The Affordable Care Act is designed to improve access to coverage for millions of Americans. Because states are the primary implementers of these requirements, this report examines the status of state action on the three major components of health reform -- the market reforms, the establishment of health insurance marketplaces, and Medicaid expansion. The analysis finds that nearly all states will require or encourage compliance with the market reforms, every state will have a marketplace, and more than half the states will expand their Medicaid programs. The analysis also shows that federal regulators have stepped in where states have been unable or unwilling to take action. These findings suggest that regulators will continue to help ensure consumers receive the benefits of the law -- regardless of the state they live in -- but raise questions about how this variation might affect consumers as state insurance markets undergo significant transition in 2014.