Capitol Hill

The massive health care overhaul bill President Obama signed in March is now law. However, the battle regarding our health care system's future appears to be far from over. Now that federal legislation has been enacted, many of the law's opponents have shifted their efforts to the courts, state legislatures and 2010 midterm elections. The outcomes of numerous challenges in these venues could have far-reaching implications for implementation of the law and health care policy.

State-level challenges

Within weeks of the law's passage, Florida and 20 other states filed a lawsuit contending a key component of the law is unconstitutional. The lawsuit argues Congress lacks the authority to require individuals to purchase health insurance or pay a penalty, which the law mandates beginning in 2014. The lawsuit also argues the law infringes on states' rights by requiring states to extend coverage to low-income residents without providing necessary resources.

A decision in this case could come late this year or in 2011. Many legal experts believe the chance of this lawsuit being upheld is slim, but even a partial verdict in favor of the plaintiffs could undermine key components of the health care law.

Virginia and Idaho have passed laws prohibiting the enforcement of the individual mandate among their residents, and Virginia also has filed a lawsuit arguing the federal law infringes on its statute. Developments in this case could come this summer. Arizona, Georgia and Oklahoma have passed similar legislation, which also could lead to litigation. At last count, seven other states also were considering similar measures.

Several states also are holding referendums seeking to nullify the law's individual mandate. Arizona, Florida and Oklahoma will hold referendums in November, and Missouri will do so in August. Efforts to hold similar referendums are under way in 11 other states.

It is unclear how the state-level activity will play out during the coming months. It also should be noted that efforts to pass legislation or state constitutional amendments opposing the federal law have been unsuccessful in 15 states. But success in even a few states could prove troublesome to the federal law's successful implementation.

Other challenges

The health care law's future also could hinge on the outcome of this fall's midterm elections. Congressional Republicans will attempt to make the elections a referendum on the law, and this could help them retake majority control or gain numerous seats in the House and Senate.

Even if Republicans gain a majority in Congress and can muster the votes to repeal the health care law in 2011, they will not have the votes to override a presidential veto. However, Republican control of the House would enable them to pursue changes to the law's most controversial components. Moreover, though a vast majority of the $1 trillion in spending authorized by the law does not require further legislation, the Congressional Budget Office estimates between $10 billion and $20 billion in annual appropriations is needed to implement the law. Congress has yet to approve the funding, and this situation could give Republicans added leverage if they gain control of either the House or Senate.

Ultimately, complete repeal of the law does not appear realistic. However, successful challenges at the state level or in the courts or a change in control of Congress could produce significant changes to the law before its major components take effect in 2014.

Whether this can be achieved depends largely on public perception of the law, and polling conducted since the law's passage consistently has shown it has less than majority support among the public.

For example, an Associated Press poll in April found support for the law at 39 percent and opposition at 50 percent.

Further debate

Given the clear lack of consensus about the law, further debate regarding health care policy is inevitable, and significant changes are possible.

Duane L. Musser is NRCA's vice president of government relations.