How health care risk is pooled is of defining importance to health care systems. This paper explores provisions in the House and Senate health reform bills that could pool risk across state lines. These provisions include options for states to jointly operate insurance exchanges and enter into interstate health insurance compacts, as well as the development of national health plan offerings. Using available literature and discussions with an array of experts in the fields of health policy, insurance, regulation, and purchasing pools, the paper summarizes the potential for cross-state pooling and the challenges faced in implementation of the specific strategies.