This issue brief is the first in a series that describes the experiences of the David and Lucile Packard Foundation’s state-based Finish Line grantees in 2014, a critical year for health insurance expansion under the Affordable Care Act (ACA). The brief focuses on the grantees that work in Arkansas, Pennsylvania, and Utah—three states that are pursuing alternative approaches to Medicaid expansion, including the use of Medicaid funds to buy private insurance for eligible adults. The brief highlights lessons for children’s advocacy organizations in other states.