President Barack Obama's health care law has indeed managed to change the U.S., but major elements of his signature domestic achievement face an uncertain future as a roller-coaster enrollment period winds down.
Americans are unlikely to go back to a time when people with medical problems could be denied coverage by private insurance companies. But Obama's overhaul needs major fixes if it is to go down in history as a legacy achievement like Medicare or Social Security, the long-entrenched and popular programs that provide retirement benefits and health care coverage to seniors.
Republicans have again made repeal of "Obamacare" their official battle cry ahead of the November elections when control of Congress will be at stake. But even if the Republicans win control of the Senate and Congress were to repeal the law next year, the president would veto it. Opponents would then need a difficult two-thirds majority in both chambers to override Obama's veto.
The Affordable Care Act was passed in 2010 on a strict party-line vote when Democrats still controlled both the House and Senate. The U.S. had been the only major developed country without a national health care system, leaving nearly 50 million people in the country without health insurance and millions more with inadequate coverage. But many of its key provisions did not take effect until this year—including the start-up for policies offered by private companies through exchanges created by the federal and state governments.
The 6-month-long sign-up season, which got off to a rocky start in October due to severe website glitches, comes to an end on Monday. After the HealthCare.gov site finally got fixed, more than 6 million people have managed to sign up for coverage, many of them receiving government subsidies to lower the cost of purchasing health insurance policies on the exchanges. The website is seeing heavy traffic this weekend, and consumers may encounter a wait or last-minute glitches.
The enrollment figures are large enough for the exchanges to stay afloat economically, but the new insurance markets created by the law are anything but customer friendly. Many consumers have bought policies with restricted access to top-tier hospitals and the latest medications. The administration's next big challenge is to make 2015 open enrollment more manageable for consumers unaccustomed to dealing with insurance jargon. Until now, those signing up have skewed toward an older crowd. That could lead to higher premiums next year, making the program a harder sell for younger people.
This year, the Obama administration has been able to pitch the health care reform by pointing to the "carrots" in the law: subsidies to purchase policies and guaranteed coverage despite pre-existing medical conditions. But the "sticks" are just over the horizon: collecting penalties from individuals who remain uninsured and enforcing requirements that medium- to large-sized employers provide affordable coverage.
The health care law also expanded Medicaid, the government's health insurance program for the poor, but a 2012 Supreme Court decision that upheld the Affordable Care Act also allowed states to opt out of the Medicaid expansion. Nearly half the states, mostly led by Republicans, are still opposed or undecided about expanding Medicaid. As a result, millions of low-income people who otherwise would have been covered remain uninsured.
Many basic facts about the ultimate effects of the health insurance program remain unclear. It's not known how many of those who have gotten coverage were previously uninsured—the ultimate test of the law. Independent measurements by Gallup do show fewer uninsured Americans, but such progress hasn't won hearts and minds. The public remains deeply divided, with opponents of the law outnumbering supporters.
Republicans are united by their desire to repeal "Obamacare," contending that the law's mix of taxes and mandates is killing jobs while making health insurance more expensive for many. However, Republicans remain divided over what to replace it with.
Among Obamacare consumers is Dan Luke of St. Paul, Minnesota, the owner of a small video production company who had been uninsured since he was turned down for coverage last year due to a pre-existing condition. The condition? Luke was born with one eye due to a birth defect, and he uses a glass eye.
He's happy with the coverage he and his wife have bought; they're saving $300 a month on premiums compared with the last time they had insurance. But he said he had to endure weeks of website run-arounds.
"There is a lot of bureaucracy involved," said Luke. "It's sort of like taxes, filled with loopholes and pitfalls. They should make it easier for people to get insurance and pay for insurance, rather than have to prove so many things and jump through so many hoops."
Those comments echo sentiments broadly reflected in national opinion polls. Most Americans want lawmakers to fix the problems with the health care law, rather than scrapping it. A new AP-Gfk poll finds that only 13 percent expect the law will be completely repealed. Seventy-two percent say it will be implemented with changes, whether major or minor.
Explore further: Poll: Obama health law fails to gain support