Maryland is widely recognized as a leader in implementing national health reforms, particularly developing their state health insurance exchange well ahead of other states. Health insurance exchanges were created under national health reform as an understandable, fair marketplace for consumers and small businesses to understand and purchase health plans that provide value for the price; federal premium subsidies to make insurance affordable for individuals are only available in the exchanges. In a state visit this week, executive agencies, legislative branch and advocates all agreed that Maryland’s public and inclusive process was key to their success. Maryland passed enabling legislation, created their governance structure, and engaged six inclusive advisory committees last year. As one policymaker said, “It’s not possible that we missed anyone.” Through a transparent, comprehensive process with expert consultant support, those committees and the Board developed a strong set of operating policies that position the state to have a strong, effective exchange in place to help Maryland residents choose the best health plan for their needs by 2014. Using the same inclusive, transparent process, they are moving forward with decision-making and operationalizing those policies. Stakeholders credit soliciting public input often, engaging broad and diverse membership on committees, good communications, and transparent policymaking for their success. Legislation creating the Board excluded members with conflicting interests, creating an expert group with credibility, allowing the state to avoid problems Connecticut has encountered. Stakeholders also credit the decision to create a quasi-public entity with has critical to success. The new entity, outside government, provided public accountability and a fair process but also allowed faster procurement of expert consulting and facilitation services from diverse sources. To keep momentum going and recognizing the huge number of tasks, policymakers decided to make decisions in steps. Early on they finalized decisions in policy areas that achieved consensus, and put off more contentious debates for later such as whether to negotiate with plans to qualify for the exchange or approve any that meet standards. The financing model for the exchange’s administrative functions also remains to be worked out. Maryland is now deciding how to hire, train and certify navigators, to inform the public and assist consumers and small businesses in making the best purchasing decisions.