The Fund supports networks of state health policy decision makers to help identify, inspire, and inform policy leaders.
A bipartisan group of state health policymakers from both the executive and legislative branches who are focused on improving population health.
Networks of state officials, advocates, and others aiming to invest in and transform primary care.
A program dedicated to advancing state-based efforts to make health care more affordable for residents, employers, and states.
The Milbank Memorial Fund supports two state leadership programs for legislative and executive branch state government officials committed to improving population health.
A leadership development program for early and mid-career state government officials who are committed to improving the health of all people in their communities.
A leadership program for senior state government officials who are committed to improving population health.
The Fund focuses on creating an affordable health care system built on strong primary care and partnerships that improve health outcomes for all.
Improving state leaders’ ability to enact and implement evidence-based health policies.
Advancing policies that create a more prevention- and primary care-oriented health system.
Improving population health through policies that contain health care cost growth.
Our state health policy resources offer relevant data analysis and best practices.
The Fund publishes reports, issues briefs, and case studies on state health policy issues.
Short takes on health policy issues from Milbank staff and guest authors.
Insights from Milbank President Debra Lubar on state health policymaking.
Reported articles and Q&As on timely health policy issues, as well as foundation updates.
Milbank Memorial Fund and Milbank Quarterly webinars featuring state health policymakers and researchers.
Updates and expert contact information for reporters.
The Milbank Memorial Fund is a private foundation that works to improve population health and health equity.
October 22, 2026
Quarterly Article
Amit Jain
Sunil K. Jain
Jun 29, 2026
December 2025
Mental Health and Substance Use Challenges
Back to The Milbank Quarterly
Policy Points:
Context: Federal interoperability initiatives like Trusted Exchange Framework and Common Agreement transport clinical records across boundaries but fail to aggregate and enrich state-governed datasets, including Medicaid claims, prescription monitoring records, and social service registries. This fragmentation creates fiscal and administrative liability for states, exacerbated by the One Big Beautiful Bill Act’s mandate for twice-yearly Medicaid redeterminations and work verifications beginning in 2027 amidst tightening state budgets.
Methods: Synthesizing health information exchange literature, existing state operational models (Maryland, Indiana, California, North Carolina), and federal statutory requirements, we propose a cooperative federalism governance model, technical data architecture, and multi-payer financing strategy for state-designated health data utilities (HDUs).
Findings: We propose an HDU architecture that can be adapted across multiple states, designed to directly advance clinical care delivery by functioning as an enrichment layer integrated natively into electronic health record workflows. By synthesizing longitudinal clinical encounters, controlled substance histories, claims, and social needs registries in real time, the proposed utility would deliver actionable predictive risk scores and automated point-of-care alerts to prevent avoidable readmissions, curtail redundant advanced imaging, and coordinate cross-sector interventions for high-risk patients. Operationally, the model pairs this bedside enrichment with automated eligibility and frailty verification, ensuring high-need individuals maintain continuous access to essential clinical services.
Conclusions: Clinical data fragmentation is rooted in governance silos rather than technical barriers. Establishing state-designated HDUs through a cooperative federalism model bridges bedside clinical practice, public health, and Medicaid administration. HDUs provide the integrated infrastructure necessary to prevent clinical crises, protect vulnerable populations, and improve care delivery at scale across the United States.