I have been writing for a while about the lack of a federal police force for the insurance regulations which are now the centerpiece of health care reform. This puts a tremendous burden on state regulatory frameworks to enforce whatever rules are written at the federal level. That’s a few years down the road. But the health care lobby, mindful of the dynamics of the debate, has already begun to shift its resources to the state level.

Like about a dozen other states, Florida is debating a proposed amendment to its state constitution that would try to block, at least symbolically, much of the proposed federal health care overhaul on the grounds that it tramples individual liberty.

But what unites the proposal’s legislative backers is more than ideology. Its 42 co-sponsors, all Republicans, were almost all recipients of outsized campaign contributions from major health care interests, a total of about $765,000 in 2008, according to a new study by the National Institute on Money in State Politics, a nonpartisan group based in Helena, Mont. [...]

Advocates of a sweeping overhaul by the federal government, on the other hand, say the magnitude of the health care industry’s contributions shows the dangers of leaving such a question up to individual states, where campaign finance and ethics rules vary from strict to negligible.

“The states are the next battle,” said Richard Kirsch, national campaign manager for the liberal advocacy group Health Care for America Now, “and the insurers and health care industry are primed up and ready to go. The industry has enormous power at the state level, and very few states have state-level consumer groups that are able to lobby effectively against them.”

It’s not just the lack of infrastructure to battle at the state level, but the lack of understanding of how central states are to the legislation. There’s no supplementary enforcement, outside of Congress hauling some insurance executives in for oversight hearings. The law will live or die at the state level. And if you think that the White House had to play nice with stakeholders to keep them on the side of reform, magnify that exponentially to determine the money advantage for the health care lobby in the states.

Over the last six years, health care interests have spent $394 million on contributions in states around the country; about $73 million of that went to those 14 states. Of that, health insurance companies spent $18.2 million, according to the institute.

Passing laws amending state constitutions to invalidate certain aspects of the legislation is more theater (and the subject for future court battles). The real effort will go into fighting any attempt at meaningful regulation of key industries.