As Congress examines the health care crisis and struggles to find apolitically acceptable reform package, it seems increasingly likely that federal reforms, if any, will delegate key decision-making authority to the states. Since several states are considered health reform innovators, and since federal officials are unable to reach consensus on a national reform strategy, Congress may well ask these laboratories of democracy’ to guide and shape the overall reform effort. However, it may not be wise to rely on the states to initiate and implement health policy reforms. If not, and the federal government instead should play the leadership role, what might an appropriate (and potentially feasible) intergovernmental partnership look like?