Skip to main content

Advanced Search

Advanced Search

Current Filters

Filter your query

Publication Types



Fund Reports


States' Roles in Shaping High Performance Health Systems

States shape the health system in many ways, determining or influencing key system components such as insurance coverage, quality of care, and information and provider infrastructures. They affect these components in their roles as purchasers, regulators, analysts, planners, collaborators, and conveners, as well as providers of information and technical assistance. Despite this activity, there is little systematic effort to monitor states, learn from their choices, and spread innovations from state to state. In addition, coordination between states and the federal government is often lacking.

This report presents findings from the State Health Policies Aimed at Promoting Excellent Systems (SHAPES) project, undertaken by the National Academy for State Health Policy (NASHP), with support from The Commonwealth Fund, to identify and spread information about state health policies and practices aimed at promoting high performance health systems. The project was guided by the following principles, which are based on the key attributes of high performance as defined by the Commonwealth Fund Commission on a High Performance Health System:

  • States can work toward the goal of ensuring that everyone has equitable and affordable coverage of essential health care services.
  • States can strive to ensure that everyone receives the right care at reasonable cost; this care should be equitable, safe, patient-centered, and coordinated.
  • States can help develop and improve health system infrastructure to ensure that everyone has access to health services that promote long and healthy lives.

Noteworthy Findings

States are pursuing system improvements across the full spectrum of their authority, including health care purchasing, regulation of providers, gathering and analyzing of performance data, and efforts to expand the availability and affordability of health insurance. Using surveys of six state agencies as well as a review of other state survey reports, this study revealed a great deal of variation in states’ involvement in such efforts across the country.

Health Insurance Coverage
States can play a major role in ensuring affordable health coverage, not only by maximizing the use of federal programs, but going beyond them with state-only investments and public–private approaches.

Federal financial support is most available for children, and many states are working to extend that support to cover all children. This study also confirmed that states are working to cover adults. Medicaid generally does not provide funding for states to provide coverage to healthy, working adults without children, so states must obtain federal waivers to cover them. Seventeen states have such waivers. In addition, at least two states (Washington and Pennsylvania) are using state funding, with no federal financial assistance, to cover childless adults.

Some states also promote coverage for childless adults through programs aimed at expanding coverage for small employers. Nearly three-quarters of the states that responded to NASHP's surveys indicated they have policies or programs aimed at reducing the cost of coverage for small employers and their workers. Twelve states reported they use premium assistance; six reported they have reinsurance programs; four reported they have purchasing pools; and 24 states responded they use other types of programs. These alternative strategies include state tax credits to make coverage more affordable for small employers, allowing small businesses and self-employed people to form purchasing alliances, allowing insurers to sell plans with reduced benefits, and regulating rates in the small group market.

States also are exerting influence over insurance benefit design—not only in public coverage programs, but also in the private marketplace—by defining minimum benefit packages and requiring parity in mental health coverage. To streamline public coverage enrollment and renewal, states are using technology, but there is significant potential for them to do more in this area.

Quality, Safety, and Value
States are engaging in collaborative efforts to improve quality of care, both with the private sector and in cross-agency efforts. States are using a variety of levers as purchasers, including requiring reporting on quality, employing specific contractual provisions for vulnerable populations, and having joint quality requirements in multiple-agency purchasing.

In particular, public reporting is a critical ingredient for system accountability. It can generate interest in improvements to maximize quality, safety and efficiency, and is a necessary tool for consumer choice. Over half of states that responded to the SHAPES survey are publicly reporting quality data or patient safety data or both kinds of data. Most, but not all, of these states have legislative mandates requiring such reporting.

Health System Infrastructure
Information is an essential element in maintaining and improving health systems, and technology offers increasingly sophisticated tools for information collection, maintenance, and exchange. Over half of responding public health agencies and governors' offices reported that their states have a public health information system that integrates data from multiple sources. Immunization data and vital statistics data were most commonly included in these systems, followed by hearing screenings, laboratory data, newborn screenings, hospital discharge information, and cancer registry data. The primary users of these data systems are public health agency employees, followed closely by employees in other state agencies and private sector health care providers. Only seven states reported public use of the data.

States are addressing health system provider capacity by monitoring the safety net, addressing provider shortages, and reimbursing for telehealth. A number of states cited collaborative relationships with other entities in these efforts, including primary care associations that represent community health centers.

Takeaway Messages

  • States' multiple roles in the health care system create opportunities for promoting performance; many states avail themselves of these opportunities.
  • Every state reported some activity that promotes achievement of a high performance health system.
  • States continue to focus strongly on securing insurance coverage and access to health care services for vulnerable populations.
  • States are moving beyond historic roles to exert influence with the private insurance market, leverage purchasing power, and collaborate more with the private sector.
  • Few states are actively pursuing system performance in areas such asefficiency and patient safety.
  • In every area examined, there is room for states to do more in pursuit of a high performing health system.
  • Ongoing mechanisms to monitor, study, and report state activities could help diffuse and speed adoption of promising policies and practices.
  • More in-depth exploration of specific areas of state activity could yield richer information that would aid state and national efforts to improve system performance.
  • Opportunities for state-to-state exchange could help transfer knowledge and experience and spark new and innovative approaches through joint stateproblem-solving.

A more extensive report of survey findings and other data is available at

Publication Details



C. Hess, S. Schwartz, J. Rosenthal et al., States' Roles in Shaping High Performance Health Systems, The Commonwealth Fund, April 2008.