As the GOP babbles on the sidelines about repeal, lawmakers in Washington, D.C., and state capitols are working to make expanded health care coverage a reality.

The Affordable Care Act is almost a year old, but genuine prospects for health reform began to seem real this week. President Obama endorsed legislation to give states the right to tailor plans that best fit their needs.

Specifically, he acquiesced on a key point: timing. The bill the president signed into law in 2010 has a launch date of 2014. States cannot seek exemptions until 2017. A proposed change sets out guidelines to allow states to shape their own plans from the start.

As the GOP babbles on the sidelines about repeal, lawmakers in Washington, D.C., and state capitals are working to make expanded health care coverage a reality.

In Olympia, state Sen. Karen Keiser, D-Kent, chairwoman of the Senate Health and Long Term Care Committee, is working to create a health insurance exchange, as required by the federal law. Substitute Senate Bill 5445 would help with the purchase of individual insurance and small employer group insurance.

The exchange not only creates a marketplace for affordable health care, but also provides access to federal tax credits and cost-sharing subsidies, and meets personal responsibility requirements in federal law. Passage of SSB 5445 puts Washington on the path toward developing all the governance, operation and administration of a health insurance exchange.

At the federal level, Sen. Ron Wyden, D-Ore., had authored a section of the Affordable Care Act to provide a “Waiver for State Innovation.” Thanks to Wyden, the law permits states to seek exemptions if their homegrown plan provides coverage at least as comprehensive as the federal plan, is as affordable and protective against out-of-pocket costs, and will cover as many people as the federal plan. All without raising the federal deficit.

Credit Wyden with leading the way. Language “Empowering States to be Innovative” was in his 2006 Healthy Americans Act, a reform effort that never found traction.

Wyden’s current bill would allow innovative state plans to start with the health reform law’s effective date in 2014. That way states would not have to follow the federal template, only to make wholesale revisions three years later.

So what might those states avoid? This is where Wyden’s bill, supported by Republican Scott Brown of Massachusetts and endorsed by Obama, raises anxiety levels. States might wave goodbye to the individual mandate, the employer penalty for not providing coverage, exact federal standards for a basic health insurance policy, and health insurance exchanges. States could even design premium and co-pay rules so they collect the money for truly hybrid plans. Vermont is looking at a single-payer system.

States could not get out of providing health insurance as comprehensive and affordable as the federal plan.

Watch how congressional Republicans respond to giving their home states a chance to craft plans that fit local needs. For now, GOP strategy is to confuse and rattle public opinion.

Serious work is being done elsewhere. The focus on health care expenses and impacts on government deficits is real. Keiser has another bill in Olympia that aggressively targets Medicaid fraud and seeks ways to protect and reward insiders willing to expose the epic thievery and help bolster anemic recovery rates. For starters, how about requiring all service and equipment vendors to be Medicare certified?

Innovation takes all forms. Atul Gawande, writing in the Jan. 24, 2011, issue of The New Yorker, describes the vast sums of money spent on relatively small numbers of patients. Special efforts to target and care for those individuals save extraordinary amounts of public dollars.

The work and conversation is about moving ahead. Generously financed heckling from the political sidelines has nothing to do with the lives of real people.

Lance Dickie’s column appears regularly on editorial pages of The Times. His e-mail address is ldickie@seattletimes.com