State Agencies · RHTP-05.TD1

State Agency Decision Authority Matrix

Purpose

Article Cross References (6) References (5)

Purpose
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This technical document provides a comprehensive reference documenting who holds decision authority for RHTP implementation across all 50 states. The document distinguishes between formal authority (what organizational charts show) and actual authority (who makes decisions in practice), revealing the authority gaps that shape implementation outcomes.

This is not merely a directory. It organizes data to reveal patterns of authority concentration, fragmentation, and gap that predict implementation success or struggle. Users should consult this document when seeking to understand state-specific governance dynamics, identify comparable states for cross-state learning, or assess where formal accountability diverges from actual implementation control.

Methodology
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Data Sources
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Primary sources include state RHTP applications, CMS cooperative agreement documentation, state organizational charts, and Governor executive orders. Secondary sources include NASHP policy analyses, state news coverage, and prior federal program evaluations. Gap assessments derive from analysis of decision patterns, revision histories, and stakeholder interviews where available.

Authority Gap Classification
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Classification	Definition	Indicators
Low	Lead agency controls resources and decisions	Fast implementation timelines, minimal revision to proposals, lead agency spokesperson dominance
Moderate	Lead agency decides within constraints set by others	Required coordination with Medicaid/Governor, moderate revision patterns, shared public representation
High	Lead agency implements decisions made elsewhere	Extensive Governor review, Medicaid override on key decisions, long approval timelines
Very High	Lead agency lacks meaningful decision authority	Nominal lead with decisions made by Governor’s office or other agencies, symbolic role

Limitations
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Authority gaps are difficult to observe directly. Assessments reflect available evidence but cannot capture all informal dynamics, personal relationships, or political contexts that shape actual decision-making. Assessments should be treated as informed estimates subject to revision as implementation proceeds and additional evidence emerges.

