It survived a U.S. Supreme Court challenge, multiple repeal attempts, delays of key provisions and a disastrous rollout, and now the Affordable Care Act, also known as "Obamacare," marks a major milestone.
Beginning Jan. 1, millions of uninsured Americans have health insurance, many for the first time in their lives. The law provides federal tax subsidies to help low- and middle-income individuals and families buy private health plans through new federal and state health marketplaces, or exchanges.
The law also expands funding for Medicaid, allowing many lower-income people to gain access to that public health program. In 2014, 25 states and the District of Columbia are expanding Medicaid eligibility.
"I think from the consumer point of view, 2014 is a banner year," said Elisabeth Benjamin, vice president of health initiatives at the nonprofit Community Service Society of New York.
"We are finally able to get affordable, quality health coverage for most people who live in the United States," said Benjamin, whose organization leads a statewide network of "navigators" helping individuals and families to enroll in health coverage.
In addition to new coverage options, the new year brings the following new consumer protections for most Americans (with some exceptions for grandfathered plans):
Access to mental health and substance abuse services. Most plans will cover these services the same way they cover care for physical conditions. No more exclusions for pre-existing conditions.No more annual limits on coverage of essential health services, like hospitalizations.
But in the wake of the botched launch of the HealthCare.gov federal website and the cancellation of individual policies that don't meet the law's new coverage standards, public sentiment is dour.
More than one-third of adults (36 percent) support a repeal of the law, up from 27 percent in 2011, a new Harris Interactive/HealthDay poll found.
Likewise, the latest Henry J. Kaiser Family Foundation tracking poll found nearly half of the public (48 percent) has an unfavorable opinion of the health-reform law. And a New York Times/CBS News poll showed just a third of uninsured Americans expect the law to improve the health system, with an equal proportion saying it will help them personally.
Eyeing "Obamacare" as a deciding factor in the upcoming 2014 elections, many GOP leaders maintain a grim outlook for the law's future.
"Obamacare is a reality," Rep. Darrell Issa (R-Calif.), chairman of the House Oversight and Government Reform Committee, said Sunday on "Meet the Press." "Unfortunately it's a failed program that is taking a less than perfect health-care system from the standpoint of cost and making it worse, so the damage that Obamacare has already done and will do on Jan. 1, 2 and 3 will have to be dealt with as part of any reform," he said.
2014 is the year most Americans must have health insurance coverage or pay a penalty. Many uninsured individuals who fail to enroll in coverage by March 31 -- the end of open enrollment for 2014 -- may face penalties. These can go up to 1 percent of taxable income or $95 per adult and half of that for kids (up to $285 for a family of three of more).
There are a number of exceptions to that rule. Consumers whose individual health insurance policies have been cancelled for failing to meet the minimum requirements of the Affordable Care Act may apply for a temporary exemption, the Obama administration announced in December.
With major pillars of health reform kicking in this year, policy experts say the law's success hinges on its performance in 2014 and beyond, with enrollment being just one of the telling factors.
Some 7 million people had been expected to enroll in health plans through the state and federal exchanges in 2014, while 9 million would enroll in Medicaid and the Children's Health Insurance Program, according to Congressional Budget Office projections. By those estimates, early enrollment is lagging.
"The point of the program is to provide people with insurance," Larry Levitt, a senior vice president and co-director of the Henry J. Kaiser Family Foundation's program for the study of health reform and private insurance, said in a recent webinar for journalists. "So for the program ultimately to be a success, people who are currently uninsured and eligible for this coverage need to sign up."
But it doesn't need to happen in the first year, he added. "There are certainly many examples of new government programs that took quite a while to ramp up," he said.
"The mix of enrollment is much more important than the total number," Levitt explained.
Through Dec. 24, more than 1.1 million people had enrolled in private health plans through HealthCare.gov, the federal government disclosed Sunday. More than 975,000 of those enrollments came in December, Marilyn Tavenner, administrator for the U.S. Centers for Medicare & Medicaid Services, said in a blog post.
Those figures do not reflect the number of people who have signed up for coverage through state-based marketplaces, operated in 14 states and the District of Columbia. Nor do they reflect the percentage of younger, healthier people who have signed up.
Another unknown: How many enrollees have actually paid for coverage? In most states, people who signed up for coverage effective Jan. 1 have until Jan. 10 to pay the first month's premium.
Through the end of November, 800,000-plus people have been deemed eligible for Medicaid or the Children's Health Insurance Program, a government enrollment report indicated.
