That leaves House Republicans with few clear options. They could try to deny the administration money to carry out the law, but that may not work. Major elements, such as tax credits to help make health insurance more affordable, were written as entitlements, meaning that they will be automatically funded. And if a drive to deny the money threatens to shut down the government, it could backfire politically.
Leading proponents of repeal acknowledge it may take the election of a Republican president to accomplish the goal. That means both parties will probably take the major issues in the health care debate to the voters in 2012, when Obama is expected to run for a second term and the House and Senate will again be up for grabs.
The drive to repeal has opened Republicans up to charges that they would increase the federal deficit. The Congressional Budget Office, the nonpartisan budget referee, says the legislation would increase deficits by $230 billion from 2012 to 2021. That's because spending cuts and new taxes more than offset the cost of expanding coverage. [Take the poll: Should Congress raise the debt ceiling?]
Republicans counter that even if that's technically true, it would save money in the long run to repeal a big new program before it gets off the ground.
GOP governors, in their letter to Washington leaders Friday, argued the law is already limiting their options by requiring them to maintain certain levels of Medicaid coverage to continue receiving crucial federal money. Medicaid is a federal-state program that serves more than 50 million low-income people.
"The effect of the federal requirements is unconscionable; (they) force governors to cut other critical state programs, such as education, in order to fund a one-size-fits-all approach to Medicaid," wrote the governors, calling on Congress to lift the requirements. If the request advances, it could open the door to other attempts to change the law, or undermine it.
Voting with the Republicans on Friday were four Democrats who had opposed the law last year — Reps. Dan Boren of Oklahoma, Mike McIntyre and Larry Kissell of North Carolina, and Mike Ross of Arkansas.