As a roller-coaster sign-up season winds down, President Barack Obama's healthcare law has indeed managed to change the country.
Americans are unlikely to go back to a time when people with medical problems could be denied coverage.
But Obama's overhaul needs major work of its own if it is to go down in history as a legacy achievement like Medicare or Social Security.
Major elements of the Affordable Care Act face an uncertain future:
- As a 6-month-long sign-up season comes to an end Monday the administration's next big challenge is to make 2015 open enrollment more manageable for consumers unaccustomed to dealing with insurance jargon. There's also concern premiums will rise next year.
- The new insurance markets created by the law are anything but customer friendly. After the HealthCare.gov finally got fixed, more than 6 million people have managed to sign up, allowing the exchanges to stay afloat economically. But many consumers have bought policies with restricted access to top-tier hospitals and the latest medications. The website is seeing heavy traffic this weekend, and consumers may encounter a wait or last-minute glitches.
- Nearly half the states are still opposed to or undecided about the law's expansion of Medicaid, the government's health insurance program for the poor. As a result, millions of low-income people who otherwise would have been covered remain uninsured.
- This year's pitch has been about the "carrots" in the law: subsidies and guaranteed coverage. 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.
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.