There is an acknowledged need for extensive reform to the health care delivery system in the United States. The Patient Protection and Affordable Care Act offers unprecedented opportunities to transform care delivery, with numerous provisions that support systemic improvements. States have an imperative to greatly improve system efficiency if they are to effectively and sustainably implement the law’s changes, particularly mandatory coverage expansion. This report examines specific Affordable Care Act provisions that support state system improvement goals and profiles efforts in 10 states: Colorado, Kansas, Maine, Massachusetts, Minnesota, Oregon, Pennsylvania, Rhode Island, Vermont, and Washington. The report highlights the opportunities and challenges that federal health care reform will bring and offers suggestions for how state and national leaders can streamline implementation.