This suggests to me that people who think the Obama administration has everything on health care reform figured out. and knows how to get it, that they are playing genius chess, are just wrong:

Lack of Medicare Appointee Puzzles Congress
by Robert Pear for the New York Times, August 18

President Obama has made health care his top priority. He says the cost of Medicare and Medicaid is "the biggest threat" to the nation's fiscal future. But to the puzzlement of Congress and health care experts around the country, Mr. Obama has not named anyone to lead the agency that runs the two giant programs.

The agency, the Centers for Medicare and Medicaid Services, is the largest buyer of health care in the United States. Its programs are at the heart of efforts to overhaul the health care system. If it had an administrator, that person would be working with Congress on legislation and could be preparing the agency for a new, expanded role.

"The vacancy stands out like a sore thumb," said Dr. Denis A. Cortese, president of the Mayo Clinic, often cited by the White House as a health care model.

"In effect," Dr. Cortese said, "Medicare is the nation's largest insurance company. The president and Congress function as the board of directors.

"Under a strong administrator, it could take the lead in making major changes in the health care delivery system, so we'd get better outcomes and better service at lower cost."....

Trying to remake the health care system without a Medicare administrator is like fighting a war without a general.

"You need a general," said Senator John D. Rockefeller IV, Democrat of West Virginia and chairman of the health subcommittee of the Finance Committee. Of the job vacancy, Mr. Rockefeller said: "It's a big problem. I can't explain it.....

That Obama started his health care reform push before even having an appointee suggests to me that the Obama adminstration's health care reform "plan" was always to see what happens with Congress and the public and then go from there. They are waiting to see what reforms are allowed before they even figure out what they want to do about Medicare and Medicaid and who they want to run it. Yes, have their preferences, but don't feel it appropriate to push them too strongly. 

Some might call that "fly by the seat of the pants," others might call it "ground up, grass roots, community activist style," others might call it "weak Federal executive theory," but it is certainly not the work of a genius chess player trying to execute a plan. Granted, it might be partly because they see starting with a full-out plan and "war" to support it as repeating the mistakes of the Clinton administration, but that's just more proof that they set out with the idea of dealing with whatever happened with Congressional proposals and public reaction, to just attempt to steer the direction a bit, and not to lead so much.