Healthcare management

Provide an example from current events, in which the “Paradox of Excess and Deprivation” is evidenced.


The following article from The New York Times captures the political tensions leading up to the passage of The affordable Care Act. The full text appears below and is also accessible through this link:

NYTimes Healthcare Reform Background

Updated: March 4, 2011

After decades of failed attempts by a string of Democratic presidents and a year of bitter partisan combat, President Obama signed legislation on March 23, 2010, to overhaul the nation’s health care system and guarantee access to medical insurance for tens of millions of Americans.

It was the largest single legislative achievement of his first two years in office, and the most controversial. Not a single Republican voted for the final version, and Republicans across the country campaigned on a promise to repeal the bill. After they took control of the House and expanded their ranks in the Senate in the November elections, action on health care was at the top of their agenda.

On Jan. 19, 2011, the House voted 245 to 189 in favor of repeal, in what both sides agreed was largely a symbolic act.

A few weeks later, Senate Democrats defeated a bid by Republicans to repeal the sweeping health care overhaul, as they successfully mounted a party-line defense. The vote was 47 to 51, with all Republicans voting unanimously for repeal but falling 13 votes short of the 60 needed to advance their proposal.

Republicans denounced the overhaul as impeding job creation and giving the government too big a role in the health care system. Democrats highlighted the law’s benefits, especially for the uninsured, and noted that the nonpartisan Congressional Budget Office had projected that the law would reduce future deficits.

Lawmakers in both parties joined forces, however, to repeal a tax provision in the law that would impose a huge information-reporting requirement on small businesses. That vote was 81 to 17, with 34 Democrats and all 47 Republicans in favor.

The health care law seeks to extend insurance to more than 30 million people by expanding Medicaid and providing federal subsidies to help lower and middle-income Americans buy private coverage. Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages in medical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.

On a separate track, more than 20 challenges to some aspect of the sprawling act have been filed around the country, many put in motion by Republican governors and attorneys general. Many focused on the so-called individual mandate, a requirement that all Americans buy health coverage or pay a fine (or tax, depending on who is describing it). The insurance mandate is central to the law’s mission of covering more than 30 million uninsured because insurers argue that only by requiring healthy people to have policies can they afford to treat those with expensive chronic conditions.

By February 2011, three judges had upheld the mandate and two had found it unconstitutional. The issue is considered almost certain to be determined by the Supreme Court.

Later that month, President Obama signalled flexibility on the issue. He said he was willing to amend the measure to give states the ability to opt out of its most controversial requirements right from the start, including the mandate that most people buy insurance, as long as they could find another way to expand coverage without driving up health care costs. Under the current law, states must wait until 2017 to obtain waivers.

While the various challenges played out, federal and state regulators moved into high gear rolling out early provisions and laying the groundwork for the broader changes to come in 2014. In September 2010, a number of important provisions took effect. Insurers were banned from dropping sick and costly customers after discovering technical mistakes on applications and required to offer coverage to children under 26 on their parents’ policies.

Its passage assures Mr. Obama a place in history as the American president who succeeded at revamping the nation’s health care system where others, notably Harry Truman and Bill Clinton, tried mightily and failed. Republicans would like it to assure that Mr. Obama is a one-term president as well.

The measure will require most Americans to have health insurance coverage; would add 16 million people to the Medicaid rolls; and would subsidize private coverage for low- and middle-income people. It will regulate private insurers more closely, banning practices such as denial of care for pre-existing conditions. The law will cost the government about $938 billion over 10 years, according to the nonpartisan Congressional Budget Office, which has also estimated that it will reduce the federal deficit by $138 billion over a decade.

The victory for Mr. Obama and the Democratic leaders of Congress came after a roller-coaster year of negotiations, political combat, hearings delving into the minutiae of health care and a near-death political experience after they appeared to have reached the brink of success. On Nov. 7, 2009, the House had approved its bill by a vote of 220 to 215, while the Senate passed an $871 billion bill on Dec. 24.

