Medicare and Medicaid, the federal government's health insurance programs for the elderly and poor, play a big role in the health care reform proposals being considered on Capitol Hill. President Obama and Democrats in Congress hope to cut Medicare spending by nearly a half-trillion dollars over the next decade, and reform plans call for a big expansion of Medicaid during the same period.

The proposals raise serious questions. Is it really possible to take so much money out of Medicare and not affect coverage? Is expanding Medicaid a good idea?

Congress would like to pose those questions, and many more, to the top administrator of the Medicare and Medicaid programs. Except there isn't one. Even though the job is critical to the current health care debate -- and would become even more critical should reform pass -- Obama hasn't gotten around to filling it yet.

The position is officially known as the administrator of the Centers for Medicare and Medicaid Services, usually referred to as CMS, which is part of the Department of Health and Human Services. The administrator oversees about $700 billion in annual spending -- more than the entire defense budget. It is a very big job.

But at the moment, it's held by an acting administrator, Charlene Frizzera, formerly the chief operating officer of CMS. Frizzera has extensive experience in the field, but so far at least, she is not the permanent head of CMS. When Obama names a candidate for the job, he or she will have to be approved by the Senate Finance Committee and confirmed by the entire Senate.

"It's a very big concern that the agency lacks a permanent administrator," says Iowa Sen. Charles Grassley, the ranking Republican on the Finance Committee. "An acting administrator, no matter how well-qualified, lacks the authority to lead and is difficult to hold accountable."

Even without a permanent chief, CMS is playing a big, and often controversial, role in the current health care debate. You may remember the flap when the government imposed a gag order on some insurers who had the audacity to tell their policyholders that Medicare cuts might affect their coverage. That gag order, since lifted, came from CMS.

The agency is also coming up with analyses of various health care proposals that don't always please Democratic leaders. A few weeks ago, CMS actuaries concluded that the version of the House reform bill then under consideration would cost more than was thought, and that Medicare savings would be less than estimated but would still mean benefit cuts for some seniors. It wasn't exactly what House Democrats wanted to hear.

The last time Medicare was such a hot topic in Washington, during the debate over the 2003 Medicare prescription drug entitlement, George W. Bush's head of CMS, Thomas Scully, was an influential player on Capitol Hill. Now, with the stakes even higher, there's nobody to play that part.

Asked about the vacancy, White House spokesman Reid Cherlin said, "Filling this role is a priority for the administration, and we're working to name an administrator as soon as possible." But some Republicans suspect the White House is not entirely unhappy with the situation as it exists today.

"If Obama nominated someone for the job, lawmakers would have an intense interest in their views about health care," says one Republican Senate aide.

That could make running CMS a very uncomfortable job, because senators would expect the administrator to testify at length on why the White House believes extensive cuts can be made to Medicare without cutting the quality of care. So perhaps the president is content to have no one in the job while the debate is going on; the position can be filled later, when the heat is off.

The top spot at CMS isn't the only important job vacancy in the Obama administration. According to the White House Transition Project, a group that monitors the job-filling process, a large number of key positions in the administration remain unfilled. As of Oct. 1, for example, Obama had nominated candidates for fewer than half of the positions in the Treasury and Justice departments that require Senate confirmation.

But given the circumstances, the top job at CMS is special. Congress is considering huge changes to our health care system, especially Medicare and Medicaid. Lawmakers need an authoritative voice to give them the unvarnished facts before taking actions that can't be undone. But the president hasn't seen fit to fill the job.

Byron York is chief political correspondent for The Washington Examiner.

(Nov. 6, 2009)