Section 1: Lead Agency Identification
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Complete State Listing
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State	Lead Agency	Agency Type	FY2026 Award	Rural Pop.
Alabama	Alabama Department of Public Health	DOH	$203.4M	2.1M
Alaska	Alaska Department of Health	DOH	$272.2M	275K
Arizona	Arizona Health Care Cost Containment System	Medicaid	$167.0M	720K
Arkansas	Arkansas Department of Finance and Administration	Admin/Finance	$208.8M	1.3M
California	Department of Health Care Access and Information	HCAI	$233.6M	2.7M
Colorado	Colorado Department of Public Health and Environment	DOH	$200.1M	730K
Connecticut	Connecticut Department of Social Services	DSS/Medicaid	$154.2M	195K
Delaware	Delaware Department of Health and Social Services	Combined HHS	$157.4M	213K
Florida	Florida Department of Health	DOH	$209.9M	662K
Georgia	Georgia Department of Community Health	Combined HHS	$218.9M	2.9M
Hawaii	Hawaii Department of Health	DOH	$188.9M	420K
Idaho	Idaho Department of Health and Welfare	Combined HHS	$186.0M	640K
Illinois	Illinois Department of Public Health	DOH	$193.4M	2.2M
Indiana	Indiana State Department of Health	DOH	$206.9M	1.7M
Iowa	Iowa Department of Health and Human Services	Combined HHS	$209.0M	960K
Kansas	Kansas Department of Health and Environment	DOH	$221.9M	867K
Kentucky	Kentucky Cabinet for Health and Family Services	Combined HHS	$212.9M	1.87M
Louisiana	Louisiana Department of Health	DOH	$208.4M	1.35M
Maine	Maine Department of Health and Human Services	Combined HHS	$190.0M	620K
Maryland	Maryland Department of Health	DOH	$168.2M	450K
Massachusetts	Massachusetts Executive Office of Health and Human Services	Combined HHS	$162.0M	238K
Michigan	Michigan Department of Health and Human Services	Combined HHS	$173.1M	2.0M
Minnesota	Minnesota Department of Health	DOH	$193.1M	1.28M
Mississippi	Mississippi State Department of Health	DOH	$205.9M	1.6M
Missouri	Missouri Department of Social Services	DSS/Medicaid	$216.3M	1.9M
Montana	Montana Department of Public Health and Human Services	Combined HHS	$233.5M	550K
Nebraska	Nebraska Department of Health and Human Services	Combined HHS	$218.5M	720K
Nevada	Nevada Department of Health and Human Services	Combined HHS	$179.9M	520K
New Hampshire	New Hampshire Department of Health and Human Services	Combined HHS	$204.0M	430K
New Jersey	New Jersey Department of Health	DOH	$147.3M	138K
New Mexico	New Mexico Human Services Department	Medicaid/HSD	$211.5M	840K
New York	New York State Department of Health	DOH	$212.1M	2.0M
North Carolina	North Carolina Department of Health and Human Services	Combined HHS	$213.0M	3.4M
North Dakota	North Dakota Department of Health and Human Services	Combined HHS	$198.9M	500K
Ohio	Ohio Department of Health	DOH	$202.0M	2.8M
Oklahoma	Oklahoma State Department of Health	DOH	$223.5M	930K
Oregon	Oregon Health Authority	Health Authority	$197.3M	780K
Pennsylvania	Pennsylvania Department of Health	DOH	$193.3M	1.8M
Rhode Island	Rhode Island Executive Office of Health and Human Services	Combined HHS	$156.2M	25K
South Carolina	South Carolina Department of Health and Environmental Control	DOH	$200.0M	1.6M
South Dakota	South Dakota Department of Health	DOH	$189.5M	369K
Tennessee	Tennessee Department of Health	DOH	$206.9M	2.4M
Texas	Texas Health and Human Services Commission	Combined HHS	$281.3M	4.3M
Utah	Utah Department of Health and Human Services	Combined HHS	$195.7M	680K
Vermont	Vermont Agency of Human Services	Combined HHS	$195.1M	460K
Virginia	Virginia Department of Health	DOH	$189.5M	1.7M
Washington	Washington State Department of Health	DOH	$181.3M	1.12M
West Virginia	West Virginia Department of Health	DOH	$199.5M	870K
Wisconsin	Wisconsin Department of Health Services	Combined HHS	$203.7M	1.4M
Wyoming	Wyoming Department of Health	DOH	$205.0M	370K

Lead Agency Type Distribution
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Agency Type	Count	States
Department of Health	24	AL, AK, CO, FL, HI, IL, IN, KS, LA, MD, MN, MS, NJ, NY, OH, OK, PA, SC, SD, TN, VA, WA, WV, WY
Combined HHS	19	DE, GA, ID, IA, KY, ME, MA, MI, MT, NE, NV, NH, NC, ND, RI, TX, UT, VT, WI
Medicaid/DSS	4	AZ, CT, MO, NM
Health Authority	1	OR
Other	2	AR (Finance), CA (HCAI)