But even as the House and Senate worked to merge their bills, their fate was put in jeopardy on Jan. 19, 2010, by an upset Republican victory in a special election to fill the Senate seat in Massachusetts held for decades by the late Senator Edward M. Kennedy, depriving the Democrats of the 60th vote needed to block a Republican filibuster of a final bill. After weeks of uncertainty, Mr. Obama and Democratic leaders in Congress settled on a strategy in which the compromises needed to align the two versions were stripped down to only those measures that fit within a budget reconciliation bill, which under Senate rules could not be filibustered, a move that paved the way for passage.

The pivotal moment in the long legislative battle came in a dramatic Sunday evening vote, when the House on March 21 approved, 219 to 212, the health care bill that the Senate had passed in December. Later that week, the House and Senate completed passage of a set of fixes to the bills, compromises worked out as part of the complicated legislative maneuvering that allowed Democrats to achieve their long-sought goal despite having lost their filibuster-proof 60-vote “supermajority” in the Senate in January.


The Democrats’ desire for universal access to health insurance runs deep. President Franklin D. Roosevelt hoped to include some kind of national health insurance program in Social Security in 1935. President Harry S. Truman proposed a national health care program with an insurance fund into which everyone would pay. Since then, every Democratic president and several Republican presidents have wanted to provide affordable coverage to more Americans.

President Bill Clinton offered the most ambitious proposal and suffered the most spectacular failure. Working for 10 months behind closed doors, Clinton aides wrote a 240,000-word bill. Scores of lobbyists picked it apart. Congressional Democrats took potshots at it. And Republicans used the specter of government-run health care to help them take control of Congress in the midterm elections of 1994.

One of the most significant differences between 1993-94 and 2009-10 is that employers and business groups, alarmed at the soaring cost of health care, took a seat at the negotiating table. Insurance companies, which helped defeat the Clinton plan, began 2009 by saying they accept the need for change and want a seat at the table. As the bills developed, however, they became strong opponents of some Democratic proposals, especially one to create a government-run insurance plan as an alternative to their offerings.

In his budget for 2010, Mr. Obama gave an indication of the scope of his ambitions on health care reform when he asked Congress to set aside more than $600 billion as a down payment on efforts to remake the health care system over the next 10 years. But after sending Congress his budget plan, Mr. Obama’s White House, displaying a surprisingly light touch, encouraged Democrats in Congress to make the hard decisions.

By the end of March 2009, the chairmen of five Congressional committees had reached a consensus on the main ingredients of legislation, and insurance industry representatives had made some major concessions. The chairmen, all Democrats, agreed that everyone must carry insurance and that employers should be required to help pay for it. They also agreed that the government should offer a public health insurance plan as an alternative to private insurance.


Democrats worked on three separate paths to develop legislation in the summer of 2009. On June 14,House Democratic leaders introduced their bill, which in addition to a public plan included efforts to slow the pace of Medicare spending, a tax on high-income people and penalties for businesses that do not insure their workers. After a revolt by a conservative group of “Blue Dog” Democrats that led to more exemptions for businesses, the plan was adopted by three committees without Republican support.

In the Senate, the Health, Education, Labor and Pensions Committee worked on a bill with a public insurance plan, while the Senate Finance Committee, led by Senator Max Baucus, Democrat of Montana, worked on a bill that sought to avoid one, which Mr. Baucus thought was necessary to gain bipartisan support.

On July 15, the Senate health committee passed its bill on a party-line vote of 13 to 10, with all Republicans opposing the package. Both Republicans and Democrats acknowledged that the health committee bill was just part of what would eventually be a single Senate measure.


During the Congressional recess in August 2009, the White House appeared to lose control of the public debate over health care reform to a wave of conservative protests.

Democratic Party officials acknowledged that the growing intensity of the opposition to the president’s health care plans — plans likened on talk radio to something out of Hitler’s Germany, lampooned by protesters at Congressional town-hall-style meetings and vilified in television commercials — had caught them off guard.

On Sept. 9, Mr. Obama confronted a critical Congress and a skeptical nation, decrying the “scare tactics” of his opponents and presenting his most forceful case yet for a sweeping health care overhaul that has eluded Washington for generations.

