House Republicans symbolically voted on Wednesday to repeal the Patient Protection and Affordable Care Act law, following the Supreme Court’s recent decision to uphold most of the law two weeks ago.   The  Senate will not allow the House bill to advance.  The vote was 244 to 185 with five Democrats voting for repeal and no Republican voting against.  It was the second time since Republicans took control of the House in 2011 that the House has voted to repeal the law.  The House has also voted more than 30 times to rescind specific provisions of the law.

Meanwhile, Mitt Romney has been steadfast in his opposition to the Patient Protection and Affordable Care Act.  He continues to vow that, on his first day as president, he would act to repeal the law.  However, the reality for a President Romney may be somewhat more complicated. The future of the law remains unsettled with the November election its next major hurdle, while Americans remain consistently divided over the law.

Many political analysts predict that Romney would aggressively work to make good on his promise if elected, but doing so could carry political pitfalls since millions of Americans do support the law and many are already benefiting from some of its provisions.

Unless Republicans gain large numbers in Congress, Romney most likely would not have the votes to simply repeal the entire law.  Few analysts expect the GOP to have a 60-vote, filibuster-proof majority in the Senate come January, the advantage needed to pass most controversial legislation.  Without it, Romney would have little chance of pushing a repeal bill through Congress.  However, even without a filibuster-proof majority in the Senate, Republicans could use a process called “reconciliation” to repeal parts of the bill that relate to spending.   He “could use the budget process to repeal all of the portions of the Affordable Care Act that relate to spending money, which is where all the controversy is,” said Gail Wilensky, a former top healthcare policymaker in both Bush administrations.

He could also issue waivers to all 50 states exempting them from the law’s requirements.  However, although the law permits states to apply for exemptions, they must prove that they have alternative programs in place to provide comparable benefits. Governor Romney’s Day One plan includes an executive order instructing federal agencies to return maximum possible authority to the states,” Romney spokeswoman Andrea Saul said in an e-mail to the Washington Post.  “This will include as much flexibility as the law permits, including waivers wherever possible under the law. He will then begin the work of fully repealing Obamacare and replacing it with common-sense reforms that will ensure Americans have access to the highest quality health care in the world,” Saul said.

Romney could instruct the Department of Health and Human Services to drag its feet, pushing back deadlines. He could also ask other federal agencies to slow down implementation and turn off funding.  He could also instruct officials to write regulations, where the law is ambiguous, to exempt the largest number of people.