Section 2: Authority Gap Assessment
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Complete Assessment Table
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State	Lead Agency Type	Formal Authority	Actual Authority Locus	Authority Gap	Assessment Basis
Alabama	DOH	Program administration	ADPH with Governor coordination	Moderate	Political context, Medicaid separate
Alaska	DOH	Full program control	ADOH with limited constraints	Low	Small government, direct relationships
Arizona	Medicaid	Integrated payment/program	AHCCCS with political uncertainty	Low-Moderate	Medicaid trigger law creates political gap
Arkansas	Admin/Finance	Fiscal management	DFA coordinates; UAMS implements	Moderate-High	Lead agency is fiscal, not programmatic
California	HCAI	Healthcare infrastructure	HCAI with DHCS Medicaid coordination	Moderate	CalAIM waiver creates coordination needs
Colorado	DOH	Public health programs	CDPHE with HCPF Medicaid	Moderate	Medicaid under separate agency
Connecticut	DSS/Medicaid	Medicaid integration	DSS with DOH coordination	Low-Moderate	Medicaid lead aligns authority
Delaware	Combined HHS	Integrated authority	DHSS unified control	Low	Small state, consolidated structure
Florida	DOH	Population health	FDOH with AHCA Medicaid	Moderate	Non-expansion creates political dynamics
Georgia	Combined HHS	Integrated programs	DCH with Governor oversight	Moderate	Recent partial expansion adds complexity
Hawaii	DOH	Island health systems	DOH with geographic autonomy	Low	Island structure simplifies coordination
Idaho	Combined HHS	Integrated authority	DHW unified but conservative politics	Low-Moderate	Political constraints on expansion
Illinois	DOH	Public health	IDPH with HFS Medicaid coordination	Moderate-High	Large bureaucracy, separate Medicaid
Indiana	DOH	Program administration	ISDH with FSSA Medicaid	Moderate	Medicaid under separate agency
Iowa	Combined HHS	Recent consolidation	HHS unified (post-2022 merger)	Low	Consolidation reduced fragmentation
Kansas	DOH	Environmental and health	KDHE with political constraints	Moderate	Non-expansion limits integration
Kentucky	Combined HHS	Integrated authority	CHFS with strong Medicaid program	Low	Early expansion built capacity
Louisiana	DOH	Health programs	LDH with Medicaid coordination	Low-Moderate	Expansion state with DOH Medicaid
Maine	Combined HHS	Integrated services	DHHS unified authority	Low	Expansion and consolidated structure
Maryland	DOH	Population health	MDH with MIA coordination	Moderate	Separate health regulatory functions
Massachusetts	Combined HHS	Executive office oversight	EOHHS coordinates multiple agencies	Low-Moderate	Executive office model with sub-agencies
Michigan	Combined HHS	Integrated authority	MDHHS comprehensive control	Low	Consolidated structure, expansion state
Minnesota	DOH	Public health focus	MDH with DHS Medicaid	Moderate	Medicaid under separate agency
Mississippi	DOH	Health programs	MSDH with political constraints	High	Non-expansion, limited capacity
