WASHINGTON - After taking a largely symbolic stand on Wednesday, Republicans on Thursday will begin a new phase of their effort to overturn the sweeping 2010 health care law, pursuing a variety of strategies: court tests, funding cutoffs and piecemeal changes.
The GOP-led House of Representatives voted Wednesday 245-189 to repeal the law, but that effort is likely to go nowhere in a Senate still ruled by Democrats, and even if it passed there, repeal wouldn't survive a certain presidential veto.
That's one reason why on Thursday the House plans another vote directing its committees to look for specific changes they can make to the health care law.
Changes over the next two years could involve reducing paperwork burdens on businesses, permitting the sale of coverage across state lines, denying the government funds to implement the law, and denying funds for a series of grants and other health-related programs.
Still, many political hurdles stand between House Republicans and success in those endeavors, as one house of Congress generally needs to reach compromise with the other house - and the president - to achieve anything.
Senate Republican Leader Mitch McConnell of Kentucky said the GOP will push for repeal despite the seemingly long odds, since Democrats control 53 of the 100 seats.
"The Democratic leadership in the Senate doesn't want to vote on this bill," McConnell said after the House vote. "But I assure you, we will. We should repeal this law and focus on common-sense steps that actually lower costs and encourage private sector job creation."
Republicans may have a better chance of success in court.
Some 25 other states have joined Florida's lawsuit in federal court challenging the health care law - six signed on Tuesday - and Virginia is pressing a separate case. All those states echo a key Republican argument in contending that the law's requirement that nearly everyone buy insurance by 2014 or face penalties is unconstitutional.
In December, federal District Court Judge Henry Hudson ruled that a person can't be forced to buy coverage; the Obama administration is appealing. But Virginia, which filed the suit, also is appealing, saying that Hudson should have overturned the entire law. The case is expected to wind up before the U.S. Supreme Court.
First, though, some Democrats in Congress say they're open to some change: "We will certainly look at any good ideas that come down," said House Minority Whip Steny Hoyer, D-Md.
But they also warn that the law is a carefully crafted balancing act, and removing one piece could jeopardize the success of another.
For instance, Republicans are eager to overturn the individual mandate, but would keep the terms barring insurers from rejecting people with pre-existing conditions.
Doing that, though, risks sending premiums higher, since in theory healthy people would be less inclined to buy coverage while the number of people needing coverage would increase.
"The argument for a mandate is that if you're going to lower costs, improve access and improve the quality of care, you have to increase the risk pool," said House Minority Leader Nancy Pelosi, D-Calif.
Several bipartisan discussions are under way on Capitol Hill about possible changes in the law, but without strong support from the administration they are expected to languish.
As a result, most of the Republican efforts are likely to be little more than political posturing, independent analysts suggest.
"Republicans need to ask themselves whether they want to impede implementation of a law that they disagree with but that they cannot stop," said Paul Ginsburg, president of the Center for Studying Health System Change, a research group.
Republicans insist that by picking off pieces that may be unpopular, they can chip away at the law, but they're vague about precisely what they will do next, or when.
Asked about a timeline, House Majority Leader Eric Cantor, R-Va., said the committees "are not all organized right now."
Once they are, analysts look for these issues to surface quickly:
-Small business. Probably the provision most likely to win congressional approval is repealing the new requirement that every business-to-business transaction involving goods or services cumulatively worth more than $600 be reported to the government.
The requirement is expected to raise about $17 billion over 10 years, since it's expected to encourage better transaction reporting.
The business community has howled about it.
It's "creating a tremendous new paperwork compliance burden for small business," said Susan Eckerly, a senior vice president at the National Federation of Independent Business, the nation's leading small business advocacy group.
Support appears to be growing for repealing this provision, and making up the lost money by curbing some of the law's prevention programs. For instance, the law creates a Prevention and Public Health Fund that's estimated to cost $12.9 billion through 2019.
-Implementation funds. The nonpartisan Congressional Budget Office estimates that government agencies will need $10 billion to $20 billion over the next 10 years to help put the law into effect.
For instance, the Internal Revenue Service will need personnel and technology to help put into place the new system of tax credits aimed at helping lower-income people afford coverage. And the Department of Health and Human Services will be writing a series of regulations governing how insurance exchanges, or marketplaces, work.
House budget-writers can try to deny the funds, but the effort is unlikely to get far. Even if such terms get through the House, the Senate's unlikely to go along, because Democratic leaders want the law implemented.
-Grants and other programs. CBO estimates that the law authorizes spending about $106 billion through 2019 for such programs. But, it said in a Jan. 6 letter to Speaker John Boehner of Ohio that more than $86 billion "were for activities that were already being carried out under prior law" or previously approved.
Among them: $39 billion for the Indian Health Service and $34 billion for more grants to different health centers.
"The Indian Health Service funds are crucial for a lot of states, and these programs have had strong bipartisan support," said James Horney, director of federal fiscal policy at the Center on Budget and Policy Priorities, a liberal budget watchdog.
-Coverage across state lines. People can now only buy individual health insurance policies sold by firms licensed in their state. Republicans are eager to break down those state barriers, and their plan is expected to be a top priority.
But the effort will face a tough opponent: States, which have most regulatory authority over insurance and argue that they can best protect consumers and closely watch whether insurers remain financially viable.
When the issue came up last year, leaders of the National Association of Insurance Commissioners issued a statement saying they were "strongly opposed" to any bill in which the federal government allows insurance carriers to sell their products in our states using the regulatory rules of another state."