The U.S. has finally moved towards the reform of its health system. On March 23, 2010 the Patient Protection and Affordable Care Act was signed into law by President Barack Obama. With goals of expanded health coverage, access to quality, affordable health care, and reducing health care costs, the law sought to ensure that eligible U.S. citizens had health insurance regardless of ability to pay or existing medical conditions. Key to meeting the goal of providing health insurance was the creation of state Health Insurance Exchanges (HIEs). To support the provision of guaranteed health care coverage to millions of uninsured and at-risk/vulnerable populations HIEs were mandated to contract with community based organizations and consumer advocacy agencies to serve as navigator programs. These agencies were charged with reaching, educating, and enrolling individuals into health plans. Establishing HIEs to serve as public marketplaces for purchasing health plans is new to the U.S. private insurance market. Thus, selecting business models and creating governance structures were key to HIE effectiveness in carrying out federally mandated functions. Also, ensuring the use of navigator strategies that were successful in reaching at-risk/vulnerable populations was critical. This research examined the creation of State Based HIEs in sixteen states and the District of Columbia to assess HIE business models and governance structures. It also explored traditional patient navigator programs to identify strategies proven to be successful in reaching at-risk/vulnerable populations for the delivery of health care services and treatment. Findings show that choice of business model (state agency, quasi-governmental, or non-profit) and governance structure (board membership apportionment, appointment, and composition) could impact HIE effectiveness. Key was removal of certain design issues and barriers that impacted effective operation. A review of traditional navigator programs identified strategies that were successful in reaching at-risk/vulnerable patients and facilitating treatment and care. Program elements such as advocacy, ethnic and racial concordance, and use of navigators who had experienced the same illness, were among some of the factors that were identified as elements of successful strategies. This research is expected to provide baseline information on the development of State Based HIEs and HIE navigator programs as health reform in the U.S. continues to evolve.