We examine five states that had low marketplace enrollment relative to Urban Institute 2015 projections. The paper identifies reasons for lower than expected enrollment in each state. The study finds that each of the study states began with relatively low uninsurance rates so enrollment increases are challenging. Other problems are affordability, problems with IT systems, and a shortage of navigators and assistors in at least parts of these states. In some states such as in West Virginia and Iowa there was strong political opposition. The study concluded that enrolling the remaining uninsured will be increasingly challenging in these states.