The new Republican House is expected today to keep a campaign promise by voting to "repeal Obamacare" -- even though health care leaders in Buffalo and elsewhere are not exactly clamoring for the move.
Knowing the repeal effort is likely to stall in the Democrat-run Senate, health care professionals and other vested interests are looking beyond today's vote.
They are more focused on a likely series of efforts over several years to change and improve what is known as the Affordable Care Act.
"We shouldn't be repealing the law," said Dr. Michael W. Cropp, president of Independent Health, one of Western New York's largest insurers. "We should move forward. The bill isn't perfect. But at least it's a good starting position from which we can understand how we move forward."
While it is too soon to know exactly how the bill will be changed, some things are clear:
* With Democrats in control of the Senate and President Obama's veto powers, chances for a complete repeal in the next two years "are remote at best," said Rep. Chris Lee, R-Amherst.
* Congress, nevertheless, is likely to repeal a controversial provision of the law forcing employers to fill out vast numbers of additional tax forms.
* In the House, at least, Republicans will push legislation to deal with medical malpractice costs and other elements left out of the original bill.
* Some programs created under the bill could be starved for funding at the insistence of House Republicans.
While the federal courts debate a central element of the bill -- the provision forcing all Americans to have health insurance -- the Republican House merely is beginning to approach the issue by giving the people what they want, said Rep. Tom Reed, R-Corning.
"The repeal bill is driven by the results of Nov. 2," when the GOP regained control of the House, Reed said. "The people clearly spoke. If the Senate and the president want to ignore the people's will, they do it at their own peril. We're at least going to stand in the House of Representatives as the people's house and respond to people."
On the other side of the political spectrum, Rep. Brian Higgins, D-Buffalo, offered a different interpretation of today's vote. "This is an exercise in political theater," he said.
Repeal does have strong advocates. A survey of small businesses by the Discover credit card company found a majority supported the move.
"Small-business owners are suffering from rising health care costs, and according to the survey, most don't believe the current law is the solution," said Ryan Scully, director of Discover's small business card program.
In Western New York, "to be honest with you, I haven't heard anyone saying we're advocating repeal," said Dr. Mark J. Lema, president-elect of the Erie County Medical Society. "But I can tell you that many elements of the bill need to be changed."
Republicans agree. Lee, who will be extensively involved in health care issues on the Ways and Means Committee, said the party is likely to deal with those individual elements in separate pieces of legislation over the coming months.
"The more practical approach is to take this piecemeal," he said.
First and foremost, business people -- including doctors -- are up in arms over a once-unknown provision of the law that forces employers to file 1099 tax forms for every purchase they make valued at $600 or more.
Scheduled to take effect next year, that provision would burden employers with an avalanche of new paperwork. It's one of the few provisions in the bill that the Buffalo Niagara Partnership opposes, said Craig Turner, a vice president at the regional chamber of commerce.
The partnership is not alone. Obama has expressed his willingness to fix the 1099 tax burden, and Republicans have vowed to do so.
That leads to one conclusion.
"That thing's got to go," said Cropp, of Independent Health. "It's toast."
The nation's trial lawyers could get toasted, too, by the new Congress. Medical malpractice reform was conspicuously absent from the Democrat-passed health bill. So now Republicans are likely to try to reform what physicians call a lawsuit-happy system that's forcing them to practice defensive medicine -- ordering expensive and unnecessary tests merely out of the fear of getting sued.
Lee, for one, said malpractice reform legislation is crucial.
"If we can focus on that, ultimately we can start bending the cost curve" and making health care more affordable, Lee said.
Republicans today are scheduled to reveal their "repeal and replace" legislation, which will offer a more detailed look at the party's health care plans.
Reed said the Republican legislation would preserve some of the more popular aspects of the Democratic bill, such as the patching of the "doughnut hole" that makes prescription drugs more expensive for some senior citizens, as well as the language allowing people to keep children on their health care plan up to age 26.
House Republicans also plan to preserve the part of the bill that bars insurers from discriminating against people with pre-existing medical conditions.
The trouble is, by repealing the health bill before replacing it, Republicans are voting to end some popular measures with no guarantee that they ever would be re-enacted.
Rep. Louise M. Slaughter, D-Fairport, was more than happy to point out just a few of them.
"It took us decades to finally make it illegal for insurance companies to charge women 48 percent higher premiums just for being a woman and to stop the egregious practice of discrimination against domestic violence victims," she said of provisions in the original health bill. "It's unfathomable to vote against these protections."
But Republicans want to do just that and more. They also are talking about including language in spending bills that would bar the government from paying out any money to implement any of the Obama health bill's provisions.
"This would immediately suspend the president's effort to infuse his crippling policies into our lives and provide a de facto near-term repeal," Rep. Steve King, R-Iowa, said this week in an essay in Politico.
Such an effort is months away, and the greatest threat to the health care bill is even farther down the road.
Several federal court cases have questioned the constitutionality of the law's requirement, to take effect in 2014, that everyone buy health insurance.
A judge in Virginia has ruled that the provision is unconstitutional, setting up a likely battle before the U.S. Supreme Court in the next few years.
A ruling against the individual mandate would knock out one of the law's central premises -- that by forcing healthy young people to buy health insurance, the nation could afford the costly ban on higher insurance rates for those with pre-existing conditions.
"That's a problem, because without the mandate, people could wait to buy coverage till they needed it," thereby driving up costs, said Donald Ingalls, vice president of governmental affairs at BlueCross BlueShield of Western New York.
For now, though, health care reform "is the law of the land," said Ingalls, who added that BlueCross BlueShield is hard at work getting ready to comply with provisions of the law -- even if the law is likely to change.