Missouri	DSS/Medicaid	Medicaid programs	MO HealthNet with 2021 expansion	Low-Moderate	Recent expansion building capacity
Montana	Combined HHS	Integrated programs	DPHHS unified control	Low	Expansion state, consolidated agency
Nebraska	Combined HHS	Integrated services	DHHS with recent expansion	Low-Moderate	2020 expansion still building systems
Nevada	Combined HHS	Integrated authority	DHHS unified structure	Low	Consolidated with expansion
New Hampshire	Combined HHS	Integrated services	DHHS unified control	Low	Small state, consolidated structure
New Jersey	DOH	Limited rural scope	NJDOH with minimal rural context	Moderate	Urban-dominant state limits rural focus
New Mexico	Medicaid/HSD	Medicaid programs	HSD Medicaid-led implementation	Low	Medicaid lead aligns authority
New York	DOH	Major health programs	NYSDOH with extensive bureaucracy	Moderate	Large state, complex coordination
North Carolina	Combined HHS	Integrated authority	NCDHHS with 2023 expansion	Low-Moderate	Recent expansion adds integration opportunities
North Dakota	Combined HHS	Integrated services	NDHHS unified control	Low	Small state, consolidated structure
Ohio	DOH	Program administration	ODH with ODM Medicaid coordination	Moderate	Medicaid under separate agency
Oklahoma	DOH	Health programs	OSDH with OHCA Medicaid	Moderate	SoonerSelect complicates coordination
Oregon	Health Authority	Unified health authority	OHA comprehensive control	Low	Unique integrated structure
Pennsylvania	DOH	Public health	DOH with DHS Medicaid	Moderate-High	Separate Medicaid, political complexity
Rhode Island	Combined HHS	Executive office	EOHHS comprehensive control	Low	Tiny state, consolidated structure
South Carolina	DOH	Health and environmental	DHEC with political constraints	High	Non-expansion, capacity limitations
South Dakota	DOH	Health programs	DOH with political autonomy	Moderate	Non-expansion, limited Medicaid integration
Tennessee	DOH	Population health	TDH with TennCare Medicaid	Moderate-High	Non-expansion, separate TennCare
Texas	Combined HHS	Massive scope	HHSC coordinates enormous system	Moderate	Scale creates coordination challenges
Utah	Combined HHS	Integrated services	DHHS with political constraints	Moderate	Partial expansion model complicates
Vermont	Combined HHS	Integrated authority	AHS comprehensive control	Low	Smallest rural pop, unified structure
Virginia	DOH	Public health	VDH with DMAS Medicaid	Moderate	Medicaid under separate agency
Washington	DOH	Public health focus	DOH with HCA coordination	Moderate	Health Care Authority manages Medicaid
West Virginia	DOH	Health programs	WVDOH with BMS Medicaid	Moderate	Expansion state but separate Medicaid
Wisconsin	Combined HHS	Integrated services	DHS with unique Medicaid structure	Low-Moderate	BadgerCare complexity adds uncertainty
Wyoming	DOH	Health programs	DOH with political autonomy	Low-Moderate	Small state, non-expansion politics

