Background: The Real Constraints Are Not Technical

The RFI’s background section diagnoses a fragmented and aging technology landscape: siloed systems, unnecessary variability, vendor lock-in. I recognize every element of that diagnosis from the inside. But before CMS builds a standards program to address it, I offer an observation from decades of proximity to the problem: none of the states I have worked with have been blocked by an absence of technology or an absence of standards.

FHIR is mature. X12 is mature. NIST frameworks are mature. Cloud architectures, API patterns, rules engines, and data platforms capable of supporting any state Medicaid program exist today and existed five years ago. If the availability of modern technology and well-defined standards were the binding constraint, the MES landscape would already look very different.

The binding constraints are elsewhere, and they are consistent across every state I have observed.

Lead time: The elapsed time from deciding to try something, to a running experiment, to proven outcomes, to a decision about what to do next is measured in years, when the work demands weeks.

Decision distance: Choices about how services work are made by people many layers removed from the point of service delivery, and every layer adds delay and subtracts context.

Procurement structure: Traditional contracting models require states to define the right problems and solutions upfront, even in environments characterized by volatility, uncertainty, complexity, and ambiguity, where certainty is impossible. These models also favor a small group of incumbent vendors with strong incentives to preserve the status quo.

Misapplied frameworks: Constructs like MITA, enterprise architecture taxonomies, and module certification categories that ask states to describe systems in great detail while doing nothing to evaluate or change the conditions under which systems get built.

This RFI states its goal directly: "to gather specific, actionable information to ensure the program effectively addresses the most significant barriers to MES transformation," and to understand what is working, what requires improvement, and how CMS can best support states and vendors.

I have taken that stated goal as the assignment. The questions that follow it largely explore the mechanics of standards, but the most significant barriers to MES transformation are not standards mechanics, and a response confined to the questions would miss the goal. The recommendations below are addressed to the barriers.

The hypothesis underpinning this response is that the prevailing approach to modernization has been fundamentally ineffective, not merely inefficient. The United States spends more than $16 billion annually on Medicaid enterprise technology, yet the return on that extraordinary investment is difficult to identify in the outcomes that matter to residents, caseworkers, and taxpayers.

The recommendations that follow begin from the premise that this is unacceptable, not simply suboptimal. In several areas, they call for reversing the assumptions and practices that shape today's approach rather than incrementally refining them.

Readers who believe the existing emphasis on solutions, standards, and architecture requires only modest improvement may find these recommendations disproportionate. In my judgment, formed over two and a half decades working in this field, they are proportionate to the scale and persistence of the problem.