When Mr. Obama said it was not true that the Democrats were proposing to provide health coverage to illegal immigrants, Representative Joe Wilson of South Carolina yelled back, “You lie!” Mr. Wilson apologized but his outburst led to a six-day national debate on civility and decorum, and the House formally rebuked him on Sept. 15.

The president’s speech appeared to restore momentum to the reform effort, at least for the moment, according to polls that followed.


When Mr. Baucus introduced his long-awaited plan in the fall of 2009, the bill closely resembled what Mr. Obama said he wanted, except that it did not include a new government insurance plan to compete with private insurers.

Unlike the other bills, the Baucus plan would impose a new excise tax on insurance companies that sell high-end policies. The bill would not require employers to offer coverage. But employers with more than 50 workers would have to reimburse the government for some or all of the cost of subsidies provided to employees who buy insurance on their own.

The bill got a significant boost when the Congressional Budget Office announced that despite its price tag, it would reduce the federal deficit by slowing the rate of health-care spending.

On Oct. 13, 2009, the committee voted to approve the legislation. The vote was 14 to 9, with all Republicans opposed except for Senator Olympia J. Snowe of Maine. Two weeks later, Ms. Snowe’s support was lost, when Mr. Reid, the majority leader, announced he would include a public option in the legislation he took to the Senate floor.


Before Speaker Pelosi put the House bill to a vote, she had to broker a series of compromises that ultimately brought along just enough support from conservative Democrats to win passage. The biggest changes concerned the public option plan, which would have to negotiate rates just as private insurers do, rather than offering a rate set slightly above what Medicare pays; the plan would also confront strict controls on abortion. After heavy lobbying by Catholic bishops, the measure was amended to tighten restrictions on abortion coverage in subsidized plans bought through the insurance exchanges, to insure that no federal money was used to pay for an abortion. Both changes angered Ms. Pelosi’s base of liberal Democrats, but they chose to support the bill nonetheless.

Democrats said the House measure — paid for through new fees and taxes, along with cuts in Medicare — would extend coverage to 36 million people now without insurance while creating a government health insurance program. It would end insurance company practices like not covering pre-existing conditions or dropping people when they become ill. And despite its price tag, they pointed to an analysis by the Congressional Budget Office that said it would reduce the deficit over the next 10 years.

In a sign of potential difficulties ahead, some centrist Democrats said they voted for the legislation so they could seek improvements in it in a conference with the Senate.


By early November 2009, the broad outlines of the bill Senator Reid would introduce on the Senate floor were clear — it would include the public option that was part of the health committee’s bill, but with an “opt out” provision for states, and many of the taxes and fees written in to the Finance Committee’s version.

Though broadly similar to the House bill, Mr. Reid’s proposal differed in important ways. It would, for example, increase the Medicare payroll tax on high-income people and impose a new excise tax on high-cost “Cadillac health plans” offered by employers to their employees. Mr. Reid’s bill would not go as far as the House bill in limiting access to abortion. And while he would require most Americans to obtain health insurance, he would impose less stringent penalties on people who did not comply.

The official cost analysis released by the nonpartisan Congressional Budget Office showed that Mr. Reid’s bill came in under the $900 billion goal suggested by Mr. Obama. But 24 million people would still be uninsured in 2019, the budget office said. About one-third of them would be illegal immigrants.

The Congressional Budget Office said the House bill would reduce deficits by $109 billion over 10 years and cover 36 million people, but still leave 18 million uninsured in 2019.


As debate began, Mr. Reid began searching for changes that could pull together the 60 votes that would be needed to avoid a Republican filibuster. The Democratic caucus contains 60 members, including two independents, but one of those independents, Joseph I. Lieberman of Connecticut, said he would block a vote on any bill containing a public option. To win his vote, it was dropped, as was a compromise proposal to expand Medicare to allow people aged 55 to 64 to buy in to the plan — both moves that angered the Senate’s liberals, who pointed out that Mr. Lieberman had spoken in favor of the Medicare expansion three months before.