Authority Gap Summary
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Gap Level	Count	Percentage	Characteristics
Low	15	30%	Consolidated HHS agencies, small states, or Medicaid leads
Low-Moderate	11	22%	Generally aligned but with coordination needs
Moderate	17	34%	Medicaid under separate agency, standard coordination
Moderate-High	4	8%	Significant fragmentation or political complexity
High	3	6%	Non-expansion with capacity limitations

Section 3: Decision Authority by Function
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Function-Specific Authority Assessment
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This section identifies who holds decision authority for key RHTP functions, recognizing that authority often distributes across multiple entities.

State	Budget Authority	Subaward Approval	Vendor Selection	Performance Action	Overall Control
Alabama	DOH/Governor	DOH	Central Procurement	DOH	Distributed
Alaska	DOH	DOH	DOH	DOH	Lead-Dominant
Arizona	AHCCCS	AHCCCS	AHCCCS	AHCCCS	Lead-Dominant
Arkansas	DFA	DFA/UAMS	Central Procurement	DFA	Fiscal Control
California	HCAI	HCAI	Dept. General Services	HCAI	Lead with Constraints
Colorado	CDPHE	CDPHE	State Purchasing	CDPHE	Lead with Constraints
Connecticut	DSS	DSS	DAS	DSS	Lead with Constraints
Delaware	DHSS	DHSS	DHSS	DHSS	Lead-Dominant
Florida	DOH	DOH	DMS	DOH	Lead with Constraints
Georgia	DCH	DCH/Governor	DOAS	DCH	Distributed
Hawaii	DOH	DOH	SPO	DOH	Lead with Constraints
Idaho	DHW	DHW	DHW	DHW	Lead-Dominant
Illinois	IDPH	IDPH	CMS	IDPH	Lead with Constraints
Indiana	ISDH	ISDH	IDOA	ISDH	Lead with Constraints
Iowa	HHS	HHS	DAS	HHS	Lead-Dominant
Kansas	KDHE	KDHE	Dept. Admin	KDHE	Lead with Constraints
Kentucky	CHFS	CHFS	Finance Cabinet	CHFS	Lead-Dominant
Louisiana	LDH	LDH	OCP	LDH	Lead with Constraints
Maine	DHHS	DHHS	DAFS	DHHS	Lead-Dominant
Maryland	MDH	MDH	DGS	MDH	Lead with Constraints
Massachusetts	EOHHS	EOHHS/Sub-agencies	OSD	EOHHS	Executive Coordination
Michigan	MDHHS	MDHHS	DTMB	MDHHS	Lead-Dominant
Minnesota	MDH	MDH	Admin	MDH	Lead with Constraints
Mississippi	MSDH	MSDH/Governor	DFA	MSDH	Distributed
Missouri	DSS	DSS	OA	DSS	Lead with Constraints
Montana	DPHHS	DPHHS	Dept. Admin	DPHHS	Lead-Dominant
Nebraska	DHHS	DHHS	DAS	DHHS	Lead-Dominant
Nevada	DHHS	DHHS	Purchasing	DHHS	Lead-Dominant
New Hampshire	DHHS	DHHS	Admin Services	DHHS	Lead-Dominant
New Jersey	DOH	DOH	Treasury	DOH	Lead with Constraints
New Mexico	HSD	HSD	GSD	HSD	Lead-Dominant
New York	DOH	DOH	OGS	DOH	Lead with Constraints
North Carolina	DHHS	DHHS	P&C	DHHS	Lead-Dominant
North Dakota	NDHHS	NDHHS	OMB	NDHHS	Lead-Dominant
Ohio	ODH	ODH	DAS	ODH	Lead with Constraints
Oklahoma	OSDH	OSDH/OHCA	OMES	OSDH	Distributed
Oregon	OHA	OHA	DAS	OHA	Lead-Dominant
Pennsylvania	DOH	DOH	DGS	DOH	Lead with Constraints
Rhode Island	EOHHS	EOHHS	Purchasing	EOHHS	Lead-Dominant
South Carolina	DHEC	DHEC/Governor	MMO	DHEC	Distributed
South Dakota	DOH	DOH	Bureau of Admin	DOH	Lead with Constraints
Tennessee	TDH	TDH	Central Procurement	TDH	Distributed
Texas	HHSC	HHSC	HHSC Procurement	HHSC	Lead-Dominant
Utah	DHHS	DHHS	DPM	DHHS	Lead with Constraints
Vermont	AHS	AHS	BGS	AHS	Lead-Dominant
Virginia	VDH	VDH	DGS	VDH	Lead with Constraints
Washington	DOH	DOH	DES	DOH	Lead with Constraints
West Virginia	WVDOH	WVDOH	Purchasing	WVDOH	Lead with Constraints
Wisconsin	DHS	DHS	DOA	DHS	Lead-Dominant
Wyoming	DOH	DOH	A&I	DOH	Lead with Constraints

Control Pattern Summary
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Pattern	Count	Definition
Lead-Dominant	20	Lead agency controls most functions directly
Lead with Constraints	22	Lead agency decides within procurement/administrative constraints
Distributed	6	Authority shared across multiple agencies/Governor
Executive Coordination	1	Executive office coordinates sub-agencies
Fiscal Control	1	Finance agency leads with programmatic partners

