Maryland launched initial development of its health insurance exchange the day after the health care law was signed by President Barack Obama in March 2010. Now the state is one of the first to receive conditional approval for operating its new health care marketplace, much of the time under the guidance of a pediatrician-turned-bureaucrat, Joshua Sharfstein.

Sharfstein gave up a plum position in January 2011 as principal deputy commissioner of the Food and Drug Administration to return to his roots in Maryland, where the Harvard Medical School graduate had served as health commissioner in Baltimore.

As the state’s secretary of health and mental hygiene, Sharfstein spent long hours in meetings hammering out the fine points of the state exchange. In his mission to build public engagement, he also is a regular on Twitter as @drJoshS. He tweeted a photo of the kosher-certified goodies he brought in for one recent meeting to thank the members of the exchange governing board.

Political objections to the health care law weren’t an issue in deep-blue Maryland, where the legislature in 2011 authorized the exchange as a public corporation and independent unit of state government. Yet there were still major questions such as what kind of exchange model should be picked and how to build a new computer system that will determine whether people are eligible for federal subsidies or Medicaid.

Four advisory committees were set up and met 22 times, making 27 recommendations to state lawmakers that were enacted earlier this year. To foot costs, the state received a $6.2 million “early innovator” grant from the Department of Health and Human Services and additional funding totaling $150 million.

“I think that we have broad agreement in the state that Maryland could benefit quite a lot by doing this well, and that Marylanders could benefit,” Sharfstein said in an interview. “We have had incredible engagement by brokers, doctors, hospitals, advocates, carriers, businesses — well over 100 people spent a lot of time helping us think through these different pieces.”

And he points to the regular contact that state officials have had with HHS when they needed help.

“From the beginning our approach hasn’t been to throw up our hands,” Sharfstein said. “It’s been to roll up our sleeves and say, what’s the challenge and what’s the solution?”