The Unfulfilled Promise of Obamacare

The Affordable Care Act was supposed to bring health coverage to the uninsured. As the law takes effect, the reality looks far different from the promise

Justin Clemons for TIME

An uninsured single mother of two, Nicolette Cooksey is one of nearly 2 million Texans who would have been covered under the Affordable Care Act if the state had opted to expand Medicaid.

The Affordable Care Act (ACA) — or Obamacare — was designed to provide coverage for two-thirds of the nearly 48 million U.S. residents without health insurance. But as the centerpiece of the law takes effect — the marketplaces where people can buy health insurance, called exchanges, launched on Oct. 1 — the reality looks far different. Twenty-seven states declined to set up exchanges or cooperate with the federal government to run them. And many are finding other ways to prevent the law from working as planned.

Obamacare suffers from other startup snafus. Confusion is widespread: a recent survey by the Commonwealth Fund found that those most likely to benefit from the new insurance exchanges and subsidies to purchase coverage know the least about them. Meanwhile, parts of the law have been delayed, such as a requirement that employers with at least 50 workers offer health insurance. And then there are the glitches: on the first day of enrollment, most exchange websites had technical problems caused by overwhelming demand and computer-system malfunctions.

The cumulative effect of political opposition, public confusion and the sheer complexity of launching the largest new entitlement in almost 50 years means many Americans who stand to benefit from Obamacare don't realize it, while millions of others who are uninsured will get no relief at all. And it may be years before anyone can measure success or failure.