Who would have thought a program that was to benefit millions of Americans could be the undoing of Barack Obama's presidential legacy?
The Affordable Care Act, aka Obamacare, was supposed to fix all that was wrong with medical costs and insurance coverage. Truth to tell, the insurance industry, though regulated by the states, operates with virtual impunity when it comes to setting rates and deciding who and what will be covered.
Until states started imposing coverage requirements by law, it was a crapshoot for most consumers when it came to coverage of any given procedure.
In a country considered the richest in the world and where medical care has a reputation as unmatched, more than 48 million people do not have health insurance -- most of them middle class or working poor or those known as the young invincibles, young adults who don't think they need coverage.
The idea of universal healthcare coverage goes back 100 years to Teddy Roosevelt's doomed 1912 campaign. His progressive supporters campaigned for state guarantees for sickness insurance.
Various presidents since have promoted the idea, including Harry Truman, Richard Nixon, Bill Clinton and even George W. Bush. But because nearly 55 percent of American workers have had access to health insurance through their employers and more than 32 percent are covered by government programs like Medicaid and Medicare, the idea has never gotten very far.
With healthcare consuming a sixth of the U.S. economy, costs rising inexorably for decades and the percentage of elderly skewing demographics, Obama thought the climate was right for real reform.
Jason Furman, chairman of the Council of Economic Advisers, said last week healthcare costs are now growing at their slowest pace in decades, largely as a result of the ACA.
"Measured using personal consumption expenditure price indexes, inflation for healthcare goods and services is currently running at just 1 percent on a year-over-year basis, the lowest level since January 1962," Furman said.
Some ACA reforms were incorporated from the get-go. Shortly after the bill was signed into law in 2010, parents were allowed to keep their children on their policies until age 26, people with pre-existing conditions no longer could be denied coverage and insurance providers had to spend 80 percent of premiums collected on claims.
But the showiest part of the law -- the state insurance marketplaces -- didn't kick in until Oct. 1 and there's the rub.
The federal website on which consumers were to sign up for coverage didn't work, and carriers canceled millions of low-end policies and started limiting doctor networks.
Suddenly, Obama's promises that buying insurance would be as easy as shopping on Amazon, and if you liked your insurance you could keep it, had backfired.
The symbol of hope and change became same-old, same-old, critics said.
"Our healthcare system is so complicated and convoluted that any conceivable proposal is bound to make someone worse off. And in healthcare, worse off can mean real pain and suffering that creates powerful, emotional stories that echo through the news cycle," writes Dr. David Blumenthal, president of the Commonwealth Fund, a philanthropic foundation that promotes quality healthcare, especially for the poor. "There is simply no way for presidential healthcare reformers to avoid grievous political harm, as the experience of President Barack Obama is now demonstrating in spades."
Why bother then?
Blumenthal said healthcare reform was inevitable.
"Before the ACA, the current healthcare system -- and especially its private insurance market -- was collapsing before our eyes, like a house tipping into a sinkhole," he said.
"Individual and small-group insurance policies are products with no future unless those markets are reformed to make coverage affordable, and to protect consumers against insurance that, while seemingly cheap, provides no meaningful protection against the cost of illness. Private insurers recognize this fact, which is why they have been such steadfast [though quiet] supporters of the ACA and the marketplaces it is trying to create."
The latest Commonwealth Fund survey of 13 industrialized countries indicates "unequivocally that the United States has the worst health insurance among industrialized nations. Whether you're talking administrative hassles, out-of-pocket expenses, costs of administration, complexity of policies or adequacy of coverage, the U.S. consumer gets a bad deal.
"The system is not only bad, but getting worse. Every year, more people lose insurance as they or their [usually small] employers get priced out of the health insurance market by rising premiums."
The Commonwealth Fund puts the number of uninsured at 55 million (the U.S. Census Bureau says more than 48 million) and the number of underinsured at 30 million.
"The U.S. has more uninsured and underinsured citizens than the entire population of Germany, where, by the way, private insurance organizations compete, no one is uninsured or underinsured, and the economy is thriving," Blumenthal said.
Edmund F. Haismaier, a senior research fellow in the Center for Health Policy Studies at the conservative Heritage Foundation, said the ACA has forced insurers to rethink their business plans.
"In the three years since the enactment of Obamacare, there has been substantial disagreement between its supporters and opponents about the law's likely effects on healthcare markets," wrote Haismaier, who argues the ACA reduced rather than increased competition in the market, with smaller carriers that focus on the individual market declining to participate in the state exchanges.
"For the vast majority of states, the exchanges will offer less insurer competition than the state's current individual market. Most of the insurers whose principal business is employer-group coverage appear to expect significant erosion in that coverage segment due to Obamacare inducing employers to drop their current group plans. ...
"The insurers who have elected to participate in the exchanges are mainly a mix of Blue Cross carriers seeking to extend their current market dominance, group-market carriers seeking to retain enrollees when employers drop coverage and Medicaid managed-care insurers expanding into a market that they view as very similar to their current business.
"In fact, Obamacare's complicated, income-based design of premium and cost-sharing subsidies will result in the exchange market essentially offering something like Medicaid managed-care for the middle class.
"The resulting picture is one that millions of Americans are likely to find unappealing. It is yet another reason why Congress should simply scrap the entire -- ill-conceived -- law and replace it with simpler and better solutions."
Obama met last week with state insurance commissioners after blindsiding them and the insurance industry the previous week with his announcement that it's OK to continue offering policies that don't meet ACA standards.
At a meeting with the Wall Street Journal CEO Council, Obama blamed a lot of the trouble with the healthcare.gov website on government procurement methods while other Democrats accused Republicans of being invested in the law's failure.
With Obama's promise the federal website, healthcare.gov, will be fixed by Dec. 1, the administration has a scant week left to fix it.
The administration continues its damage control efforts, tweeting daily about individuals who were able to sign up for coverage and apologizing for the shaky website rollout.