For the first time in nearly a decade, the top spot at one of the federal government's most important agencies is close to getting filled.

The Senate Finance Committee met Tuesday to consider the nomination of Marilyn Tavenner, President Obama's pick to run the Centers for Medicare and Medicaid Services.

This is an agency with a budget of nearly $1 trillion. It oversees the entitlement programs largely seen as the biggest threat to the federal budget—not to mention the entire implementation of the Affordable Care Act.

The Medicare administrator position is considered so politically toxic that no one has even survived confirmation since 2006. The Senate Finance Committee passed on the opportunity to confirm Tavenner in 2011, when Obama first nominated her for the top spot—and when the health law was winding its way up to the Supreme Court.

This all makes Tavenner's hearing Tuesday morning all the more surprising. She received endorsements from senators on both sides of the aisle. Senate Finance Chairman Max Baucus (D-Mont.) said Tavenner was ready to "officially take the reins of CMS." Ranking member Orrin Hatch (R-Utah) described her as "up to the challenge" of running a massive agency with 5,800 employees.

The two-hour hearing focused more on state-specific issues, raised by the senators' constituents, rather than more sweeping questions about the future of the health-care law or changes to Medicare spending.

Baucus wanted to know know about Medicare treatment for asbestos victims in his state. Sen. Chuck Schumer (D-N.Y.) wanted to know why a hospital in his state had lost three residency slots; Sen. Johnny Isackson (R-Ga.) wanted to know whether Medicare might approve reimbursement for needle stick devices used by diabetics.

"I assume you'll be confirmed because you've done a great job" Isackson told Tavenner, before moving onto questions about whether she would push to change the doc-fix (she would) and if she could "check on" a pending application Georgia has for a Medicaid waiver (Tavenner plans to do that as well).

Why the assumption that she'll be confirmed?

Tavenner gave reporters a bit of her perspective on the issue after the hearing, noting that she has already worked at the agency, serving 18 months as acting administrator. When senators of either party have problems like these in their states, they reach out to Tavenner.

"I've had three years of working inside the agency," she said. "I've gotten to know more of them in [situations like] 'here's an issue, is there a solution?' or 'here's a piece of the law that I'm unclear about, can you clarify it for me?' I think it's just been a matter of building those relationships over a few years."

Health policy is certainly an ideological issue for legislators on Capitol Hill. At the same time, it's also a practical issue of ensuring that the many services CMS offers get delivered to the people who need them. That seemed to be senators' biggest concern in this hearing. Tavenner's three years of working on that issue could make her path to confirmation a bit more clear.