The last Democrat to come on board was Senator Ben Nelson of Nebraska, who won a series of changes: a provision to strip the insurance industry of its anti-trust exemption was dropped; language was added to allow states to decide to block plans covering abortion from their insurance exchanges; and the bill now provides Nebraska with additional Medicaid funds.

Republicans vowed to use every parliamentary device at their disposal to slow the measure, which they said was being rammed through the Senate in an unseemly rush. But with Mr. Nelson on board, Mr. Reid’s bill survived the first serious procedural hurdle by reaching the 60 vote mark needed to fend off a filibuster.

When the roll for the final vote was called at 7:05 a.m. on Dec. 24, 2009, it was a solemn moment. Senators called out “aye” or “no.” Senator Robert C. Byrd, the 92-year-old Democrat from West Virginia, deviated slightly from the protocol. “This is for my friend Ted Kennedy,” Mr. Byrd said. “Aye!”

The 60-to-39 party-line vote came on the 25th straight day of debate on the legislation.


But less than a month later, the victory of Scott Brown, a previously little known Republican state senator, in the Massachusetts special election to fill Mr. Kennedy’s seat, upset all calculations and left Democrats scrambling for approaches that might allow them to pass some version of the bill.

The most widely discussed approach called for the House to approve the Senate bill — thereby avoiding a filibuster if the Senate needed to vote on a compromise bill. That vote would be preceded by the passing of a separate bill containing the changes both houses could agree to. Democratic leaders believed that most of those could be put into a so-called budget reconciliation bill, which under Senate rules cannot be filibustered. But House Democrats were reluctant to move until the Senate moved first, and several conservative Democrats said they opposed using reconciliation. In mid-January 2010, Mr. Reid and Ms. Pelosi signalled that they did not expect quick action.

In his State of the Union address to Congress, delivered on Jan. 27, 2010, Mr. Obama called on Congress to finish the job. He appealed once more for Republicans to put forward ideas that could lead to a bipartisan approach. He added, “Do not walk away from reform. Not now. Not when we are so close. Let’s find a way to come together and finish the job for the American people.”

But he did not lay out his preferences for the bill’s final form or lay out a means of passage. Almost two weeks later, in an interview during the Super Bowl’s pre-game show, Mr. Obama announced a bipartisan, half-day summit at the White House, a high-profile gambit that would allow Americans to watch as Democrats and Republicans tried to break their political impasse. The plan would put Republicans on the spot to offer their own ideas on health care and show whether both sides were willing to work together.


Republicans never offered a unified health care bill, but the party’s Congressional leaders sketched out a fairly well-developed set of ideas intended to make health insurance more widely available and affordable, by emphasizing tax incentives and state innovations, with no new federal mandates and only a modest expansion of the federal safety net.

The Republicans rely more on the market and less on government. They would not require employers to provide insurance. They oppose the Democrats’ call for a big expansion of Medicaid, which Republicans say would burden states with huge long-term liabilities.

While the Congressional Budget Office has not analyzed all the Republican proposals, it is clear that they would not provide coverage to anything like the number of people — more than 30 million — who would gain insurance under the Democrats’ proposals.

But Republicans say they can make incremental progress without the economic costs they contend the Democratic plans pose to the nation. As one way to encourage competition and drive down costs, Republican members of Congress want to make it easier for insurance companies to sell their policies across state lines, an idea included in a limited form in the Democratic bills.


On Feb. 22, 2010, days before his health “summit” meeting with Republicans, Mr. Obama released a detailed set of proposals. The bill was intended to achieve Mr. Obama’s broad goals of expanding coverage to the uninsured while driving down health premiums and imposing what the White House called “common sense rules of the road” for insurers, including ending the unpopular practice of discriminating against people with pre-existing conditions. It would offer more money to help cash-strapped states pay for Medicaid over a four-year period, and, in a nod to concerns among the elderly, end the unpopular “donut hole” in the Medicare prescription drug program.

