“State lawmakers know two things: the feds are not going to do something about drug prices anytime soon, and states have to pay the price,” said Trish Riley of the National Academy for State Health Policy.

So states have embraced their role as laboratories of democracy, a description invoked in a Supreme Court decision by Justice Louis Brandeis, in 1932. Recent precedent for states leading the way in health care include the Children’s Health Insurance Program and even the structure of the Affordable Care Act, both of which were rolled out in states before becoming federal law.

Historically, the federalist philosophy of states taking the policy lead has resonated with political conservatives. And some current drug pricing reforms have a distinctly free-market flavor. More than a decade ago, Massachusetts adopted the health care program that would later influence President Barack Obama’s Affordable Care Act while the state was governed by a Republican, Mitt Romney. Now Massachusetts, governed by another Republican, Charlie Baker, is asking the federal government to allow its state Medicaid program to increase price competition among drugmakers by excluding some high-priced medicines from coverage if an identical cheaper version is available. Last week, Ohio’s Republican governor, John Kasich, urged President Trump to give similar authority — and the negotiating clout that comes with it — to all states.

In Utah, a Republican state representative from Provo, Norman Thurston, is sponsoring legislation to allow the state government to engage in wholesale re-importation of medicines from countries like Canada. “You have manufacturers who are willing to sell the same drugs we use for far lower prices in other places,” he said. “But we are their biggest customer, so where is our volume discount? This is a violation of basic free-market principles.”

Thurston’s bill passed the Utah House on Feb. 18, and similar proposals are pending in other states. A federal bill that would allow patients to personally import medicines has attracted the support of conservatives like Senators Ted Cruz and Rand Paul.

Proposals like these reveal an ideological fault line in the longstanding cozy relationship between the pharmaceutical industry and Republicans. Prescription drug makers are not paragons of the free market. Their business model relies on government-imposed monopolies of patents — even when the drugs’ discovery was made possible by federal funding — followed by restrictions imposed by the government on itself on negotiating down the cost of the medicines it purchases. The Medicare program, for example, is barred by federal law from using its bulk purchasing power to get discounts.