Strategy three: It's all in the interpretation

The Affordable Care Act lays out principles of reform, and federal agencies create rules for how those principles are carried out. Interest groups will battle over interpretation.

Opponents such as the National Federation of Independent Business will lobby for less regulation, while consumer advocacy groups will push for strict interpretations.

Strategy four: State resistance

Resistant states could delay or refuse to implement parts of the law. The American Legislative Exchange Council, which promotes limited government, recently issued a list of tactics states can use to slow or stop the health care reform provisions from being implemented.

But the federal government can implement some parts of the law if states fail to act, such as creating health insurance exchanges, and uncooperative states could lose federal funding.

"Usually money trumps ideology at the state level, where politics are generally more pragmatic than they are in Washington; but the recent elections brought substantial changes to many state legislatures, and the patterns I saw when I was in state government may or may not be a good predictor of behavior this time," Kaiser Family Foundation President and CEO Drew Altman wrote in an analysis of the House repeal vote for the foundation's website.

Strategy five: Sue 'em

In a Florida-led lawsuit, 26 states and the National Federation of Independent Business are challenging the constitutionality of the Affordable Care Act's Medicaid expansion and the individual mandate, which required those without health insurance to purchase it by 2014. Virginia is also challenging the individual mandate in a separate lawsuit, and Oklahoma says it will do the same.

U.S. District Court Judge Roger Vinson in Florida heard oral arguments in December and said then that he will rule on the suit "as quickly as possible."

U.S. District Court Judge Henry Hudson in Virginia struck down the individual mandate as unconstitutional in a December ruling. The federal government filed a notice of appeal Jan. 18.

Both cases are expected to wind up in the U.S. Supreme Court.

"I think we'll hear from the Supreme Court before 2012," Domenech says. "The cases are actually very simple."

Whether the challenged provisions could be severed from the law, allowing the rest of the Affordable Care Act to stand, is uncertain. But even if some parts of health care reform are struck down, the practical ramifications would be enormous if the individual mandate were removed. The mandate creates a large enough risk pool to keep premiums down and enable insurers to cover pre-existing conditions.

"It is the linchpin," Edison says. "Everything is built on the mandate. It's what got insurance companies, hospitals and some doctors to the table."

Only time will tell the outcome of the various battles, but one thing is sure: Debate over fixing the health care system won't end anytime soon.

"It's not that our members don't want health reform," Austin says. "They don't want this one."

Edison says the law is already improving lives. How the nation handles reform, she says, "really speaks to who we are as a people."

This article was reported by Barbara Marquand for

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