Managing Medicaid Through a Gubernatorial Transition: A Q&A with Jeff Lunardi

In this edited Q&A and video with Milbank’s Morgan McDonald, MD, Jeff Lunardi—then interim Medicaid director at Virginia’s Department of Medical Assistance Services (Cardinal Care)—shares practical lessons on prioritization, nonpartisan leadership, and agency stability during a gubernatorial handoff.

Can you briefly introduce yourself and the transition scenario Virginia was facing?

I spent a little over 12 years in Virginia state government — about nine or ten in nonpartisan legislative roles (policy analysis and program evaluation), and then nearly three years as deputy director of Medicaid at Cardinal Care, an appointed position. Virginia transitions governors every four years no matter what, because our governors can’t serve consecutive terms. This particular transition also involved a party change, which is not unusual in our purple state. The complicating factor was timing: we were implementing major federal requirements and launching new initiatives while simultaneously handing off leadership. I served as interim Medicaid director, then supported our incoming permanent director as he got up to speed.

What competing priorities were you managing?

The first priority was the stability of the agency and the long-term career staff who do the work. “Agency Stability” was literally written on my whiteboard for months. The practical implication was clear communication: what we could and couldn’t share about the transition, what the programmatic priorities were, and reassurance that leadership was focused on supporting staff.

We were also navigating budget season and legislative session. Virginia’s outgoing governor introduces the budget, so much of the fall is consumed by budget development even as you’re preparing for a new administration. Then we had the new federal requirements, not just community engagement but also provider assessments and state-directed payment changes. At the same time, we were implementing the Rural Health Transformation Program (RHTP). And we were going from a Republican to a Democratic administration, so there was a period of uncertainty that maybe slowed RHTP implementation. But I was grateful that the outgoing and incoming leadership worked collaboratively. There was no animosity or political push and pull about the priorities in rural health.

How did you prioritize program work during the transition?

We used a simple framework: impact and timeline. Then we turned it into nuts-and-bolts project management. For each requirement or initiative, we asked: What’s the policy work? What systems/procurement work is needed? What staffing does it take? Who is accountable? And how are we tracking progress? The goal was to “organize the chaos,” so people knew what decisions needed escalation, especially so the incoming leadership could quickly understand where implementation stood and what choices were coming next.

Did you have to decide not to do certain things?

Yes — we called it “ruthless prioritization,” guided by “back to basics.” First: enroll eligible people, ensure access to needed services, and pay providers. Next: what the legislature required on deadline, what federal requirements were time-sensitive, and what CMS submissions had hard due dates. A lot of good “nice-to-have” initiatives—process improvements, analytic enhancements, workgroups — went on the back burner for a couple months. We gave each other the grace to say, “that can wait.”

Were there “signature” priorities you wanted to ensure continued into the new administration?

From a Medicaid standpoint, the clearest example was ongoing behavioral health reform. In Virginia, that work long predates any one administration and has moved forward across parties for a decade-plus. Each set of leaders puts their stamp on it, but it hasn’t been a partisan issue, so it was easier to reinforce continuity even amid major new requirements. We were also intentional in transition briefings to distinguish between items that might be politically charged in the outgoing budget versus items we believed were simply good policy for the members and the program.

How did you handle the politics without becoming political as an agency?

I leaned on my background as a nonpartisan legislative staffer. The reality is you work in a partisan environment, and you have to understand political pressures, but if you stray into partisanship, you lose credibility. So, I tried to be factual and transparent: what’s on the table, what it costs or saves, what it changes operationally, and what the risks are. And I “forced” some uncomfortable conversations with the right people — those with whom you can have a candid, safe dialogue — to understand where the incoming team was headed. Sometimes the honest answer early on was, “We don’t know yet,” and you have to make space for that, too.

Where did compromise show up most in practice?

With rural health we were staffing up quickly to meet timelines, but the incoming administration had a different view of the skillset or staff mix and how to structure grants management. We slowed down intentionally because it’s a multi-year program and getting the right team to support their strategy was worth a short delay. Another recurring challenge was stakeholder narratives: external groups can get to new decision-makers fast, and the agency then has to catch up to provide the full picture from the state’s perspective. Sometimes that meant being “politely persistent” to ensure the new leaders could make informed decisions.

What did communication look like internally?

We approached it on three levels. First, the executive leadership team: I set a low threshold for bringing decisions to the group, because I wasn’t going to be there long-term to live with them. So I wanted to make sure the entire team understood and was heard on decisions. Second, the division-directors, who run day-to-day operations and decide what needs escalation: we tried to over-communicate and invite input. Third, broad staff communication: we had to be honest about what we knew and what we didn’t, reinforce that most of the organization wasn’t changing, and keep pointing back to mission and priorities. We also tried to give people explicit permission to raise their hand and say, “I have nine things and I can do seven. Tell me what comes off the list.”

Did staff anxiety surprise you, and how did you address it?

It did. This was my first executive-branch transition; in the legislative branch, transitions happen frequently but can feel less disruptive because many players stay the same. In the agency, the fear of the unknown can drive poor decisions and prioritization. So, a lot of my job became listening, setting expectations, and reassuring people when a decision simply wasn’t going to get leadership attention immediately. When something was fully teed up, I’d tell staff: you’ve done what you can. Now focus elsewhere, and I’ll own that decision. That helps people stop spinning and keep moving.

What was it like managing cross-branch work during legislative session?

The timing in Virginia creates an awkward moment: session starts under the outgoing governor, and the new governor takes office shortly after. I had to brief legislators on items tied to the outgoing administration’s budget while knowing that, days later, I’d be serving the new administration. The way through was neutral language and factual framing. Explain what a proposal does, what it costs or saves, implementation timing, and service impacts. When asked “why” something was proposed, sometimes I could explain the rationale. Other times I couldn’t, and I would offer to discuss alternatives. Practically, it also meant being very transparent with the new administration once they started and saying, “stop me now if that’s not what you want me to say.”

What leadership lessons would you share with others heading into a transition?

Humility matters — recognize it isn’t about you. The job is stability for the program, the organization, and the people doing the work, while supporting the incoming team’s ability to lead. And, again, people are going to be in different places personally in their career during a transition. I had decided that for me and my family, the time was right to move on from state government, so I wasn’t auditioning. But the best thing you can do regardless of your aspirations is make it about the program and the agency and trust that the incoming leadership is going to see that value.

Condensed with the assistance of AI.