Maryland: All-Payer Model

• Total Cost of Care

• The AHEAD (Achieving Healthcare Efficiency through Accountable Design) Model

Oregon: Universal Health Plan

Washington: WA Cares Fund

“The 2025 edition of the Scorecard on State Health System Performance once again demonstrates that when it comes to having affordable health coverage, access to good-quality care, and the ability to lead a healthy life, where you live matters. In many cases, the wide variations in health and health care we see come down to the policy choices that state leaders make: for example, whether to expand Medicaid eligibility, whether to ensure women can access the full range of reproductive care services, or whether to boost investment in primary care.

“But states cannot address these concerns on their own. Federal leadership and financial commitment are also critical. Medicaid is an example of how the federal government partners with states to respond to changing needs: for example, during a recession, federal funding rises at a time when state revenues typically decline. The Affordable Care Act’s marketplaces and insurance regulations offer another example. By establishing nationwide affordability standards, insurance subsidies, and rules prohibiting insurers from excluding coverage of preexisting conditions, the ACA leveled the playing field for Americans and narrowed wide state differences in coverage and access to care.

“Similar federal and state efforts are needed to improve other areas of health system performance as well as to address the gaps in access and affordability that remain.”

Source: David C. Radley, Kristen Kolb, and Sara R. Collins, 2025 Scorecard on State Health System Performance: Fragile Progress, Continuing Disparities (Commonwealth Fund, June 2025). https://doi.org/10.26099/w0ns-ae34

“Medicaid’s experience demonstrates an important, related characteristic of U.S. federalism: its cyclicality. Generally, over time, the national government has been the source of social policy initiatives in liberal periods in our history. In conservative periods, on the other hand, some states have been sources of innovation and expansion in the social sector. In the 1920s, for example, when the country was ‘Keeping Cool with Coolidge,’ states were the source of progressive initiatives such as unemployment insurance, public assistance, and workers’ compensation. James T. Patterson noted that the states ‘preceded the federal government in regulating large corporations, establishing minimum labor standards, and stimulating economic development.’ ³ He added that ‘the most remarkable development in state government in the 1920s was the increase in spending.’ ⁴ State initiatives planted the seeds of Franklin D. Roosevelt’s New Deal.

“This same pattern can be seen further back in time. A surge of state initiatives in domestic affairs characterized the conservative Republican period in the 1880s. Allen Nevins and Henry Steele Commager wrote that ‘the first great battles of the reform movement were fought out in the states.’ ⁵ Compulsory school attendance laws and the creation of state boards of education, reforms of political processes, a growing role for state boards of charity, child labor laws, and state regulatory policies in licensing and zoning are examples of state domestic policy innovations at the turn of the century. ⁶ A specific health example of state initiatives later followed by federal action is school vaccination laws, which originated in the nineteenth century. Massachusetts led in 1855; New York followed in 1862; and Indiana, in 1881. All states now have such laws, often coupled with compulsory school attendance laws. Federal grants-in-aid and safety regulations for vaccinations came much later, in 1986 and 1993. ⁷

“In the 1980s, when the pendulum of social policy nationally swung toward conservatism, there was a similar spurt in state activism in response to President Ronald Reagan’s policies to cut domestic spending. States reshaped programs to reflect state priorities, increased their funding of programs in areas in which the federal government had become less active, and assumed more control over the activities of local governments and nonprofits. ⁸ In these and other ways, states increased their influence vis-à-vis the federal government and their relationships with local governments and nonprofits. More recently, Randy Bovbjerg and other Urban Institute scholars pointed to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 as an example of a state initiative that stimulated national policy activism: ‘HIPAA adapted some state and small group insurance market reforms and applied them nationally.’ ⁹“

Source: Richard P. Nathan. Federalism And Health Policy. Health Affairs 2005 24:6, 1458-1466 10.1377/hlthaff.24.6.1458.

“Interestingly, and consistent with the story we tell about the ACA [Affordable Care Act], neither federalism nor nationalism has ever been fully embraced in healthcare policy. When it comes to federalism, it was the case long before the ACA that classic federalism values such as states as ‘laborator[ies]’ of ‘experiment[ation]’⁴² had often been effectuated in health policy not by traditional federalism (the preservation of separate spheres of state authority) but by nationalism (federal laws setting a baseline and inviting state participation with funding nudges). States have been limited in what they can accomplish alone in healthcare experimentation.⁴⁴ Disincentives, such as industry exit, prevent a single state from bearing all of the costs of innovation risk that would arise if it were one of the few making costly regulatory demands.⁴⁵ Federal laws that allow for state experimentation within federal law often provide a steadier path toward experimentation.⁴⁶ The ACA offers a striking example: It was modeled on a major Massachusetts experiment, which the state undertook not alone but rather with federal permission and funds (largely from the Medicaid program).⁴⁷

“On the other side, healthcare nationalism often is characterized as an oppressive interloper in state domains, and has been so characterized with respect to the ACA.⁴⁸ But history shows not only that states sometimes need federal intervention to make their own healthcare systems work—federal intervention typically comes in response to some state regulatory or market failure—but also that federal intervention, when it comes, tends to be focused and incremental. Although Congress has debated fuller-scale national programs⁴⁹ and has occasionally enacted laws that are sweeping (still never universal), it typically enacts compromise legislation that instills piecemeal or targeted federal reform.⁵⁰

“This strategy in turn has prevented a complete vision of healthcare nationalism from being realized. Uniformity and equality of access to healthcare are still wanting, and fragmentation of the U.S. healthcare system remains a salient problem.⁵¹ Federal intervention has tended to be highly incremental and therefore incomplete. Take the ACA again as an example: Despite being a major federal intervention in health policy, the ACA perpetuated and entrenched the fragmentation of U.S. healthcare by expanding the various and very differently structured healthcare programs already in existence—some state-led, some federal, some mixed—rather than starting fresh with a single, integrated approach.⁵²“

Source: Gluck, Abbe & Huberfeld, Nicole. (2018). What Is Federalism in Healthcare For?. Stanford Law Review. 70. 1689-1803.

KFF: State Health Policy Data

National Academy for State Health Policy

World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems and policies in the US and sixteen other OECD member nations.

Page last updated August 12, 2026 by Doug McVay, Editor.