A central provision of The Patient Protection and Affordable Care Act (PPACA) requires the establishment of exchanges in each state, on-line marketplaces through which eligible individuals and small business employers can compare and select health insurance coverage from participating health plans. Exchanges are to begin enrolment by 1 October 2013, with coverage to commence 1 January 2014. States have some flexibility with respect to exchanges by choosing to establish and operate an exchange themselves (ie: state-based), or by ceding this authority to HHS (ie: federally facilitated). States may also choose to enter into a partnership with HHS whereby HHS establishes the exchange and the state assists with operating various functions. According to HHS, 18 states will establish a state-based exchange, while 25 will have a federally facilitated exchange. Seven states will partner with HHS. This book examines the states’ responsibilities for establishing exchanges, the actions selected states have taken, and the challenges they have encountered.