The pivotal health care policy players this year are the nine justices on the Supreme Court, who are on course to decide the constitutionality of the 2010 overhaul by June. If it’s struck down, Hill Republicans will start deliberating a replacement; if it’s upheld, Democrats will move to put it into full effect. In the interim, attention will be focused anew on the long-term future of the Medicare formula for reimbursing doctors.

Cybele Bjorklund

Minority staff director, House Ways and Means Subcommittee on Health

Bjorklund knows Medicare policy cold. Never mind that her side is in the House minority; she will be a central staff player in whatever Congressional debate happens on health care this year — as has been the case every year since 2001, when she took over as the top Democratic aide on the subcommittee.

In the coming weeks, her principal job will be helping lawmakers find billions of dollars in payment offsets to fix Medicare’s physician payment formula. Her first priority might be blocking increases in monthly premiums for seniors.

Her influence is assured by her detailed knowledge about how almost any change in Medicare policy could affect health care for the nation’s politically powerful elderly population. Lawmakers are loath to disrupt the status quo of care for seniors, and Democrats on the Health subpanel set the tone on the Hill when it comes to protecting beneficiary interests.

The panel is sometimes referred to as Medicare’s board of directors because it oversees the Centers for Medicare and Medicaid Services. In this Democratic administration, Bjorklund has especially close ties to the agency, in part because several colleagues have left the Hill for the CMS to help implement the 2010 health care overhaul. She keeps a lawyerly eye on whether the regulations coming out of the CMS square with Congressional intent in writing the health care law, which she helped negotiate.

Bjorklund isn’t a lawyer, though. A journalism graduate from the University of Oregon, she began her career doing public relations for a TV station and then a hospital in Indiana, then earned a master’s degree in public health with a concentration in law at Johns Hopkins University in 1994 — just as President Bill Clinton’s remake of the health care system was running aground. (She says she said to herself, “I’m tired of talking about what people do in health policy; I’d like to go to school to do health policy.”)

She spent a year as a Medicare analyst at CMS’ forerunner agency before coming to the Senate as a health care aide to a pair of prominent Democrats, first Tom Daschle (S.D.) and then Edward Kennedy (Mass.).

— John Reichard

Chuck Clapton

Minority health policy director, Senate Health, Education, Labor and Pensions Committee

Funny and self-effacing, Clapton said he can’t vouch for the mental competence of anyone who would name him one of the most influential health care aides on Capitol Hill. But a look at the issues he’ll be dealing with this year, who he’ll be advising and the chops he brings to the job leaves no other conclusion.

One focus this year will be the Food and Drug Administration’s product approval and safety oversight mechanisms because Congress plans to update the agency’s user-fee programs for brand-name drugs, generics, medical devices and lower-cost biotech drugs. It’s must-pass legislation; otherwise, much of the FDA’s funding evaporates Oct. 1.

Clapton will be working closely with his boss, panel ranking member Mike Enzi (R-Wyo.), who also holds seats on the Budget and Finance committees. That puts Clapton “at the intersection of a number of key debates in the entitlement space,” noted Dan Boston, executive vice president with the lobbying firm Health Policy Source.

Clapton also will be at the center of strategizing about GOP Members’ next moves to combat the 2-year-old health care overhaul law. If the Supreme Court strikes down all or part of the statute as unconstitutional this spring, Clapton will be among those aides in the room deciding what, if any, legislation to draft as a possible replacement.

Clapton is every bit the warrior against Obamacare, but his good cheer and knowledge of health care policy have won him the respect and affection of Democratic colleagues.

He’s been on the Senate side since 2008 after working for a handful of Energy and Commerce and Ways and Means members in the House. He said he works to emulate two of his past bosses, ex-Reps. Jim McCrery (R-La.) and Harris Fawell (R-Ill.), in striving to soak up all the small details of health care policy.

— John Reichard

Howard Cohen

Chief health counsel, House Energy and Commerce Committee

Health care is the Cohen family business. But the senior Republican staff attorney and his wife, Podesta Group health care lobbyist Sharon Cohen, often take the opposite view from their 24-year-old daughter, Laura, an analyst at the Women’s Health Policy and Advocacy Program at Brigham and Women’s Hospital in Boston.

When she comes to Capitol Hill to talk health care policy, her father tells her to simply “go see the Democrats.” (The youngest Cohen interned at Energy and Commerce in high school and college, and her dad said she may well return and be on the other side of a bargaining table from him someday.)

