The real action is in states, where Republicans are using federal courts and governors' offices to lead the assault against Obama's signature domestic achievement, a law aimed at covering nearly all Americans.
In a post-election bow to tea partiers by the new GOP House majority, Republican lawmakers are undertaking an effort to repeal the health care law in full knowledge that the Democratic Senate will stop them from doing so. [Check out a roundup of political cartoons on healthcare.]
Republicans prevailed Friday in a 236-181 procedural vote, largely along party lines, that sets the stage for the House to vote next week on the repeal.
Shortly before the House vote, Republican governors representing 30 states opened up a new line of attack, potentially more successful.
In a letter to Obama and congressional leaders, the governors complained that provisions of the health care law are restricting their ability to control Medicaid spending, raising the threat of devastating cuts to other critical programs, from education to law enforcement in a weak economy. It's ammunition for critics trying to dismantle the overhaul piece by piece.
Moreover, a federal judge in Florida is expected to rule shortly in a lawsuit brought by 20 states that challenges the law's central requirement that most Americans carry health insurance. A judge in Virginia ruled it unconstitutional last month, while in courts in two other cases have upheld it. It's expected that the Supreme Court will ultimately have to resolve the issue. [See who donates the most money to Congress.]
Obama made history last year when Congress finally passed the law after months of contentious debate, closing in on a goal that Democrats had pursued for generations. Republicans say they changed history by taking back the House in the midterm elections, partly on the strength of their pledge to tea party supporters and other conservatives to undo the divisive law, whose complexities, costs and consequences remain largely unknown.
Some Republicans hope to get enough momentum going to force Obama and the Democrats into an early capitulation. "If you have to do an amputation, get it over with," Rep. Steve King, R-Iowa, a repeal leader, said after the House vote. "We need to get this showdown over so we can go on to other issues."
But Senate Democrats say what King and other House Republicans think matters little, since they will block any repeal legislation on the other side of the Capitol.
During last year's election campaign, many Democrats sought cover when the health care law would come up. On the House floor, they unleashed a full-throated defense, accusing Republicans of trying to take away benefits that many people are already receiving, such as lower prescription costs for Medicare recipients, extended coverage for young adults on their parents' plan and newly available insurance for people with serious medical problems.
"Repeal this bill, and you're going to find more Americans dying," said Rep. John Garamendi, D-Calif. [See which industries donate the most to Garamendi.]
The overhaul would provide coverage to more than 30 million now uninsured, expanding Medicaid to pick up more low-income Americans and offering tax credits to help the middle class buy coverage. Most Americans would be required to carry health insurance, either through an employer, a government program or by purchasing their own policy. The legal challenge to that mandate is coming mainly from Republican state attorneys general.
Polls suggest the public remains divided over the underlying law as well as the question of whether it should be repealed, scaled back or expanded.
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.