Tom Betlach, the longtime head of Arizona’s Medicaid program, will step down January 4 after working for the state for 27 years. Betlach, 52, has led the Arizona Health Care Cost Containment System since 2009, a remarkably long tenure for any Medicaid director in the country. Betlach led the department through steep cuts after the Great Recession and oversaw expansion of the state’s Medicaid program under the Affordable Care Act. After extensive service to the state through numerous gubernatorial tenures, Betlach, who previously served as the state budget director, is ready for a new challenge.
What will you do when you step down?
I’m not really retiring. I’m going to take two months off and then I’ll do some consulting.
So would you be doing more consulting in Arizona or elsewhere?
Probably more elsewhere. That would be the plan. The interesting thing to me is that Medicaid directors generally turn over every two years and I think it’s a major risk to the Medicaid program. So, I think there’s opportunities to help new Medicaid directors coming into their roles get a better flavor for the challenges that they’re facing.
Why do so many Medicaid directors leave after such short tenures?
There’s a variety of reasons. One is the challenge associated with the job. The other is that oftentimes, they have opportunities outside state government to go make more money and not have all the challenges that you do in being a Medicaid director. Sometimes, the gubernatorial dynamics play into it. The last time we had a gubernatorial cycle that was equivalent to this one, back in 2014, I think we had 25 Medicaid directors that came in the next year that were new.
How have you managed to stick around for so long?
Part of it, I think is, my continued public service. For me, it’s been making a career within the public sector. But the reason I’ve been able to stick around, and I say this all the time, I have a great team here at AHCCCS. That’s the first ingredient that has allowed me to stick around. The second is the program has enjoyed tremendous support, not only from my boss, the governor, but the program has historically enjoyed a lot of support from the Legislature in terms of Arizona created this unique model in 1982. It was the last state to create a Medicaid program. It did it in a unique way in terms of mandatory managed care and I think the AHCCCS brand is viewed positively in terms of the policymaking community. It’s those three things. It’s the people, the mission, the support that we need in order to be successful.
When you first started working in state government, was your end goal always to work on Medicaid?
No, it wasn’t. I came into the budget office and I found it a very different place to grow up in state government. You’re really able to deal with a number of different policy areas and so it’s incredibly interesting. But the budget office also takes its toll during the holidays, and we had three young kids at the time and so you could only miss so many holiday events. That’s when I thought it was time to find something else to do. I looked around and I thought Medicaid was maybe the most interesting program at the state level.
How steep was the learning curve when you started this job?
One of the great things about being in a variety of these different roles is that you get to learn a lot, and so really having the opportunity to expose yourself to all this new information was tremendous. One of the ways that I learn is I just ask a lot of questions and I learned that from my budget days.
What has been the biggest challenge in overseeing the state’s Medicaid program?
I think the biggest challenge from the Medicaid director perspective and my time in that role, was during the Great Recession because I think that was the time when the state was going through its biggest challenge. When you look at the fact that we sold a lot of assets that we had, as a state, to increase taxes and yet, we did the deepest budget cuts of any state by far and away in our Medicaid program.
The Medicaid expansion fight was lengthy and complicated. Was there a time when you thought expansion wouldn’t come to fruition?
To Governor Brewer’s credit, when she made the decision that she was going to restore and expand Medicaid, you could tell that she was all in on that decision. It obviously wasn’t an easy decision for her and it wasn’t an easy policy debate around that topic, given the politicization of that decision, but she was pretty determined. To her credit, she stuck with it and I felt once she made that decision, ultimately we would be able to accomplish it just because of how committed she was to seeing that through.
How has Arizona’s Medicaid program changed since you started?
It’s changed a lot just in terms of size and scope and who we cover. Let’s go back to when I was budget director, I think we covered half a million people before the Prop. 204 expansion. Then we grew again in the recession and grew again during the Great Recession. Obviously the program, the size and scope and the number of Arizonans enrolled in it has changed significantly in terms of the population that we serve. Programatically, what’s changed is we’ve had significant fundamental changes. The first is the integration of behavioral health services for our members and getting rid of that carve out. Our work around individuals that are in both Medicare and Medicaid. Arizona has been a leader in that in terms of really trying to have people served by the same organization for both.
Was there a specific moment when you realized you wanted to step down as Arizona’s Medicaid director?
No. It was just that having done this for nine years is a really long time – very few Medicaid directors make it nine years. To a certain extent, I think organizations need to hear a fresh voice every now and then. It just seemed like a natural point. You clearly want to serve a governor through an election like that and then to not have to go through another legislative session, that seems like an upside to me.