Cohen’s own Hill experience dates to 1989, when he worked on a minority committee staff of three health care generalists. (Now the panel has nine health care policy specialists, in addition to Oversight and Investigations subpanel aides who are examining the 2010 health care law.) He then spent a short stint lobbying for Greenberg Traurig before opening his own shop, HC Associates, in 2001. He returned to the committee a year ago, along with Bush administration veteran Julie Goon, to prepare the GOP’s multifaceted challenge to the health care overhaul.

Bringing attention to problems in the law remains a big part of Cohen’s day-to-day duties, although it’s unclear whether Republicans will get far with a “replacement” bill this year. Instead, the committee’s agenda includes working on a policy change to prevent cuts in Medicare payments to physicians and updating the Food and Drug Administration’s user-fee regime. Agency authority to charge prescription drug and medical device user fees expires this fall. Cohen predicted that, despite slower-than-expected progress toward a deal between the FDA and the industry on the user fees affecting medical devices, a rewrite will get done in time.

All the while, the panel will be working on options for reining in the costs of Medicare and Medicaid. Given the history of standoff over those entitlements, though, the issue may still be on Cohen’s plate if and when his daughter starts working for the other side.

— Rebecca Adams

Dan Elling

Majority staff director, House Ways and Means Subcommittee on Health

One way or another, Congress will make some sort of adjustment this year to the Medicare physician payment formula because, without a change, a 27 percent cut in the reimbursement rate will prompt thousands of doctors to flee the program and leave millions of seniors without the doctors they’ve known. Whether it’s negotiating with other Hill health care staffers or fielding endless “suggestions” from drug companies, insurance firms, specialist groups and other stakeholders, Elling will once again be a go-to guy for Republicans — starting with the “doc fix” debate.

And while GOP dreams of repealing the 2010 health care overhaul will have to wait until at least after the elections, Elling and his eight-person staff will be looking for ways to chip away at the law or slow down its implementation.

Even in the current adversarial climate, Elling finds himself trying to fashion a compromise on the last 10 percent of an issue.

“We try to find either a midpoint or you try to move on to something else,’’ he said. “Obviously there’s a fair amount of posturing you need to do because you’re representing a certain position. But also there’s a job to be done and everybody retreating to their corners isn’t always going to work.”

His staff is the clearinghouse for House GOP proposals on health care. Almost daily, Elling bounces ideas off the staff of the nonpartisan Medicare Payment Advisory Commission. That’s because it wouldn’t be prudent to let the administration know what the GOP is considering before House GOP leaders are ready to announce it, lest it leak to Democrats.

Elling’s interest in health care policy grew out of his work on that topic for a market research firm in Minnesota. After that, it was being in the right place at the right time that led him to do health care policy work for Ways and Means Republicans — first for Jim Ramstad (Minn.), then for Nancy Johnson (Conn.). (Both are now out of Congress.) And it has never hurt his credibility with K Street that for a short time he worked for GlaxoSmithKline, the pharmaceutical giant.

— Dena Bunis

David Schwartz

Chief health counsel, Senate Finance Committee

At the age of 40, Schwartz has already weathered the passage of a landmark piece of legislation — the 2010 health care overhaul. Now the native of Little Neck, on Long Island, is monitoring the implementation of the law for Finance Chairman Max Baucus (Mont.) and advising him and the committee’s other Democrats on a bulging portfolio of other health care issues.

“Being the chief health counsel, you’re responsible for everything,” he said.

It didn’t start out that way. While at George Washington University Law School, Schwartz developed an interest in disability rights, which is a “sliver of the health policy big picture,” he said. After graduation, he landed at the Social Security Administration working on Medicare provider appeals, heightening his interest in how coverage decisions are made in the health care program for the elderly and disabled. In 2004, he came to the Finance Committee on a fellowship program, and he joined the permanent staff in 2007.

The health care debate ramped up after Baucus issued a white paper on overhauling the system. During the long days and nights of committee debate and floor action, Schwartz advised on the bill’s provisions on Medicaid and the Children’s Health Insurance Program.

“I think for a lot of Members and staff, it probably was the professional experience that left them the most sleep-deprived in their lives,” he said. After the law’s enactment, Liz Fowler, the chief health counsel, departed for the Obama administration and Schwartz moved up.

Now Schwartz oversees a team of “some of the smartest people in Washington” who shape health care policy for Baucus.

A top issue this year will be the quest for a lasting remake of the Medicare physician payment system, which has been subject to a series of annual “fixes” to prevent doctors from deep cuts in their reimbursement rates.

And Schwartz will watch as the law he knows so well is challenged in a legal battle before the Supreme Court later this year. If it’s overturned or altered, it could mean many more sleepless nights ahead for the Finance veteran.

— Jane Norman