Kathleen Sebelius made a career out of praising, touting anddefending the Patient Protection and Affordable Care Act. Theoutgoing Health and Human Services secretary was the one who toutedenrollment numbers in the law, health care spending slowdowns, andsavings due to the law's provisions. She endured backlash over theadministration's PPACA delays, answered questions about concernsover it and even testified about it. And when HealthCare.govsuffered a disastrous rollout, she took the blame.

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On April 10, Sebelius made her last official praise of theoft-controversial law: She announced 7.5 million people had signedup for Obamacare through the exchanges, a number that exceeded eventhe most optimistic enrollment predictions.

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Hours later, Sebelius announced her resignation.

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Officials said she made the decision herself and was not forcedout, but there’ve been rumors the rocky rollout of the lawtarnished her relationship with the White House. Sources saySebelius approached President Obama in March about her future,telling him the March 31 enrollment deadline—and rising enrollmentnumbers—provided a transitional opportunity.

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On April 11, the president praised her leadership, thanking herfor her dedication to his signature health care overhaul.

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“Under Kathleen's leadership, her team at HHS turned the corner,got it fixed, got the job done,” Obama said in a Rose Gardenceremony. “And the final score speaks for itself.”

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Obama immediately nominated Sylvia Mathews Burwell, the directorof the Office of Management and Budget, to replace Sebelius.

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Other PPACA supporters emerged quickly to praise Sebelius'sachievements. Enroll America President Anne Filipic, featured inthe July 2013 issue of Benefits Selling, praised Sebelius for PPACAachievements during her tenure: expanded health care coverage, theelimination of pre-existing condition denial by carriers, and“peace of mind that comes with affordable, quality health insurancecoverage—through Medicaid, through CHIP and through the healthinsurance marketplace.”

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“Every day, our hundreds of staffers and tens of thousands ofvolunteers hear moving stories from Americans across the countrywho are finally able to access the medical care they and theirfamilies need, many for the first time ever,” Filipic said. “Thosefamilies—and the millions of families who will benefit in the yearsto come—represent Secretary Sebelius's true and lastinglegacy.”

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Tumultuous chapter

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Sebelius's departure comes after a rocky road for the PatientProtection and Affordable Care Act, including the tumultuous launchof PPACA's exchanges last fall. Despite calls for her ouster fromRepublicans at the time, she stayed on until after the enrollmentperiod ended March 31.

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HealthCare.gov was plagued with so many technical problems—firstand foremost, the website's inability to manage a heavy useload—that it prompted Congress to hold hearings about it in lateOctober. Early enrollment numbers were far fewer than hoped oranticipated, partly because enrollees were unable to stay on thesite long enough to sign up.

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Sebelius, at times, failed to properly defend PPACA, leavingcritics questioning her leadership and faith in the law. She oftenappeared flustered by questioning and criticism.

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During testimony last October, for example, Sebelius said thesite “never crashed,” despite the fact that screenshots of the sitebehind her read: “The system is down at the moment. We areexperiencing technical difficulties and hope to have them resolvedsoon.”

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She drew ire from Republicans and other critics. After all, shewas the face of a law that continued to confuse, and upset, thepublic: Poll after poll found that despite all the attention thelaw received, most consumers had no idea how PPACA really worked orwhat kind of deadlines it required them to meet. The press the lawdid get was mostly negative. The latest polls show opposition tothe law continues to hover near an all-time high.

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Sebelius's departure, too, adds to the ongoing skepticism aboutthe law and how well it's working. Though enrollment numbers inObamacare had a strong late surge, information on enrollees remainselusive. The administration hasn't yet released details onenrollees’ age, demographics or health status.

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Initial data from pharmacy benefits manager Express Scriptsshows that, based on their medication usage, enrollees in Obamacareare sicker than patients off the exchanges, often requiringspecialty drug prescriptions. Skewed health status in enrollment,industry insiders say, could drive premiums up for all patients inthe coming years.

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Kevin Davis, a benefits advisor at Lacher & Associates inPhiladelphia, said Sebelius's resignation “seems like a politicalmove to have a scapegoat, should the insurance carriers continue toannounce double-digit individual and small-business insurance rateincreases due to PPACA, which will naturally be political fodderfor the midterm elections.”

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“Since she said, ‘Hold me accountable’ at Congressionalhearings, now we see the accountability of falling on the sword forthe party that she foreshadowed with that comment,” Davis adds,noting he's not sure the move helps anyone.

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Some benefits insiders said Sebelius's resignation is “longoverdue,” though others expressed little hope that anything moreproductive regarding the law would get done with her gone.

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The first question, wondered Reid Rasmussen, owner offreshbennies in Dallas, is, “Who would take that job? They willhave their work cut out for them.”

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David Smith, vice president of health and welfare benefits atNorth Carolina-based Ebenconcepts, is cautiously more optimisticabout Burwell taking over the HHS post. He says it's a chance to“start fresh,” though he worries that Sebelius's experience mighthave made softened some of PPACA's woes.

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“I actually worry a bit because her experience as an insurancecommissioner helped—hence the refusal to give an extension for openenrollment this year,” Smith says. “I think we need to focus onmaking it work. But this will open the floodgates for new ideas andideally a willingness to try something different.”

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Promoting PPACA

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Despite coming under fire for the law, Sebelius always insistedPPACA was the right thing to do—and that it would work.

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Calls for her resignation died down when the website woesimproved and signups began to roll in.

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“I know that this law has been at the center of much debate anddiscourse in Washington, but what this enrollment demonstrates isthat the Affordable Care Act is working and much needed,” she wrotein a note to staffers just last month.

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In a statement, Finance Committee Ranking Member Orrin Hatch,R-Utah, said Sebelius “had one of the toughest jobs in Washington”due to having to help implement and manage the “flawed” law.

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Still, Hatch said in a statement, “While we haven't alwaysagreed, Secretary Sebelius did the best she could during thetumultuous and volatile rollout of the law.”

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Sebelius, 65, is among the longest-serving cabinet members inObama's administration. She was formerly a popular governor ofKansas for six years, praised for eliminating a billion-dollar debtshe inherited and having a bipartisan approach to governing. Hername has cropped up as a potential vice presidential—and evenpresidential—candidate.

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Before that, she was the state's insurance commissioner.

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The new HHS secretary?

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All eyes are on Sylvia Mathews Burwell, who Obama nominated tosucceed Sebelius as Health and Human Services secretary.

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Burwell, the director of the Office of Management and Budget,was confirmed last year by the Senate in a 96-0 vote. She's beenheralded by White House officials for her track record innavigating through the partial government shutdown last October andhelping win a two-year budget agreement. She's also unique in thatshe was unanimously confirmed to her post by a divided Senate.

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Though she wasn't an insurance commissioner like herpredecessor, Burwell, 48, does have ties to the industry: She wasdirector both of MetLife Inc. and of Metropolitan Life InsuranceCo. from early 2004 through early 2013.

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President Obama mentioned Burwell's experience as a MetLifedirector when he introduced her as his choice to succeed Sebeliusas the head of HHS.

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“She gained first-hand experience into how insurance marketswork, and how they can work better for businesses and familiesalike,” Obama said.

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In documents MetLife described Burwell as someone with “aninformed perspective on global financial, business andphilanthropic activities and diverse cultural considerations.”

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Burwell's resume also includes a stint as a chief of staff tothe former Treasury Secretary as well as a stint as the deputydirector of OMB. She is a graduate of Harvard University and OxfordUniversity as well as a former Rhodes Scholar.

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Allison Bell and Kathryn Mayer

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