SALEM, Ore. — Some say America has been homogenized, a chain-store nation bereft of regional distinction in dialect or dinner. But now this state, at the pioneer’s end of the road, is testing the idea that local community difference is alive and well, and that grass-roots leadership holds the key to fixing health care in America.

Under an agreement signed with the Obama administration last year, and just now taking shape, Oregon and the federal government have wagered $1.9 billion that — through a hyper-local focus on Medicaid — the state can show both improved health outcomes for low-income Medicaid populations and a lower rate of spending growth than the rest of the nation. If Oregon fails on either front, the consequences are grave, potentially tens of millions of dollars in penalties a year, bleeding a state budget still wounded from recession.

Fifteen Community Advisory Councils have been established across the state, charged with setting local goals. One of them, around the college town of Eugene, will take aim starting July 1 at smoking by pregnant women, hoping to cut neonatal costs through a system of rewards, like gift cards at the doctor’s office for women who go tobacco free. Another council, in Portland, is focusing on something that might sound ho-hum in health care, but that local leaders have identified as a care-and-cost driver: mold in low-income housing. Another group, in an economically depressed rural swath in the state’s center, will try getting people out of their cars, aiming for a payoff in reduced cardiovascular care that is both measurable and relatively quick. Hands-on work with patients is common to all the efforts, including one that is using “patient guides,” to talk through care options with people who stack up in emergency rooms with often routine medical problems.

Other states, notably Massachusetts and Vermont, are experimenting with new models as well, mainly through regulation. But Oregon’s way — one ear to the ground, health care with local input — has always been different, and the Medicaid experiment, health care experts said, has now sharpened those distinctions to an incisive edge.