Implementation of the Affordable Care Act (ACA) has opened the door to new opportunities for health policymakers to address the nation’s growing chronic disease epidemic through integrated solutions that begin to bridge the health care, public health, and social services sectors. To take advantage of these opportunities, state policymakers have incorporated a greater focus on advancing “population health,” meaning the health outcomes of groups of individuals and the determinants and policies impacting their health, in delivery system reform initiatives. A leadership position located within or aligned with the state public health agency that is charged with directing cross-sector population health improvement efforts may be beneficial to states in this new era. Among possible models for such leadership is a concept for a State Surgeon General (SSG), a position with responsibilities largely mirroring those of the U.S. Surgeon General, to provide executive-level physician leadership and contribute to the development and implementation of effective population health policies. The experiences of four states that implemented a SSG prior to passage of the ACA highlight new opportunities and challenges for the model at this juncture in time.