert intuition. Messages must be developed with and tested by the intended audience before they are deployed. Trusted community-level messengers consistently outperform national celebrities or top-down messaging in driving actual behavior change. For mental health specifically, campaigns are most effective when they normalize help-seeking as a routine sign of strength rather than framing it as crisis response.

On the mechanics of behavior change, the speakers stressed the value of a clear, single-minded call to action tied to a specific and easy first step over broad awareness messaging that asks nothing concrete of the audience. For states with limited communications budgets, she highlighted that many Ad Council assets, including PSAs and digital content, are open source and available at no cost, making it possible to customize national campaigns with local branding and resources without building from scratch. She closed with a measurement imperative: reach and awareness are insufficient metrics. Campaigns that cannot demonstrate downstream shifts in attitudes and behaviors over time should be reassessed.

Looking Ahead

Across all sessions, several threads defined the moment for state HHS systems: absorbing H.R. 1's fiscal consequences while protecting vulnerable populations, deploying Rural Health Transformation dollars for durable impact, making behavioral health a functional part of care, and building the technology and workforce capacity to deliver on current commitments. To help address some of these matters, the NGA Center for Best Practices is launching a Policy Academy to support governors' offices in strengthening SNAP and Medicaid systems through technology, operational and governance improvements.