State approaches to health reform in the face of economic constraints were the focus of the "U.S. Health System in Transition" conference, hosted by Brandeis University's Council on Health Care Economics and Policy in May 2013. At the event, Commonwealth Fund president David Blumenthal, M.D., discussed next steps in health care cost control while others speakers addressed questions surrounding the Medicaid expansions, health insurance exchanges, high-cost patients, and the role of state regulation. A new report summarizes the discussions and policy recommendations that emerged.