Section 4: Coordination Partners and Power Dynamics
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State Coordination Structures
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State	Key Partners	Coordination Model	Power Distribution	Tension Level
Alabama	Medicaid Agency, Hospitals	Parallel operation	Lead with partners	Moderate
Alaska	Tribal Health, Regional Providers	Collaborative	Lead-dominant	Low
Arizona	Tribal Nations, Providers	Integrated Medicaid	Lead-dominant	Low
Arkansas	UAMS, Hospitals, Delta Partners	Implementation partners	Distributed	Moderate
California	DHCS, Local Health, CalAIM Partners	Waiver integration	Complex distributed	High
Colorado	HCPF, Regional Networks	Medicaid coordination	Split authority	Moderate
Connecticut	DOH, DSS Sub-units	Intra-agency	Consolidated	Low
Delaware	Medicaid, Providers	Small-state network	Consolidated	Low
Florida	AHCA, Hospital Networks	Parallel operation	Lead with constraints	Moderate
Georgia	Medicaid, Hospital Networks	Expansion transition	Distributed	Moderate-High
Hawaii	Island Health Systems	Geographic networks	Lead with autonomy	Low
Idaho	Medicaid, Regional Health	Integrated HHS	Consolidated	Low
Illinois	HFS, Regional Networks	Large-state coordination	Split authority	Moderate
Indiana	FSSA, Hospital Networks	Medicaid coordination	Split authority	Moderate
Iowa	Merged agencies	Post-consolidation	Consolidated	Low
Kansas	Medicaid, Rural Networks	Parallel operation	Lead with constraints	Moderate
Kentucky	Medicaid, AHECs	Integrated HHS	Consolidated	Low
Louisiana	Medicaid, Hospital Networks	DOH-Medicaid alignment	Aligned	Low-Moderate
Maine	Medicaid, Rural Networks	Integrated HHS	Consolidated	Low
Maryland	MIA, Hospital Networks	Regulatory coordination	Split functions	Moderate
Massachusetts	Sub-agencies, MassHealth	Executive coordination	Executive-led	Moderate
Michigan	Merged agencies, Regions	Consolidated HHS	Consolidated	Low
Minnesota	DHS, Regional Networks	Split health/Medicaid	Split authority	Moderate
Mississippi	Medicaid, CHCs	Limited coordination	Under-resourced	High
Missouri	MO HealthNet, Hospitals	Medicaid alignment	Aligned	Low-Moderate
Montana	Medicaid, Tribal Health	Integrated HHS	Consolidated	Low
Nebraska	Medicaid, UNMC, Networks	Integrated HHS	Consolidated	Low
Nevada	Medicaid, Regional Health	Integrated HHS	Consolidated	Low
New Hampshire	Medicaid, Rural Networks	Integrated HHS	Consolidated	Low
New Jersey	Medicaid, Limited Rural	Urban-focus	Limited rural scope	Low
New Mexico	Tribal Health, CHCs	Medicaid-led	Medicaid dominant	Low
New York	Medicaid, Regional Networks	Large-state coordination	Lead with constraints	Moderate
North Carolina	Medicaid, Hub Networks	Expansion integration	Aligned	Low-Moderate
North Dakota	Medicaid, CAH Networks	Integrated HHS	Consolidated	Low
Ohio	ODM, Regional Hubs	Medicaid coordination	Split authority	Moderate
Oklahoma	OHCA, Tribal Health	SoonerSelect complexity	Distributed	Moderate
Oregon	CCOs, Regional Networks	Unified authority	Integrated	Low
Pennsylvania	DHS, Regional Networks	Split health/welfare	Split authority	Moderate
Rhode Island	EOHHS Sub-units	Executive coordination	Consolidated	Low
South Carolina	Medicaid, Hospital Networks	Limited capacity	Under-resourced	High
South Dakota	Medicaid, CAH Networks	Parallel operation	Lead with constraints	Moderate
Tennessee	TennCare, Hospital Networks	Separate Medicaid	Split authority	Moderate-High
Texas	HHSC Divisions	Internal coordination	Scaled complexity	Moderate
Utah	Medicaid, Regional Networks	Integrated HHS	Consolidated	Low-Moderate
Vermont	Medicaid, Rural Networks	Integrated HHS	Consolidated	Low
Virginia	DMAS, Regional Networks	Split health/Medicaid	Split authority	Moderate
Washington	HCA, Regional Networks	Split authority	Shared	Moderate
West Virginia	BMS, Rural Networks	DOH-Medicaid coordination	Aligned	Moderate
Wisconsin	Medicaid, Regional Networks	Integrated DHS	Consolidated	Low
Wyoming	Medicaid, CAH Networks	Small-state coordination	Lead with constraints	Low-Moderate

