The University of Texas at Austin

As soon as former Senate Majority Leader Tom Daschle withdrew his nomination to be secretary of health and human services amid tax troubles three weeks ago, the chattering classes began handicapping the candidates for the newly vacant Cabinet seat.

Who would President Obama choose to head HHS, the largest-budget federal agency? Would it be one of the Democratic governors who have distinguished themselves in red states — Sebelius of Kansas or Bredesen of Tennessee? Might it be one of the party's more controversial but health-focused former governors — Dean of Vermont or Kitzhaber of Oregon?

And would the victor be connected enough to secure a coveted White House title and an office in the West Wing in addition? (Recall that Daschle was to be not only HHS secretary, but also dual-hatted as "assistant to the president for health reform.")

With all this focus on who will get a seat at the Cabinet table, few seem to be asking how much the job will really affect the already spinning wheels of health reform by the time he or she is confirmed.

As every CFO knows, budget-making is policymaking. Regardless of who may soon be nominated as health secretary, and regardless of who out in the executive branch departments will be making the speeches about administration policy priorities in May or June, what really matters is who controls the dollar amounts that will be associated with which initiatives.

This week is the time that annual priorities are revealed. On Thursday, the president is due to release his framework budget proposal for next year. Inside that dry, still-secret document of small numbers are a load of assumptions and constraints about the administration's plans for addressing the nation's health care mess of exploding costs, increasing uninsurance and excessively variable quality.

The as-yet-unnamed head of HHS will be chiefly inheriting, not shaping, most of what the health reform agenda looks like. He or she will be steering an agency on behalf of a president who has already affixed his seal to a proposal that links specific budget lines to specific programs, old and new.

So who is advising the president on these issues now? Who owns the central plan for the next phase in the politicization of American health care?

Typically, the powerful wonks in the Office of Management and Budget — the key part of the White House that doesn't turn over when there is a change of presidential administrations — wield their greatest influence at the beginning of an administration. While new political appointees are still trying to find the bathrooms, let alone understand the four corners of their jobs and the legal complexities that govern the executive branch, the budget experts speak with the voice of authority.

But today — amid an ongoing economic meltdown and in the post-Daschle vacuum — internal politics in the White House are significantly more complicated than usual.

Health policy has never fit in only one White House policy team's domain — it is certainly a domestic issue, the Domestic Policy Council would claim; but as 17% of our GDP, health care is also a major economic issue, as the National Economic Council regularly asserts.

Mindful of these enduring turf wars, Daschle demanded the creation of yet another policy shop in the White House, the Office of Health Reform, which he would personally control.

Well, now he is gone, and staffers in the West Wing — a group that has apparently already doubled in size from that of the Bush team — have been left without even the appearance of a lead policy aide on health care.

So who is quarterbacking the details of the health reform plan that will appear in the president's budget framework this week? The HHS secretary is going to find on his or her desk a budget outline — and therefore implicit health reform plan — already published. Who authored it?

Meet Zeke Emanuel.

Dr. Emanuel, head of the department of bioethics at the National Institutes of Health (one of the 11 operating divisions under HHS), is regarded by many as a genius. He has published with acclaim across a broad range of topics, from euthanasia to oncology, from bedside manner to ethical constraints on research in developing countries.

His recent book with economist Victor Fuchs on health reform, "Healthcare, Guaranteed," was regarded even by political opponents as common sense.

His last name is also worth noting. For he is the brother of the president's chief of staff, Rahm. And he is newly detailed from NIH to the White House to advise the director of management and budget on health policy. Timing here is critical.

This week's budget framework will provide hints about numerous critical health matters: Will the money set aside for a new proposal on the uninsured be in the neighborhood of $100 billion (as the budgeters want), or more like $300 billion (as Daschle's team had been quietly sketching)?

Will the administration signal its intent to completely dismantle Medicare Advantage, the program by which roughly one-fifth of seniors choose to get their public health benefit via a private insurance plan rather than through traditional government-run Medicare?

How much will they claim would be saved if the government moved further into the realm of price-setting (and innovation-retarding) for pharmaceuticals?

Will the president propose a Federal Health Board, modeled on the Federal Reserve Bank, to evaluate the comparative effectiveness of different drugs, devices and procedures — and then limit seniors' access to costlier interventions?

These are complicated arguments, in both political and policy terms, and the White House has been preparing its first major statement to address them in the president's proposed budget this week — and all of this planning has happened without an HHS secretary.

On paper, lots of presidential aides have titles superior to Dr. Emanuel. Yet, in practice, one can already feel the center of gravity in the White House shifting his way.

After all, which mere "policy adviser" does Peter Orszag, the budget director, need to tread most delicately around when announcing the budget ceilings for different new policy initiatives?

Who is currently convening the White House working group on health reform? Who are candidates for jobs at HHS most excited to be invited to meet with right now? If you guessed the guy who can walk into the chief of staff's office any time he wants, then you might have a future in politics.

Why does all of this bureaucratic intrigue matter? Because in health care — as now in finance — more and more decisions look like they are going to be made in Washington. And personnel, like budgeting, ultimately determines policy.

Sasse, a former assistant secretary of health and human services, teaches policy at the Lyndon B. Johnson School of Public Affairs at the University of Texas.