The situations in Washington State, Ohio, and Louisiana are representative of a debate that is playing out across the country. They illustrate variation in strategies for using—or declining—one-time stimulus funds, based on political and economic considerations. There is likely to be a similarly wide range of responses to broader health reform if the nation continues to follow a federalist approach that offers federal guidance and resources but allows state flexibility. This approach is likely to stimulate innovation, but also result in a lack of uniformity that may make state actions difficult and expensive to monitor and coordinate, and result in different levels of health coverage as well as access to and quality of care.