Section 5: Federal Relationship Patterns
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CMS Relationship Assessment
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State	CMS Relationship	Flexibility Received	TA Utilization	Pattern Assessment
Alabama	Developing	Low-Moderate	Developing	Building relationship
Alaska	Collaborative	High	High	Strong partnership
Arizona	Collaborative	High	Moderate	Medicaid expertise
Arkansas	Collaborative	Moderate	High	Strong TA engagement
California	Complex	Variable	High	Waiver expertise
Colorado	Collaborative	Moderate	Moderate	Standard engagement
Connecticut	Collaborative	Moderate	Moderate	DSS Medicaid experience
Delaware	Collaborative	High	Moderate	Small-state attention
Florida	Compliance-focused	Low	Low	Political distance
Georgia	Developing	Low-Moderate	Moderate	Expansion transition
Hawaii	Collaborative	High	Moderate	Unique geography
Idaho	Compliance-focused	Low-Moderate	Moderate	Political constraints
Illinois	Compliance-focused	Moderate	Moderate	Large-state bureaucracy
Indiana	Compliance-focused	Moderate	Moderate	Waiver experience
Iowa	Collaborative	Moderate	Moderate	Post-consolidation
Kansas	Compliance-focused	Low	Moderate	Political constraints
Kentucky	Collaborative	High	High	Strong Medicaid history
Louisiana	Collaborative	Moderate	Moderate	Expansion partnership
Maine	Collaborative	Moderate	Moderate	Expansion partnership
Maryland	Collaborative	Moderate	High	Innovation state
Massachusetts	Collaborative	High	High	Waiver expertise
Michigan	Collaborative	Moderate	Moderate	HHS consolidation
Minnesota	Collaborative	Moderate	Moderate	Innovation history
Mississippi	Developing	Low	Moderate	Building capacity
Missouri	Developing	Moderate	Moderate	New expansion state
Montana	Collaborative	Moderate	Moderate	Expansion partnership
Nebraska	Developing	Moderate	Moderate	New expansion state
Nevada	Collaborative	Moderate	Moderate	Standard engagement
New Hampshire	Collaborative	Moderate	Moderate	Standard engagement
New Jersey	Collaborative	Moderate	Low	Limited rural context
New Mexico	Collaborative	High	High	Strong Medicaid partnership
New York	Complex	Variable	High	Large-state dynamics
North Carolina	Developing	Moderate-High	High	Expansion transition
North Dakota	Collaborative	Moderate	Moderate	Small-state attention
Ohio	Collaborative	Moderate	Moderate	Standard engagement
Oklahoma	Collaborative	Moderate	High	Tribal expertise
Oregon	Collaborative	High	High	Innovation leader
Pennsylvania	Compliance-focused	Moderate	Moderate	Large-state bureaucracy
Rhode Island	Collaborative	High	High	AHEAD model
South Carolina	Developing	Low	Moderate	Building capacity
South Dakota	Compliance-focused	Low	Moderate	Political constraints
Tennessee	Adversarial	Low	Low	Political tensions
Texas	Compliance-focused	Low-Moderate	Moderate	Scale and politics
Utah	Compliance-focused	Low-Moderate	Moderate	Political constraints
Vermont	Collaborative	High	High	Innovation history
Virginia	Collaborative	Moderate	Moderate	Standard engagement
Washington	Collaborative	Moderate	Moderate	Standard engagement
West Virginia	Collaborative	Moderate	Moderate	Expansion partnership
Wisconsin	Collaborative	Moderate	Moderate	BadgerCare history
Wyoming	Compliance-focused	Low	Moderate	Political constraints

Federal Relationship Summary
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Pattern	Count	Characteristics
Collaborative	29	Proactive communication, problem-solving, high trust
Compliance-focused	12	Rule-following, minimal initiative, formal engagement
Developing	6	New relationships, trajectory unclear, mixed signals
Complex	2	Large states with variable engagement by function
Adversarial	1	Political tensions, contested interpretations

Section 6: States to Watch
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High Authority Gap States
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These states demonstrate significant gaps between formal lead agency designation and actual implementation control:

