The debate distills to this: Can a bill that depends on an uneasy blend of free-market incentives and government regulation succeed in providing universal access to healthcare at a reasonable cost? The premise of the act in the first place was that a system of healthcare exchanges would encourage competition and keep prices moderate even as the pool of insured people expanded.
But that assumes that states implement it in good faith. The staunch opposition of Republicans has meant that many states with little regulation of insurance companies or healthcare are delaying or actively resisting many aspects of the bill. What's clear is that opposing the bill is a good strategy if you want the reforms to fail. The success of the legislation depends on the cooperation of state governments, insurance companies and federal regulators. That is hardly unusual, but the complexity of the reforms make it all the more imperative.
Yet the divergences over the bill and its consequences mask a rather severe rift between federal actions, state conviction and popular opinion. Despite laws passing at the federal level, the reality is that the United States remains a federal system that requires vast efforts of compliance by states and by individuals. One of the great gripes of state-level politicians is that Washington is forever passing "unfunded mandates" and assorted vague and complex laws, and then leaving it to states to pay for and figure out the implementation. The Affordable Care Act is Exhibit A for these tensions.
Yet for the American system to work, some level of compliance and trust are essential. That is true for paying taxes, and it's true for healthcare reform. There is no way the government could actively force every single person to pay taxes without creating a coercive police state. And healthcare reform will not work unless multiple segments of society work jointly and cooperatively. Even the vaunted aspects of the bill that encourage competition require some level of cooperation. Various insurance companies and state agencies have to hash out the details of the proposed exchanges for the currently uninsured and provide alternatives for those currently insured under different plans.
In short, the bill requires what Silicon Valley firms have called "coopetition," which acknowledges the tensions and competition inherent in various enterprises but recognizes that there are joint needs that demand collective action. Coopetition as applied to healthcare implementation would mean different states would have thicker or thinner regulatory regimes, and more or less competitive pricing of insurance, but that all would make a good faith efforts to implement healthcare exchanges and honor the federal mandates for universal coverage.
Yet opponents have been set against the act. Unlike other examples of intransigence in the face of a national bill, obstructing the Affordable Care Act might fatally undermine it. Southern opposition to the Civil Rights Act of 1964 and the Voting Right Act of 1965 triggered federal responses that forced compliance, but there the moral issue was widely settled, and there were clear mechanism to force compliance. You can't do that with the Affordable Care Act. There is no scenario where Obama could call out the national guards to force states to open functional healthcare exchanges.