Jan. 1, 2014, seemed far away when President Barack Obama signed his health care program into law back in 2010. That is the date as of which the law's main parts will take effect, including the mandate to buy insurance and the expansion of Medicaid.
Recent years have been rather hectic, however. Republicans hoped to gut "Obamacare," first in court and then by electing a Republican president. Obama is still in the White House, however, and — thanks to a surprise vote from Chief Justice John Roberts — Obamacare, as even the president now calls it, is still law.
Jan. 1, 2014, is still the day when its main parts must go into effect, however, so the next 12months will be busy ones.
Even without controversy, implementation would be complex. The law tries to reform a sector that accounts for nearly one-fifth of America's GDP. Its 906 pages invite even more pages of regulation from the Department of Health and Human Services.
Implementation will be much harder than Democrats had imagined, however. Bickering has consumed precious time. HHS has delayed issuing essential regulations. Most important, many state governors remain uncooperative.
The big question is how the reality of reform will differ from the Democrats' vision of it. The huge law contains many provisions, but its main goal is to expand health insurance.
Beginning in 2014, insurers will no longer be allowed to refuse coverage to the sick. The cost of insuring them will be paid out of insurance fees from cheap, healthy consumers, which is why the law requires everyone to buy insurance or pay a penalty.
The law also seeks to extend Medicaid to all those earning as much as 138 percent of the federal poverty level, which was $15,415 for one adult in 2012. As of 2014 those with incomes of between 100 percent and 400 percent of the poverty level will qualify for subsidies on new state health exchanges, where individuals can shop for insurance.
The law's opponents had hoped that the Supreme Court would scrap all this. It did not, except for one piece: States may choose whether or not to expand Medicaid.
Some measures already have taken effect. HHS has started to reward hospitals for providing good care, rather than lots of it. Some employers are contesting the law's requirement that insurance should cover contraception, however, and the future of two main provisions, the health exchanges and the Medicaid expansion, is blurry.
The exchanges must be ready by October 2013, so that consumers can choose insurance beginning in 2014. Some states, most led by Democrats, have prepared diligently. HHS has doled out $1.8 billion to help. Many Republican governors have done nothing.
Even enthusiastic states will struggle to meet the deadline, however. HHS waited until after the election to propose important rules, such as the types of insurance that may be sold. The final regulations are still to come.
Republican governors who sat on their hands during the law's first years are now wagging their fingers at HHS for being slow. Many want nothing to do with the exchanges, anyway.
"For any state who's running an exchange, it is &‘state' in name only," scoffed Gov. Scott Walker of Wisconsin in November.
Opposition to Obamacare is impeding even some Democratic governors. In Missouri, voters passed a ballot measure to prevent their governor from moving forward. Democrats in Washington had hoped that each state would build its own exchange. On Dec. 17, HHS said that only 18 states had applied to do so. Of these, only five are led by Republicans.