The U.S. Supreme Court will hear arguments this month on whether President Barack Obama and Congress have the authority to require people to purchase health insurance and whether states must expand access to Medicaid — the health insurance program for the poor — or risk losing federal money.

The individual mandate and expanded access to Medicaid are central elements in a federal health care reform law meant to bring insurance to 30 million people who are without coverage.

The court is expected to rule this summer, yet even if the law is upheld, it faces political challenges after the November elections. All the Republican presidential candidates have vowed to repeal the law if they defeat Obama. The Republican-controlled U.S. House has already voted for a repeal, and the U.S. Senate could follow if the GOP wins a majority.

U.S. Rep. Mazie Hirono and former congressman Ed Case, the Democratic candidates for U.S. Senate in Hawaii, oppose a repeal and believe the health care law will help cover the uninsured, although Case is uncomfortable with the individual mandate. Former Gov. Linda Lingle, the leading Republican candidate, would not say whether she would vote for a repeal, but she said she has serious reservations about the law and described it as "a one-size-fits-all program" that is financially unsustainable.

Hirono, who voted for the law two years ago, said, "When people talk about repealing the affordable health care act, I say, ‘OK, what part should we repeal? The part that helps seniors afford prescription drugs? The part that allows young people to be on their parents’ policies until age 26? The part where we say you can’t consider being a woman as a pre-existing condition? Or the part that says we’re not going to discriminate against you because you have a pre-existing condition?’"

Hirono defended the individual mandate — in which most people who are uninsured will eventually have to buy insurance or pay a penalty — as an alternative to the uninsured going without preventive care and then getting more costly treatment when they become sick. The law promotes health-insurance exchanges that would give uninsured people, small businesses and others access to competing health plans.

Hirono said she would have voted against an amendment by U.S. Sen. Roy Blunt, R-Mo., that would have allowed businesses to opt out of providing birth control or other health plan mandates in the law by citing moral objections. Obama, after complaints from religious groups, has agreed that religious employers will not have to provide women with birth-control coverage in their health plans, but insurance companies will have to directly offer women the coverage for free.

While the Blunt amendment failed in a close, mostly party-line vote in the Senate this month, Hirono predicted Republicans will launch moves against contraception and federal family planning programs if they take the Senate. "And it would make it really hard for women to get the kind of health care that they need, and that they have gotten," she said.

Case said he would prefer that the private sector deliver on health care, but believes there was no reasonable possibility the private sector alone was going to fix the problem without the federal law. He said he hopes a health insurance exchange will encourage more competition in Hawaii.

"I don’t like mandates. So, yes, I am a little uncomfortable with it," he said. "However, the fact is that the status quo was not working for tens of millions of Americans. Too many Americans uninsured — or underinsured — being denied basic health care and then having to pay way too much for it once they got it. That was — that is — an untenable, unacceptable situation and it was getting worse.

"And it was a failure of the private sector."

The former congressman said he, too, would have voted against the Blunt amendment. He said he thought Obama’s compromise, shifting the birth-control coverage requirement to insurers, instead of religious employers’ health plans, was the right balance.

Case said his main concerns are over what was left out of the health care law. He said that, unlike Hirono, he wants to address medical malpractice liability reform, because he believes unnecessary lawsuits are a driver in rising health care costs. He also said the Obama administration should have insisted on giving the federal government the ability to negotiate with pharmaceutical companies on the bulk purchase of prescription drugs in Medicare.

"I thought that was an extremely unfortunate omission," he said.

Lingle said the national debate over whether to repeal the law has trivialized the discussion on health care.

"This overly simplistic, election-year question diverts attention from the real issue at hand: providing affordable, quality health care to as many citizens as possible," she said in a statement.

The former governor said the individual mandate raises constitutional concerns that are rightfully before the Supreme Court. She said the creation of health insurance exchanges by states has not been thought out. She said she fears that an independent payment advisory board, which is expected to contain Medicare costs, could slow patient access to medical procedures and lead to waiting lists for care.

She described the health care law as a "drag on job creation" because she believes costs are being disproportionately imposed on small and medium-sized businesses. She also, like Case, said the law does not address medical malpractice liability reform.

"On balance, I have serious reservations about the (law) as passed because it allows the federal government to force Hawaii and all other states into a one-size-fits-all program that is financially unsustainable for our state and nation," Lingle said. "While I believe we need to find bipartisan ways to provide health care to the small percentage of Hawaii’s people who want and do not currently have health care insurance, it should not be done in a way that reduces the quality and availability of health care for the majority, as I believe this law will do."

Lingle, like Hirono and Case, has said she would have voted against the Blunt amendment. She said she supports broad access to contraceptives, provided that there are clearly defined exceptions for religious institutions, a position she believes is in line with the federal guidelines being prepared by the Obama administration.

Hirono, Case and Lingle also support an exemption in the law for the Prepaid Health Care Act, a 1974 state law that requires businesses to provide health insurance to employees who work at least 20 hours a week. The state law has put Hawaii among the top states for health insurance coverage.

While Lingle sidestepped the question of whether she would vote to repeal the federal health care law, many in her party have not, directly attacking the law as a prime example of government overreach under Obama.

John Carroll, an attorney and former state lawmaker running against Lingle in the Republican primary, would repeal the law and return all health care decisions back to the states. He said requiring people to buy health insurance is unconstitutional. He also thinks individuals and religious organizations should be able to practice their religion free of government interference, such as federal mandates for birth control coverage.