In many respects, Mr. Obama’s measure looked much like the version the Senate passed on Christmas Eve 2009. But there are several critical differences that appear designed to appeal to House Democrats, who have voiced deep concerns about the Senate measure and its effects on the middle class.

To begin with, Mr. Obama would eliminate a controversial special deal for Nebraska — widely derided by Republicans as the “cornhusker kickback” — that called for the federal government to pay the full cost of a Medicaid expansion for that state. Instead, the White House would help all states absorb the cost of the Medicaid expansion from 2014, when it begins, until 2017.

And while the president adopted the Senate’s proposed excise tax on high-cost, employer sponsored insurance plans, Mr. Obama made some crucial adjustments based on an agreement reached in January 2010 with organized labor leaders, while also trying to avoid the appearance of special treatment for unions. Most crucially, the president would delay imposing the tax until 2018 for all policies, not just for health benefits provided through collectively-bargained union contracts.


On Feb. 25, Congressional Democrats and Republicans joined Mr. Obama at Blair House, across the street from the White House, for an extraordinary seven-hour televised debate on the intricacies of heath care reform.

Mr. Obama and his fellow Democrats tried to make the case that the two parties were closer than they thought, with the implication that their bill was centrist and would be acceptable to mainstream voters. Republicans countered that the gap was vast, that the bill was out of touch with what the country wanted and that Mr. Obama should throw it out and start over.

Republicans said there was no way they would vote for Mr. Obama’s bill, and Democrats were talking openly about pushing it through Congress on a simple majority vote using the controversial parliamentary maneuver known as reconciliation.

Beyond the question of government intervention in the private insurance market, their most profound disagreement was over expanding coverage to the uninsured. The Democrats wanted to cover more than 30 million people over 10 years; Republicans said the nation could not even afford the entitlement programs, like Medicare, that already exist, much less start new ones.


For most of 2009, the focus had been on the Senate, where the need for 60 votes to defeat a certain Republican filibuster had appeared to put the push for health care reform in greatest peril. But the two-track plan adopted by Democratic leaders — having the House pass the Senate plan with an agreed upon “sidecar” of fixes — meant that the only new vote the Democrats would have to win would be on a set of fixes that would fall under budget reconciliation rules, making the issue immune to filibuster.

Republicans railed against the tactic, saying Democrats were using a procedural gimmick to “jam” the legislation through; Democrats replied by listing all the major bills the Republicans had passed via reconciliation when they were in the majority, including the Medicare drug plan and both Bush tax cuts.

Mr. Obama, who had long avoided setting out a definitive set of his preferences, moved to the forefront after laying out an 11-page plan for changes to the Senate bill. The focus swung to Democrats in the House. Some conservative Democrats were unhappy with the bill’s cost, others with the weaker abortion provisions in the Senate bill. A number of liberals were angry over the loss of the public option.

A week after the health care summit, Mr. Obama bluntly challenged wavering Democrats to step up and support the bill, saying its failure would pose a greater political threat than passage. As he traveled to the districts of crucial representatives, Ms. Pelosi and her aides met almost nonstop with members of her caucus. Three days before the vote the tide seemed to swing her way, as the Congressional Budget Office declared the bill would reduce the deficit by $138 billion over its first 10 years, and a number of anti-abortion Democrats decided that the language in the Senate bill would protect against the use of federal funds to pay for abortion. But it was not until the morning of the vote, when Representative Bart Stupak of Michigan, who had become a leader of anti-abortion Democrats on the issue, said that Mr. Obama’s promised executive order would settle the issue for him, that it became clear that the bill would in fact pass.

After the House passed the Senate’s bill, it passed and sent to the Senate the so-called “sidecar” of fixes, which removed some provisions that had drawn criticism, such as a special deal on Medicaid for Nebraska, and adjusted other provisions that were unpopular with House Democrats, like the excise tax the Senate had imposed on high-cost insurance plans. In the Senate, Republicans succeeded in forcing Democrats to make minor changes in the language of the reconciliation bill, which also included an overhaul of the federal student loan program, meaning it needed to go back to the House for final passage, which it gave in a brisk session on the evening of March 25th.

