A central provision of The Patient Protection and Affordable Care Act (PPACA) requires the establishment of exchanges in each state, online marketplaces through which eligible individuals and small business employers can compare and select health insurance coverage from participating health plans. Exchanges are to begin enrollment by October 1, 2013, with coverage to commence January 1, 2014. States have some flexibility with respect to exchanges by choosing to establish and operate an exchange themselves (i.e., state-based), or by ceding this authority to HHS (i.e., 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.