Consider Maryland—a state that has been moving aggressively to implement the ACA since President Obama signed it in 2010. The state expects to hit all the federal deadlines to be ready to go in January 2014. An estimated 730,000 Maryland residents do not have health insurance, according to Joshua M. Sharfstein, M.D., secretary of the state's department of health and mental hygiene and chairman of the board the state created to implement its public exchange. Sharfstein expects half of those people will be insured under the ACA—half through commercial policies bought in the state exchange and half through Medicaid. Sharfstein also expects that the law will be a big net positive for the state's overall budget over the coming decade as it sharply reduces the cost of free care to the uninsured.