The first few weeks of the Obama administration ended up focused on the passage of a stimulus package âÄîunderstandable, what with the whole âÄústaring economic apocalypse in the faceâÄù thing. Now that weâÄôve hammered out the stimulus, though, the White House is going to have to shift gears and decide which domestic issue to take up next. ThereâÄôs plenty to work on, but the main priority should be obvious: ItâÄôs time to tackle the health care dilemma. WeâÄôve been talking about âÄúhealth careâÄù broadly for such a long time that the basic numbers are probably burned into your brain: 40-some million uninsured Americans, costs skyrocketing, a system ready to crumble. And during the campaign, President Barack Obama repeatedly pointed to health care as one of his top priorities. The time for talk is past, though. Now, we get down to the nitty gritty of actually passing a bill. ThereâÄôs already been a rather significant setback to the White HouseâÄôs health care plan. Tom Daschle was supposed to lead the charge, but income tax tomfoolery ultimately submarined his nomination to head the Department of Health and Human Services. I suppose thereâÄôs a lesson in there: kids, if you expect to hold a cabinet-level post in the near future, you should double-check your tax forms. DaschleâÄôs withdrawal has thrown the Obama team for a loop. They had created a spanking-new post, the Office of Health Reform, specifically for the former Senate majority leader. Both the OHR and HHS jobs remain unfilled, and the White House is considering scrapping the OHR entirely. Names continue to bounce around for the HHS job; recently, Kansas Gov. Kathleen Sebelius has been gaining steam, but she poses a few problems. (Specifically: sheâÄôs considered a serious threat, and perhaps even a shoo-in, in KansasâÄôs 2010 Senate race. She will be term-limited out of the governorâÄôs office by then, and itâÄôs probably not too wise for the Democrats to give up a new Senator just for the HHS job, which many other people could handle.) Whoever eventually slides into the position, theyâÄôre not going to be replacing the experience and expertise Daschle would have brought. WeâÄôve already seen some hints as to how the health reform process is going to work. During the negotiations about the stimulus, a relatively anonymous egghead named Peter Orszag ended up playing a key role. Orszag previously ran the Congressional Budget Office, the bureaucratic apparatus tasked with evaluating the fiscal impact of various proposed pieces of legislation. Obama imported Orszag to run the executive branchâÄôs analogue, the Office of Management and Budget. Orszag helped polish the stimulus bill into its final form, and in the process managed to allocate significant funds for health care technology and analysis. These additions appear to be the opening salvo in the fight over our health care future. There are two (not necessarily opposed) ways of thinking about our health care conundrum âÄî one in which you focus on getting lots of people (or, with luck, all of the people) covered, and another focused on containing the explosion of costs. Most of the time, it seems our debates on the topic focus more on the first point; recall, for example, the Obama/Clinton disagreement during primary season of the use of health care mandates. The Orszag approach, though, pretty much assumes the former âÄî yes, we should be trying to cover as many people as possible âÄî and moves straight to the more practical question: How are we going to pay for it? When you run the numbers, the majority of the expected future rise in health care costs comes not from an aging or growing population. Instead, it just turns out that we donâÄôt have a very efficient system. We spend way too much and donâÄôt get enough back, especially when compared to other developed nations. If we just let it ride with the system we have now, weâÄôll watch health care spending gobble up an obscene percentage of GDP. Orszag understands this acutely and will be a vital part of making sure we can pay for whatever universal health care package we eventually come up with. We could potentially save huge amounts of money if we do this right. And in the end, Congress will never pass a health care bill that we canâÄôt pay for. (Note: This is a good thing.) With the groundwork laid in the stimulus bill, the White House now has to seize momentum and begin pushing hard on health care. The president is still massively popular, heâÄôs got a legislative victory under his belt âÄî the political atmosphere will never be more amicable. And with economic concerns being what they are, the ability to frame the debate as one not just about health care, but also as one of basic long-term fiscal health, will be immensely helpful. The Senate (where the real fight will happen) seems ready to go. Sen. Max Baucus, D-Mont., has made his desire to pass a bill well known. Sen. Ted Kennedy wants to make health care his legacy. And an interesting little bipartisan bill called the Healthy Americans Act has been bouncing around the halls of the Capitol. Sen. Ron Wyden, D-Ore., and Sen. Bob Bennett, R-Utah, are leading the group of senators pushing the bill (a group that includes four other Republicans and a gaggle of Democrats). The HAA itself âÄî which, in rather revolutionary fashion, requires states to make health care available and requires each individual to obtain coverage âÄî might not make it through the wrangling, but itâÄôs an important starting point. The wheels are turning. WeâÄôve been dithering about on health care for decades, but at this point the problem is too big to ignore. Hopefully, the president is ready to fight. John Sharkey welcomes comments at [email protected].