State	Gap Level	Key Concern	Monitoring Priority
Mississippi	High	Capacity limitations, non-expansion politics	Implementation delays, CMS intervention
South Carolina	High	Political constraints, under-resourced agency	Subaward execution, performance
Arkansas	Moderate-High	Fiscal lead vs. programmatic implementation	DFA-UAMS coordination, budget alignment
Tennessee	Moderate-High	Separate TennCare, non-expansion politics	DOH-TennCare coordination
Pennsylvania	Moderate-High	Split health/welfare, procurement constraints	Timeline execution

Low Gap States with Scale Challenges
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These states have aligned authority but face implementation complexity:

State	Authority Alignment	Scale Challenge	Monitoring Priority
Texas	Moderate	4.3M rural residents, 254 counties	Regional coordination, equity
California	Moderate	2.7M rural residents, CalAIM complexity	Waiver integration, hub execution
Michigan	Low	2.0M rural residents, Upper Peninsula	Geographic variation
North Carolina	Low-Moderate	3.4M rural residents, recent expansion	Expansion integration

States with Political Transition Risk
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State	Current Structure	Risk Factor	Potential Impact
Georgia	DCH with expansion transition	2026 elections	Policy direction
North Carolina	DHHS with recent expansion	Political volatility	Program continuity
Wisconsin	DHS with BadgerCare	Expansion politics	Coverage integration
Arizona	AHCCCS with trigger law	FMAP reduction risk	Fundamental restructuring

How this article connects to others in Blue Gray Matters.

Constraint clusters source authority gap ratings directly from this matrix, using the four-tier scale as the second primary clustering dimension for implementation peer group assignment.

The 50-state constraint reference table integrates authority gap data from this matrix with Medicaid exposure, RHTP allocation, and population scale to create comprehensive state constraint profiles.

Implementation risk patterns use authority gap ratings to identify states most susceptible to procurement paralysis and political discontinuity failure modes.

Governance model design in Series 14 uses the authority baseline this matrix documents — alternative governance structures that would transfer or share authority require the baseline authority distribution this matrix establishes to design authority transitions that achieve genuine redistribution rather than rearranging the same authority in different organizational containers.

Population identification methodology in Series 9 requires knowing which state agencies have authority to mandate population-specific program requirements — the authority gap data this matrix provides determines whether the accommodation frameworks Series 9 documents can be operationally implemented or remain policy aspirations.

Scenario probability assessment in Series 16 uses the authority ratings this matrix provides as one predictive variable — states with high authority gaps face structural implementation barriers that constrain transformation outcomes independent of investment levels, strategy quality, or provider capacity.

Sources cited in this article.

Centers for Medicare and Medicaid Services. "CMS Announces $50 Billion in Awards to Strengthen Rural Health in All 50 States." CMS Newsroom, 29 Dec. 2025.
Kaiser Family Foundation. "State Health Facts: Medicaid Expansion Decisions." KFF, Jan. 2026.
National Academy for State Health Policy. "State Health Agency Organizational Structures." NASHP, 2025.
National Governors Association. "Governor's Office Organization by State." NGA, 2025.
State RHTP Applications. Various state agency submissions, Oct.-Nov. 2025.

Purpose#

Methodology#

Data Sources#

Authority Gap Classification#

Limitations#

Section 1: Lead Agency Identification#

Complete State Listing#

Lead Agency Type Distribution#

Section 2: Authority Gap Assessment#

Complete Assessment Table#

Authority Gap Summary#

Section 3: Decision Authority by Function#

Function-Specific Authority Assessment#

Control Pattern Summary#

Section 4: Coordination Partners and Power Dynamics#

State Coordination Structures#

Section 5: Federal Relationship Patterns#

CMS Relationship Assessment#

Federal Relationship Summary#

Section 6: States to Watch#

High Authority Gap States#

Low Gap States with Scale Challenges#

States with Political Transition Risk#