PROJECTHealth Care Stewardship Case Studies


Health Care Stewardship in Colorado, Ohio, Oregon, Minnesota, and Vermont

In early 2015, Urban conducted case studies examining health care stewardship in five states. Through interviews, we examined the unique ways each of the five states—Colorado, Minnesota, Ohio, Oregon, and Vermont—has leveraged its authority to improve the quality and efficiency of the state’s health care system.

What is stewardship?

The World Health Organization defines stewardship as “the careful and responsible management of the well-being of the population.” Government, as steward, should take responsibility for the population’s health by guiding the health system as a whole. Stewardship demands active pursuit by governments of systemwide improvements beyond typical public health and purchasing roles, such as providing health insurance to state employees. This means developing a strategic framework for health policies that reaches all citizens, building support among stakeholders, regulating and monitoring health care systems, and using data to improve.

State stewardship

As some of the biggest purchasers and primary regulators of health care, states can promote residents’ health by strategically reforming health care organizational, payment, and delivery systems. Though state governments already have clear responsibilities in providing health care to defined populations, such as Medicaid enrollees and state employees, stewardship asks these state governments to go further, considering how to bring high-quality, efficient health care to all residents. In the five states we studied, governments acted as stewards by implementing reforms including the establishment of new state agencies tasked with championing health care innovation; the implementation of bundled payments and global budgets; and the establishment of accountable care organizations, coordinated care organizations, and regional care collaborative organizations.

The case studies

After examining health care reforms in states around the country, we decided to focus on Colorado, Minnesota, Ohio, Oregon, and Vermont. Each of these states has taken an active role in its citizens’ health. Using stewardship as a lens, we assessed state health care system reforms for their effect on residents’ health. Members of the research team visited each state and interviewed key health reform stakeholders, including state officials, consumer advocates, health care providers, and researchers. Based on those interviews, we composed case studies outlining each state’s context, goals, leadership, relationship to the federal government, structures for change, progress, and sustainability.


The research team for this project included Robert Berenson, Judy Feder, Alan Weil, Nicole Lallemand, Rachel Dolan, and Emily Hayes.

Research Areas Health and health care
Policy Centers Health Policy Center