The final House vote was 220 to 207, and the Senate vote was 56 to 43, with the Republicans unanimously opposed in both chambers.


Immediately after Mr. Obama signed the bill, states began filing challenges to it in federal court. Twenty states, led by Attorney General Bill McCollum of Florida, a Republican who is running for governor, banded together to file suit in federal district court in Pensacola, Fla. The first challenge to make it to a hearing was the one filed by the attorney general of Virginia.

In October, a federal judge in Detroit became the first to rule on the lawsuits, upholding the government’s position. The next month, a federal judge in Lynchburg, Va., did the same.

Then in December, a federal judge in Richmond issued the first ruling against the law, calling the individual mandate unconstitutional. The judge, Henry E. Hudson, who was appointed by President George W. Bush, wrote that his survey of case law “yielded no reported decisions from any federal appellate courts extending the Commerce Clause or General Welfare Clause to encompass regulation of a person’s decision not to purchase a product, not withstanding its effect on interstate commerce or role in a global regulatory scheme.”

The case centers on whether Congress has authority under the Commerce Clause to compel citizens to buy a commercial product — namely health insurance — in the name of regulating an interstate economic market. Plaintiffs in the lawsuits argue there effectively would be no limits on federal power, and that the government could force people to buy American cars or, as Judge Hudson remarked at one hearing, “to eat asparagus.”

The Supreme Court’s position on the Commerce Clause has evolved through four signature cases over the last 68 years, with three decided since 1995. Two of the opinions established broad powers to regulate even personal commercial decisions that may influence a broader economic scheme. But other cases have limited regulation to “activities that have a substantial effect on interstate commerce.”

A major question, therefore, has been whether the income tax penalties levied against those who do not obtain health insurance are designed to regulate “activity” or, as Virginia’s solicitor general, E. Duncan Getchell Jr., has argued, “inactivity” that is beyond Congress’ reach.

Justice Department lawyers have responded that individuals cannot opt out of the medical market, and that the act of not obtaining insurance is an active decision to pay for health care out of pocket. They say that such decisions, taken in the aggregate, shift billions of dollars in uncompensated care costs to governments, hospitals and the privately insured.

In January 2011, Judge Roger Vinson of Federal District Court in Pensalcola, Fla., became the second to rule against the health care law. His ruling came in the most prominent of the more than 20 legal challenges mounted against some aspect of the sweeping health law.

Only Judge Vinson has declared the entire act void, including provisions that have already taken effect, like requirements that insurers cover children regardless of pre-existing conditions. Three other federal judges, meanwhile, have upheld the law.


Meanwhile, the administration issued a blizzard of regulations, including a patient’s bill of rights, and has persuaded insurance companies to make some changes sooner than required by the law. It also assembled a team of insurance experts to help carry out the law, under close supervision from the White House. At the start of July, the administration unveiled a Web site,, where consumers can obtain information about public and private health insurance options in their states. The administration and many states are also setting up high-risk insurance pools for people who have been denied coverage because of pre-existing conditions.

Administration officials have issued rules allowing young adults to stay on their parents’ policies and forbidding insurers to deny coverage to children with pre-existing conditions. They have notified nearly four million small businesses of a new tax credit to help defray the cost of insurance. They began accepting applications for a separate program that will reimburse employers for some of the cost of providing health benefits to early retirees. And the government has begun sending $250 checks toMedicare beneficiaries with high drug costs. Those provisions took effect on Sept. 23d, along with rules establishing a menu of preventive procedures, like colonoscopies, mammograms and immunizations, that must be covered without co-payments and allowing consumers who join a new plan to keep their own doctors and to appeal insurance company reimbursement decisions to a third party.

By early October, the administration had given about 30 insurers, employers and union plans, responsible for covering about one million people, one-year waivers on the new rules that phase out annual limits on coverage for limited-benefit plans, also known as “mini-meds.” Applicants said their premiums would increase significantly, in some cases doubling or more.

