By Jaymie Baxley
After three years at the helm, Jay Ludlam is stepping down as director of North Carolina’s Medicaid program.
Ludlam’s tenure included North Carolina’s expansion of Medicaid, a decade-in-the-making endeavor that has given more than 710,000 low-income residents access to coverage since December 2023. As of February, people who joined the rolls through expansion account for nearly a quarter of the state’s 3.09 million beneficiaries.
His departure comes amid federal changes that threaten the program’s future. Ludlam has repeatedly warned state lawmakers they must take action to preserve expansion before Medicaid work requirements and other provisions of President Donald Trump’s One Big Beautiful Bill law go into effect next year.
Though Ludlam said he’s concerned about all of the challenges facing Medicaid in the near term, he’s not worried about the capability of the people who will pick up where he’s leaving off.
“This is one of the best teams I’ve worked with. They are incredibly dedicated, incredibly smart, really know their work, lead with their heart — and deliver for North Carolina,” he said. “I worked in Silicon Valley in the ’90s, when it was all these entrepreneurs and consultants, and this team really puts them all to shame.”
When Ludlam was tapped to succeed former deputy secretary Dave Richard in March 2023, he came to the role with a deep command of Medicaid policy and operations.
He had spent five years as the state’s assistant secretary for Medicaid transformation, shepherding North Carolina’s shift from a traditional fee-for-service model to managed care — a sweeping overhaul designed to control costs, improve coordination and tie payments more closely to patient outcomes. After having led Missouri’s switch to managed care as the acting director of that state’s Department of Social Services, Ludlam had the experience and knowledge to shepherd North Carolina’s program through the shift, Richard said.
“We were just incredibly fortunate to get Jay at the time we did because the transition [to managed care] was massive, and we had never done anything to that size,” Richard said. “When Jay came in, he had great operational skills and created a structure inside the organization that allowed for what I think was a pretty dang smooth transition.”
The work that went into Medicaid transformation was largely invisible to beneficiaries. They just saw their coverage continuing without disruption.
“I think one of the things that I had learned in Missouri that we were able to do here was to help modernize the internal work that we do at North Carolina Medicaid,” Ludlam said. “We brought business principles to our work. We focused on data and transparency. We focused on improving our ability to forecast budget, to be able to measure outcomes.”
Those changes, Ludlam added, have created a stronger business operating model and an organizational culture that allows the department to “provide more consistent, less risky rollouts for the state.”
For North Carolinians who depend on Medicaid, the quality of program leadership rarely registers — unless something goes wrong. Smooth enrollment, seamless plan transitions and reliable access to care don’t happen by accident. They are the product of administrators who understand both the policy mechanics and the human stakes, and who build organizations capable of executing on a large scale.
An ‘incredible legacy’
Kody Kinsley, the former head of the N.C. Department of Health and Human Services who picked Ludlam to run the program after Richard’s exit, said Ludlam grew into one of the most capable Medicaid administrators in the country.
“Jay’s technical prowess and capabilities as an operational leader are second to none,” Kinsley said. “He really delivered in an immense way and, frankly, in a lot of ways that many people will never know.”
That behind-the-scenes operational prowess was key to the state’s successful rollout of expansion, Kinsley said. Nearly 273,000 newly eligible beneficiaries were automatically enrolled when the measure, which raised the state’s strict income threshold for Medicaid, went live on Dec. 1, 2023.
“Once it was enacted, we were able to make sure that people who qualified for the program on Day One had a card in hand,” Ludlam said. “We knew that they were qualified. They didn’t have to fill out a form. They didn’t have to call a phone number. They didn’t have to show up to a DSS office. They got the card and were able to access care immediately.”
National leaders took note. The National Association of Medicaid Directors recognized Ludlam and his team in 2024 with its Spotlight award for “exceptional leadership and innovation.”
The association cited North Carolina’s implementation of expansion and its handling of the “unwinding” — the yearlong process of reviewing enrollees’ continued eligibility after the federal government ended coverage protections that were enacted during the COVID-19 pandemic — as examples of the program’s operational excellence.
In addition to those milestones, Ludlam oversaw the state’s long-awaited rollout of “tailored” Medicaid plans for beneficiaries with complex needs. These specialized plans, designed to coordinate physical health, behavioral health and long-term care services for people with serious mental illness, substance use disorders and intellectual or developmental disabilities, marked a significant step toward integrating care for some of the program’s most vulnerable enrollees.
Working across the aisle
Kinsley said Ludlam “leaves an incredible legacy of delivering on the legislature’s vision of how Medicaid should operate” — a view echoed by lawmakers.
