Since its creation by the U.S. Congress in 1965, the U.S. Medicaid health care system has been a shared federal-state financing and health care delivery system for the poor. The implementation and financing of the Medicaid system has had differing paths as a result of a range of policy choices behind which are the states charged with administering the program and policymakers in Washington. The policy choices and institutional structures associated with the U.S. Medicaid system have many similarities to China's provincial and local health-care system of financing and delivery of health-care services. Past and recent reform efforts by the central government in Beijing have similarities to the policy path of the development of the U.S. Medicaid system. The policy choices made by U.S. state and federal policymakers have numerous lessons that can be learned as a result of the institutional similarities in the Chinese provincial health care system.