A labor and delivery nurse who ran Senate healthcare policy now manages $1.7 trillion in federal health spending—and she runs her team like a startup. Steph Carlton, Chief of Staff and Deputy Administrator at CMS, reveals the OKRs driving Medicare and Medicaid, why they're killing social determinants funding while building consumer health apps at scale, and how real-time provider data could collapse the 18-month lag between care delivery and payment. The team mixing founders with policy veterans is rewriting quality measures around VO2 max and app engagement, not just disease management—because preventing illness years before it happens might finally be worth more than treating it after.