“Everything that we have ever done that was game-changing and sustainable happened in the middle.”
- Karen Shields
Medicaid touches more lives, more communities and more parts of the healthcare system than most Americans realize. In April 2026, nearly 74 million people were enrolled in Medicaid and the Children’s Health Insurance Program (CHIP), including more than 35 million children. Medicaid spending reached $931.7 billion in 2024, accounting for 18% of all U.S. healthcare spending.
Despite the program’s size and reach, Medicaid is often reduced to a political talking point. Many people do not understand who it covers, how it is administered or why it looks different from one state to another.
In the first episode of Guardians of Care, host Pete Justen sits down with Karen Shields, former Deputy Director of the Center for Medicaid and CHIP Services at the Centers for Medicare & Medicaid Services (CMS) and founder of K Shields Health Tech Consulting. Shields has spent decades working inside the machinery of American healthcare, including leading operations for healthcare.gov during the Affordable Care Act rollout and working with Medicaid programs across 30 states in the private sector.
She has also experienced Medicaid personally.
Shields received Medicaid coverage for prenatal care when she was pregnant with her son and struggling to make ends meet. The coverage was temporary, but its impact was lasting.
“I needed a hand up,” she says. “And Medicaid was that hand up.”
That experience shaped how she sees the program today: not simply as a healthcare safety net, but as an investment in people, families and communities.
Watch the Full Episode on YouTube
One of the most common misconceptions about Medicaid is that CMS runs the entire program from Washington. It does not.
Medicaid is a partnership. The federal government establishes requirements, provides oversight and shares in the cost. Each state administers its own program within that framework, making decisions about eligibility, benefits, delivery models and operations.
That is why Medicaid can work differently in Texas than it does in Virginia, Montana or Maryland. It is one national program expressed through more than 50 distinct state and territorial systems.
Shields believes that structure is one of Medicaid’s greatest strengths. States can respond to the needs of their own populations while still benefiting from federal funding, governance and shared standards.
It also makes the program difficult to explain. Medicaid covers low-income adults, but it also covers children, pregnant women, people with disabilities and seniors who need services Medicare does not provide, including long-term care. Nearly half of all Medicaid and CHIP enrollees are children.
When people understand who the program serves, Shields says, their perception often changes.
The public conversation about Medicaid often presents a false choice: make coverage accessible or protect the program from waste, fraud and abuse.
Shields rejects that framing. A program designed to serve people when they are most vulnerable must also make every dollar go as far as possible. Protecting access requires protecting the program itself.
“Every dollar that we have should be optimized so that it can help the most,” she says.
Her views on program integrity were shaped in part by her experience with the Affordable Care Act. During the healthcare.gov rollout, the immediate pressure was to recover the technology, stabilize operations and get people covered. Looking back, Shields says program-integrity teams should have been engaged much earlier—not after the program was already underway and risks had begun to surface.
That lesson now informs the advice she gives healthcare leaders: involve the people responsible for access, operations, security, oversight and program integrity before a new policy, service or system is launched.
Their role should not be limited to attending a meeting or reviewing a finished plan. They need to understand the intended outcomes, identify risks and help design the program from the beginning.
That requires a change in approach on both sides. Program leaders must be willing to invite scrutiny early. Program-integrity teams must enter the conversation ready to listen and solve problems—not simply police the work or say no.
Healthcare policy can sound clear on paper and still fail the people it is intended to serve. Between an idea and its real-world impact sits an enormous operational system: technology, state agencies, health plans, providers, hospitals, community organizations, advocates and frontline teams.
Shields learned to ask a simple question before implementing a major policy or service: Who is not going to like this?
The point is not to avoid every disagreement. No policy works equally well for every stakeholder. The point is to understand who will be affected, anticipate unintended consequences and address problems before they undermine the larger goal.
That is what Shields means by “leading from the middle.” It is not passive compromise or avoiding difficult decisions. It is the work of bringing competing perspectives into the same room and building something practical enough to operate and durable enough to survive changing administrations.
“Everything that we have ever done that was game-changing and sustainable happened in the middle,” she says.
Medicaid is not usually the first program people associate with innovation. Shields argues that it should be.
Because states have flexibility to test new approaches—including through Section 1115 demonstrations—Medicaid has become a proving ground for new care models, benefits and ways of serving complex populations. The program can show what works, what does not and what may be worth expanding.
But innovation will not come from government alone. States, federal agencies, health plans, providers, community organizations and technology partners all have a role in making the program work better.
Shields is optimistic about Medicaid’s future, but not complacent. Strengthening a program of this scale will require persistence, collaboration and a willingness to stay in the difficult middle ground where access, accountability, policy and operations meet.
Her final message is direct: “This program needs to be protected. It needs to be optimized, but it needs to be protected. And we can do both.”
Karen Shields is the founder of K Shields Health Tech Consulting and a former Deputy Director of the Center for Medicaid and CHIP Services at CMS. During her federal career, she also served in senior operational leadership roles supporting the Affordable Care Act and healthcare.gov. She later joined Gainwell Technologies, where she worked with Medicaid programs across 30 states. Her work focuses on healthcare operations, technology, policy implementation and collaboration across the public and private sectors.
Guardians of Care highlights the people, programs and partnerships that make Medicaid work. Hosted by Pete Justen, the podcast brings together leaders and change-makers from across the Medicaid ecosystem to share the successes, challenges and practical lessons behind their work—and to help more people understand how Medicaid works and why it matters.
