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Republicans and conservative groups also questioned Mr. Coyle’s nomination because of his past criticism of missile-defense systems. But it was a Democratic senator, Sherrod Brown of Ohio, who put a legislative hold on the nomination of Mr. Gotbaum to coax the government to intervene in an unrelated pension dispute between a private company and its retirees.

Despite his unhappiness with the process, Mr. Baucus added that he looked forward to dealing with Dr. Berwick and the CMS in implementing the health care law.

But Republicans charged that the president used the recess appointment to avoid public scrutiny of comments they say reveal Dr. Berwick’s affinity for government-run health care.

For instance, they have pounced on an interview he did last summer with a trade journal in which he praised Britain’s nationalized health care system and said: “The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open. And right now, we’re doing it blindly.”

White House officials pointed to support among major medical societies for Dr. Berwick, founder of a Boston-area think tank on health care policy, and shrugged off questions about his comments as political gamesmanship.

“This is the exact type of political game that the American people have come to understand dominates Washington and doesn’t actually make their health care more affordable,” Mr. Gibbs said when asked whether Mr. Obama agreed with Dr. Berwick’s statements.

Holds on nominees are a time-honored Senate tradition, and were employed by Mr. Obama himself during his four years in the chamber. In late 2005, he blocked all of Mr. Bush’s Environmental Protection Agency nominees to try to force the release of new rules on lead paint. A year later, he blocked a Federal Aviation Administration nominee to try to force the FAA to decide whether Midwest wind farms would interfere with radar.

Wednesday’s actions bring Mr. Obama’s total number of recess appointments to 18. His first round, made in March, included Craig Becker, a former union lawyer vehemently opposed by Republicans and leading business groups, to serve on the National Labor Relations Board.

Mr. Bush had made 15 such appointments by this time in his presidency, and made a total of 171 in his eight years in office. That compares with 139 recess appointments by President Clinton in his two terms.