More than two dozen states have sued the Obama administration to block the law from being fully implemented.
Three federal judges -- appointed by Democratic presidents -- have upheld the law, and two federal judges -- appointed by Republican presidents -- have struck down its key provision, the individual mandate. One of them, Judge Roger Vinson in Florida, went as far as declaring the whole law unconstitutional and said all of it "must be declared void."
Unlike the cases where the ruling was in favor of the Obama administration, those in Florida and Virginia were brought by states as opposed to private parties. The Florida case, in particular, included 26 states.
The matter is likely to be taken up by the Supreme Court in the coming years although the timing of it remains blurry. Although the cases are wending their way through the appellate courts, Virginia's attorney general is asking the Supreme Court to step in and address the issue immediately.
That request is expected to reach the high court at the beginning of April, and court watchers believe it will be denied. The high court does not usually like to step in prematurely before the appellate courts have ruled.
If there is a split in the appellate courts, as expected, the Supreme Court could review the merits of the case sometime next term with a decision around June of 2012.
This fresh battle outside of the Beltway comes at a time when the states' role in implementing the law is becoming increasingly important.
"As we look forward with implementation of the health reform law, the states really become the focus now," said Jennifer Tolbert, a principal policy analyst at the Kaiser Family Foundation. "When thinking about the coverage expansions in particular because it is going to be up to the states to implement the expansion of the Medicaid program for lower-income individuals and to create the new health insurance exchanges that will provide access to private insurance for moderate and middle income individuals."
Much of the investment, such as for Medicaid expansion, comes from the federal government but states will eventually have to bear the costs.
Several governors, particularly Republicans, are resisting the changes saying they cannot sustain the costs and infrastructure investments in the long-term.
Reducing costs in the long term was one of the key points pushed by Democrats and the president, but health care experts say it's too soon to tell whether the law will make a significant impact in Americans' wallets.
ABC News' Karen Travers contributed to this report.