These early exemptions offer the first signs of how the administration may tackle an even more difficult hurdle: the resistance from insurers and others against proposed regulations that will determine how much insurers spend on consumers’ health care versus administrative overhead, a major cornerstone of the law.


In the November 2010 elections, Republicans took back control of the House and cut the Democratic majority in the Senate. After a delay caused by the shooting of Representative Gabrielle Giffords in Tucson, Ariz., the House voted on January 19, 2011 to repeal the health care overhaul, marking what the new Republican majority in the chamber hailed as the fulfillment of a campaign promise and the start of an all-out effort to dismantle President Obama’s signature domestic policy achievement.

The House vote was the first stage of a Republican plan to use the party’s momentum coming out of the midterm elections to keep the White House on the defensive, and will be followed by a push to scale back federal spending. In response, the administration struck a more aggressive posture than it had during the campaign to sell the health care law to the public. With many House Democrats from swing districts having lost their seats in November, the remaining Democrats held overwhelmingly together in opposition to the repeal.

Knowing that a full-scale repeal would be blocked by the Senate and Mr. Obama, Republicans say they will try to withhold money that federal officials need to administer and enforce the law.

Republicans also intend to go after specific provisions, including requirements that many employers to offer insurance to employees or pay a tax penalty and that most Americans obtain health insurance. Alternatively, Republicans say, they will try to prevent aggressive enforcement of the requirements by limiting money available to the Internal Revenue Service, which would collect the tax penalties.

The repeal effort is part of a multipronged systematic strategy that House Republican leaders say will include trying to cut off money for the law, summoning Obama administration officials to testify at investigative hearings and encouraging state officials to attack the law in court as unconstitutional. For House Republicans, a repeal vote would also be an important, if largely symbolic, opening salvo against the president, his party and his policy agenda.

Republicans denounced the law as an intrusion by the government that would prompt employers to eliminate jobs, create an unsustainable entitlement program, saddle states and the federal government with unmanageable costs, and interfere with the doctor-patient relationship. Republicans also said the law would exacerbate the steep rise in the cost of medical services.

For their part, the Obama administration and Democrats, who largely lost the health care message war in the raucous legislative process, see the renewed debate as a chance to show that the law will be a boon to millions of Americans and hope to turn “Obamacare” from a pejorative into a tag for one of the president’s proudest achievements. Democrats argue that repeal would increase the number of uninsured; put insurers back in control of health insurance, allowing them to increase premiums at will; and lead to explosive growth in the federal budget deficit.

Republicans said their package would probably include proposals to allow sales of health insurance across state lines; to help small businesses band together and buy insurance; to limit damages inmedical malpractice suits; and to promote the use of health savings accounts, in combination with high-deductible insurance policies.

Republicans also want to help states expand insurance pools for people with serious illnesses. The new law includes such pools, as an interim step until broader insurance coverage provisions take effect in 2014, but enrollment has fallen short of expectations. They have also proposed allowing people to buy insurance across state lines and to join together in “association health plans,” sponsored by trade and professional groups.

But state insurance officials have resisted such proposals, on the ground that they would weaken state authority to regulate insurance and to enforce consumer protections — a concern shared by Congressional Democrats.

Mr. Obama has responded to criticism by saying he would be willing to amend portions of the law. On Feb. 28, 2011, he endorsed bipartisan legislation that would allow states to opt out earlier from a range of requirements, including the mandate, if they could demonstrate that other methods would allow them to cover as many people, with insurance that is as comprehensive and affordable, as provided by the new law. The changes must also not increase the federal deficit.

If states can meet those standards, they can ask to circumvent minimum benefit levels, structural requirements for insurance exchanges and the mandates that most individuals obtain coverage and that employers provide it. Washington would then help finance a state’s individualized health care system with federal money that would otherwise be spent there on insurance subsidies and tax credits.

Prospects for the proposal appear dim. Congress would have to approve the change through legislation, and House Republican leaders said that they were committed to repealing the law, not amending it. Even if the change were approved, it could be difficult for states to meet the federal requirements for the waivers.