Three years ago Saturday, President Barack Obama put pen to paper and signed into law a sweeping health care reform law that aims to extend health insurance coverage to tens of millions of people and put the squeeze on escalating health care costs.
It was an historic moment. Obama and the Democrats who held majorities in the House and Senate succeeded where others from Teddy Roosevelt to Harry S Truman to Bill Clinton had failed. And Obamacare has withstood more than 30 votes in Congress to repeal it, a lawsuit that went all the way to the Supreme Court and a presidential election.
Combined with a ceaselessly raucous political debate about whether health care reform will help Americans who've been left behind by the system or provoke massive price increases and the Obama administration's efforts to roll out the law one piece at a time, and it seems like Obamacare's first three years have been very busy.
We ain't seen nothing yet.
The Obama administration likes to tout some parts of the law that are already in place -- like more generous prescription drug coverage, young adults being able to keep their parents health insurance until they turn 26 and a ban against insurers refusing to cover children with pre-existing conditions -- but the truth is almost none of Obamacare's biggest reforms are in place.
That's going to change really soon. On Oct. 1, small businesses and individuals who don't get coverage at work will get their first chance to find out whether health care reform is a boon or a bust. That's the day the law's state-based health insurance exchanges, also called marketplaces, are supposed to open for business.
The health insurance sold on these exchanges will be subject to an array of consumer protections at the heart of Obamacare, including a prohibition against turning away people with pre-existing conditions, limits on how much older people can be charged, a ban on charging women more than men and a guaranteed benefits package including things like maternity and prescription drug coverage.
When people sit down at their computers this fall to start shopping and finding out whether they qualify for financial assistance, that'll be the moment when health care reform stops being a political abstraction and becomes a reality for millions of people.
If the health insurance exchange websites work and are easy to use, if the application process isn't as headache-inducing as filing taxes, if there are enough people available to offer customer service and if the prices aren't through the roof, Obamacare will begin to take root in American society the way Medicare and Social Security did.
If those things don't happen, if there's widespread chaos or unaffordable health insurance, the outcry will be swift and it will be loud. Obama's legacy as president is at stake, as is the notion that government can tackle a something as big as our imperfect health care system and help to fix it.
If Obama's promises aren't fulfilled and the critics are right, health insurance customers and employers of all sizes will see their costs rise faster than they already were and get tangled in red tape for no benefit.
The health and financial well-being of many millions of Americans also is at stake. A smooth rollout of the law's coverage expansion would benefit those left out of the health insurance market because they're too sick or too poor.
The problems health care reform is supposed to solve would continue to vex us. Tens of millions with no health insurance, growing costs, shrinking health insurance benefits, and poor health would remain blemishes on a health care system capable of miracles for those who can afford it.
The American people aren't bullish on Obamacare's prospects. According to a Henry J. Kaiser Family Foundation survey conducted this month, more people view the law unfavorably than favorably. Worse, Americans know less about health care reform now than they did three years ago.
So the Obama administration, its allies, state governments, health insurance companies and anyone else who stands to gain from broader health care coverage and a better health care system have just a few months to get things right. There's a lot riding on it.