A decade ago policy makers and the public expressed a desire for order amid the chaos of United States health care policy. A new order of a kind has since emerged, but it lacks central direction and common aims. There is still no apparent unity of purpose in our “loose constellation of state and federal regulatory efforts,” randomly interacts with [public] health coverage for the elderly, for veterans, and for some of the indigent and disabled.” The dominance of the federal government, assured by its primary role in financing public health programs, has receded or become muted, primarily through the federal ‘ granting of waivers from federal requirements for certain aspects of state Medicaid programs. State programs are, to this extent, the current crucible of governmental innovation in health care delivery, but private health networks shape the state experiments. The politicization of health risks is an accomplished fact, although the role of private insurers is better established than before. It would be fatuous to describe the altered course of health care evolution as a new paradigm; it is less than that. Whether recent developments represent a new approach to federalism or simply give federalism a more concrete meaning is a question worth asking.