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As the CEOs of the largest health insurers in their states, Medicaid directors are positioned to influence the delivery of higher-quality, more cost-effective services across the health care system. This profile details Tennessee’s innovative health care transformation process and the critical role of the state’s Medicaid director Darin Gordon in the statewide restructuring. It also describes the Medicaid Leadership Institute, a unique fellowship program designed to enhance the capacity of Medicaid directors to maximize the potential of publicly financed health care.