This issue brief examines an unprecedented use of state health insurance regulatory authority to promote health system reform. In 2004, the Rhode Island legislature created the Office of the Health Insurance Commissioner (OHIC) with authority not granted to state health insurance regulatory agencies in other states. Specifically, the legislation instructed OHIC to direct insurers toward policies that promote improved accessibility, quality, and affordability for the Rhode Island health system. In 2009, OHIC used this authority to implement a set of standards to promote increased affordability through a series of requirements aimed at strengthening and expanding the state's primary care infrastructure. Insurers are required to increase their investments in primary care on a cost-neutral basis, expand use of the chronic care model medical home, and support implementation of electronic medical records. Rhode Island is testing whether state insurance regulation can foster a profound transformation in health care delivery.