HHS nominee Burwell faces formidable task in cementing ACA

(Story updated at 3:40 p.m. ET.)

On Thursday morning, HHS Secretary Kathleen Sebelius used the platform of a budget hearing on Capitol Hill to announce that enrollment in Obamacare's exchanges topped 7.5 million. A day later, she stood beside the president as he announced her resignation and introduced her successor.

President Barack Obama hailed Sebelius' perseverance in leading the agency through difficult times and noted that she had told him in March that she would resign when the enrollment period was over. “The final score speaks for itself,” he said.

To Obama's other side was his pick to assume leadership of the $1 trillion agency: Sylvia Mathews Burwell, Office of Management and Budget director. Her resume includes serving as president of the Walmart Foundation and as a deputy chief of staff to President Bill Clinton.

Mark McClellan, a senior fellow at the Brookings Institution and a former CMS administrator and FDA commissioner, said that Burwell's management experience makes her a strong pick for the post. “It's just a huge, expansive job,” McClellan said. “There is still a tremendous amount of work to do for the Affordable Care Act implementation to be completed.”

Burwell—assuming she is confirmed, as expected—will have to carry out that work under political opposition to the law that remains as intense as it was four years ago when it was enacted.

HHS still has to resolve problems with the state and federal exchanges' back-end technology to make sure that the marketplaces are functioning effectively when the 2015 open enrollment period opens on Nov. 15. Those issues were shoved to the backburner as the administration's contractors and in-house tech team worked to make HealthCare.gov function for consumers.

In addition, Burwell will need to work closely with insurers to keep them on board with the multiyear rollout of the exchanges. That includes implementation of risk-abatement programs that are designed to shield health plans from untenable financial peril. If insurers turn away from the marketplaces, it could limit competition and drive up premium prices. That could eventually undermine the exchanges' financial viability.

And HHS will need to mount an ongoing education campaign aimed at the general public about the law's rules and benefits. Polls have repeatedly suggested that too many people remain ignorant about key provisions of the Patient Protection and Affordable Care Act, including the availability of subsidies for households that compose 400% of the federal poverty threshold.

Joseph Antos, a healthcare policy expert at the conservative American Enterprise Institute, questioned Burwell's lack of business experience. He pointed out that many businesses are frustrated by the law's bumpy rollout and repeated rule changes.

But even though her nomination is complicated by the toxic politics of Obamacare, Burwell isn't expected to face a serious confirmation threat. She was approved in her current post by a 96-0 vote last year.

In addition, Democrats rewrote the rules in November to eliminate filibusters for most presidential nominees. That means only 51 votes will be needed for Burwell to gain confirmation. And one of the foremost Democratic critics of the healthcare law, Sen. Joe Manchin, immediately issued a statement supporting the nomination of Burwell, a fellow West Virginian.

“There will be a huge amount of sturm und drang,” said Theda Skocpol, a government and sociology professor at Harvard University, “and there will be a lot of yelling and screaming, but she'll be confirmed.”

The struggles of HealthCare.gov, and the partisan rancor that it sparked, drew most of the media attention during Sebelius' tenure. But Joel Ario, managing director at Manatt Health Solutions and former director of HHS' office overseeing the health insurance exchanges, points to her close work with insurance companies and state governments as a crucial legacy that she'll leave behind.

“She was a very effective secretary with the constituencies that were most important here,” Ario said. “I think a lot of the things that she wasn't able to do is a problem with our politics, which it's hardly fair to blame her for.”

Follow Paul Demko on Twitter: @MHpdemko