State Agencies

The agency designated as lead on the cooperative agreement is not always the agency with authority to move the money, hire the staff, or override the Medicaid director. Series 5 examines the five functions where that gap surfaces: lead agency authority, stakeholder coordination, procurement, performance measurement, and the federal relationship. The finding that runs through all five is that cooperative federalism produces distributed authority that formal accountability structures cannot see, and CMS oversight designed for single-agency clarity cannot capture.