By Elise Viebeck - 04/14/14 06:00 AM EDT
Sylvia Mathews Burwell will have a lot on her plate as the next leader of the Department of Health and Human Services (HHS).
If she's confirmed, the outgoing White House budget director will head up one of Washington's largest and most unwieldy bureaucracies.
And she'll enter amid high political stakes, as Democrats seek to neutralize criticism of the healthcare law and maintain control of the Senate.
Burwell's tenure will not be as challenging as that of her predecessor, departing Secretary Kathleen SebeliusKathleen SebeliusThe chaotic fight for ObamaCare California exchange CEO: Insurers ‘throwing ObamaCare under the bus’ Sebelius: 'Repugnant' for states to reject Medicaid expansion MORE.
The new HHS chief will take control at a time when much of the heavy lifting on ObamaCare has been done already.
But that does not take away from the learning curve and pressures that Burwell will confront.
Here are the top five challenges Burwell will face in her new role.
1) Survive 2014
This year will be grueling for federal health officials.
Republicans are hoping to use ObamaCare's unpopularity to take control of the Senate in November. Burwell will become a target for partisan attacks as a result.
Further plan cancelations from small businesses and premium hikes on the new marketplaces will complicate her job.
The HHS also has technical tasks to complete, like improving HealthCare.gov before the next enrollment period in November.
If not prepared, Burwell and her team could find themselves stumped by negative anecdotes about the law.
Administration allies said Burwell should start by pressuring state regulators to reject premium hikes.
"The administration has enormous influence with the states, and I think you would see them involved," former Senate Majority Leader Tom Daschle (D-S.D.) recently told The Hill.
2) Learn the institution
HHS secretary is one of the toughest Cabinet-level jobs, in part because the department is so vast.
With a budget of nearly $1 trillion and a sprawling bureaucracy of programs to oversee, Burwell will have her hands full.
The first step will be learning to navigate the institution.
In addition to ObamaCare's rollout, the HHS administers everything from Medicare and Medicaid to food safety and medical research.
Burwell is an expert in healthcare financing, but gained most of her government experience at the White House, not the HHS.
Supporters said her effective management style will translate no matter where she works.
Skeptics, however, have called into question Burwell's ability to learn the ins and outs of healthcare policy in time to make a difference at the department.
3) Build relationships
The healthcare world is full of powerful stakeholders, and Burwell will have to learn the players quickly.
As the point person in the Obama administration's relationship with health insurers, Burwell will need a deft hand to keep the waters smooth.
Her skills will also be critical in managing relations between the HHS and Capitol Hill.
Republicans frequently clashed with Sebelius during her tenure.
House Oversight Committee Chairman Darrell Issa (R-Calif.) memorably threatened to investigate the outgoing secretary for perjury.
But in one area, Burwell already has a leg up. Her extensive ties at the White House will make it easier for her to collaborate with President Obama and his team.
4) Pursue the Medicaid expansion
A key component of ObamaCare's coverage expansion still has not been fully implemented.
That's the expansion of Medicaid, which became optional for states after the Supreme Court upheld Obama’s healthcare law in 2012.
Twenty-four states had declined to embrace the policy as of April 3, leaving 5.7 million people uninsured, according to the White House.
Sebelius was noted for her willingness to work with Republican governors who wanted to pursue the expansion in alternative ways.
Whether Burwell will adopt this approach remains to be seen.
ObamaCare's supporters see the Medicaid expansion as the law's final battlefront, and Burwell will be the one leading the charge.
5) Prepare for 2015 and 2016
Even if she stays until the end of Obama's second term, Burwell's tenure will be a bit shorter than Sebelius's.
That said, the HHS nominee will oversee several crucial developments for the healthcare law next year and the year after.
The first will be the initial collection of penalties for people who didn't have health insurance in 2014.
These fees will be assessed in 2015, usually as a deduction from an individual's tax refund.
The process is likely to confuse many consumers and present challenges for both the HHS and the Internal Revenue Service.
Burwell will also see the employer mandate take effect in 2015 and 2016, assuming the current timetable does not change.
This part of the law requires companies with more than 50 workers to offer health insurance and fines firms that do not.