“Over the time I worked with Jay, I found him to have a wealth of knowledge,” said Rep. Larry Potts (R-Lexington), who presides over the state’s Joint Legislative Oversight Committee on Medicaid. “He was always available and, with his varied background, he was a go-to person when situations arose requiring quick responses.”
Rep. Donny Lambeth (R-Winston-Salem), a co-chair of the committee, said the outgoing director “left his mark” on North Carolina’s Medicaid program.
“He was key to expanding Medicaid to thousands of our citizens who could not afford health insurance,” Lambeth said, adding that Ludlam “had a passion for helping advance the program to one of the premier government-sponsored programs in the country.”
Ludlam’s ability to maintain productive relationships with Republican state lawmakers — even as their congressional counterparts were advancing sweeping Medicaid cuts in Washington — reflected a deliberate approach to keeping policy conversations grounded in North Carolina’s reality and circumstances rather than national politics.
“During the One Big Beautiful Bill debate, there was a lot of misconceptions on the part of congressional legislative staff, North Carolinians that were working in offices up in D.C. or legislators themselves about” who Medicaid serves, he said. He added that many in Washington persisted in holding a “1980s view that it’s a social welfare program.”
The reality, he said, is that working adults in rural communities tend to rely on Medicaid more than any other group.
“After Obamacare, it became a health insurance program primarily for working individuals,” Ludlam said, using the common nickname for former President Barack Obama’s Affordable Care Act. “Those individuals who aren’t working might be too ill to work or too disabled. They might be caregiving or in school.”
Medicaid work requirements, a controversial provision of the OBBBA law, will take effect in January 2027, forcing “able-bodied” enrollees to prove they are working, volunteering or attending school for at least 80 hours a month to maintain their benefits.
Ludlam called the looming mandate one of the “most complex program changes” for Medicaid. He noted that previous attempts to tie eligibility to employment, such as Georgia’s Pathways to Coverage initiative, have been expensive misfires.
“Most Medicaid programs have failed at this in the past, and they had a lot more time and a little bit more clarity than we currently do now,” he said. “I think that there is a lot of risk across the country in whether or not work requirements are going to be implemented in a way that really supports working people.”
But the more devastating consequence of the federal law, Ludlam said, will be North Carolina’s loss of more than $50 billion in federal funding for Medicaid over the next 10 years.
“That’s going to be a challenge for the state to figure out,” he said, adding that the lost revenue threatens to undo strides the state has made in improving access to care for rural residents. “We have built strategies, bipartisan strategies, to support our rural communities, and we put 12 years of sweat equity into supporting rural communities and rural hospitals. Now, we’re going to have to look for new strategies and new techniques.”
Taking lessons nationwide
Ludlam is leaving NC Medicaid to take on a leadership position at Molina Healthcare, a managed care company that has repeatedly made the Fortune 500 list.
“My focus will be on trying to bring a lot of the lessons that we learned here in North Carolina to other states,” he said of his role at Molina, pointing to the state’s now-defunct Healthy Opportunities Pilot as a model worth replicating.
Launched in 2022, the first-in-the-nation initiative used Medicaid dollars to provide food deliveries, transportation to appointments and other nonmedical services to rural residents facing significant barriers to health. An independent evaluation found that the pilot program lowered participants’ health care costs by up to $1,020 a year, but it was shuttered after lawmakers decided to discontinue its funding in 2025.
Ludlam also hopes to spread what he sees as North Carolina’s distinctive civic culture.
“We can count on our neighbors. We can count on each other. Not every state is like that,” he said. “I think that’s missing and should be broadly shared.”
Melanie Bush, the state’s assistant secretary of Medicaid, has been named interim deputy secretary. Ludlam expressed confidence in his successor, calling Bush — who is celebrating her 15th year with the agency — an easy choice.
“Melanie is exceptional,” he said. “She’s been described to me as a rock star, and I have always been impressed with her work.”
Bush brings cross-state experience that Ludlam said mirrors his own path: She worked in Texas Medicaid before coming to North Carolina, and the two have collaborated on Medicaid transformation for eight years. He credited her as the primary architect of the state’s approach to the unwinding.
“She really focused on how do we make sure that people who are eligible and are interested in staying on Medicaid are in the program — but as importantly, those people who don’t qualify for Medicaid are not in the program,” Ludlam said.
Her background also includes a stint at the legislature’s fiscal research division, giving her a fluency in the budget process that Ludlam said will serve her well as the program confronts its federal funding challenges.
“I think she’s fantastic and will be great for North Carolina,” he said. “I’m really excited for her.”
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