Health care payers are increasingly turning to accountable care strategies, linking payments to value for a defined population of patients across a continuum of care, as they seek to control costs and improve quality. We examined publicly available sources to identify and analyze state-led activity to promote accountable care. We found that 17 states are implementing accountable care strategies in Medicaid or state employee health programs. State activity runs the gamut from financing accountable care models to developing state standards that certify public and private accountable care organizations, to aligning accountable care principles with the creation of new community-based organizations or Medicaid managed care organization contracts. As more states begin to use their leverage as health payers, purchasers, and regulators to re-shape health care delivery, policymakers can learn from their accountable care design principles and early pilot results.