At century's end, states have assumed a very different role in the design, implementation, and operation of health service programs than they did twenty-five years ago. In the current volatile political atmosphere particularly at the federal level, states have taken up the mantle of healthcare reform in the final years of the 1990s. Yet there remain problems and difficulties with the current federal-state relationship in health reform. The critical question is whether states can successfully accomplish genuine reform given its politically charged, complex and costly nature. This question takes on particular significance for the most important reform-expanding coverage to the uninsured poor.

This Article explores the contours of a federal-state partnership that will move toward the societal goal of universal health coverage, and especially coverage of the uninsured poor. The Article suggests several legislative and regulatory changes. The most practical and immediate steps that Congress could take are to reform the Employment Retirement Income Security Act of 1973 (ERISA) and provide matching funds for state health insurance programs for the uninsured that allow states great flexibility in designing programs that really reach the uninsured within their boundaries.