Battered and bruised by politics and its own glitches, the centerpiece of President Obama's health care law is set to begin Tuesday, a highly anticipated date that will set into motion the Democrats' winding reforms and shape decisions at the ballot box for years to come.
State-based insurance exchanges, a linchpin of the Affordable Care Act passed by Congress three years ago, will allow Americans without job-based coverage to shop for private health insurance through online portals or over the phone, often with the help of income-based government subsidies to defray the costs of premiums.
The Obama administration and its supporters view the system as a long-term project that offers a gateway to low-cost coverage for millions of Americans. Republicans see it as a governmental intrusion on personal health and a costly attempt to provide goods and services to some at the expense of younger, healthier consumers.
These views will be pitted against each other during a six-month enrollment period that ends in March as the midterm election season heats up. Another referendum on Mr. Obama's reforms is likely to take shape as Republicans try to ride doubts and confusion about the law to defeat vulnerable Senate Democrats in red states and gain a majority in both chambers of Congress.
"I think Democrats have more at stake here," said Jim Manley, a Democratic strategist and former spokesman for Senate Majority Leader Harry Reid, even though he thinks jobs and the economy will trump Obamacare on Election Day next year.
The Obama administration was accused this year of playing politics with the law by delaying for one year, or past the midterm elections, a mandate requiring large businesses to offer employee health care coverage or pay fines.
Since then, Democrats have walked a fine line between touting the law's benefits and stressing its minimal impact on most Americans. Mr. Obama famously said on the campaign stump, "If you like your health insurance, you can keep it."
Moving forward, the political dimensions of the law's rollout are "going to be huge," said Caroline Pearson, a vice president at Avalere Health LLC, a Washington-based advisory firm. "Democrats are going to rely on success of the law to say how this is working."
The political arena has not been patient when it comes to Obamacare. Populist angst about the law's passage in 2010 caused the tea party movement to coalesce and swing control of the House back to Republicans in the fall elections.
"The difference this time around will be that opponents of the law have concrete examples of how Obamacare is hurting individuals and families," said Dan Holler, a spokesman for the conservative Heritage Action group that led efforts to defund Obamacare in August. "Even if implementation goes off without a hitch, which is highly unlikely, those personal stories will be impossible to ignore."
Both sides dug in their heels Tuesday, with House Republicans demanding a one-year delay of the health care law's individual mandate to buy insurance as part of any deal to keep the government funded past Monday night.
The White House and Senate Democrats said they would not negotiate over Obamacare and that the exchanges would debut Tuesday — period.
"Nothing will alter that," White House spokesman Jay Carney said. "That will happen."
Ford O'Connell, a Republican strategist, said Mr. Obama would "rather cough up a lung" than defund the law, so congressional Republicans' best shot to dismantle Obamacare is to win more seats in Congress, particularly during midterm elections that tend to turn out higher numbers of white and elderly voters.
"That's who detests Obamacare the most," he said.
In the meantime, Ms. Pearson said, it should not be hard for the Obama administration to reach its six-month target of 7 million enrollments on the exchanges.
Yet, she added, Republicans will scrutinize plans that are affordable at first glance but carry high out-of-pocket costs and do not offer the same protections as employer-based insurance.
Confusion about the law is another hurdle, a concept underscored by a Gallup poll released Monday that found slightly more than half of uninsured Americans are "not at all familiar" with the exchanges and only 5 percent are "very familiar" with them.
Computer-based hiccups also are delaying facets of the enrollment experience, which has been compared to shopping for plane tickets or hotel rooms via online travel sites.
Mila Kofman, executive director of the D.C. Health Benefit Exchange Authority, said a feature on the individual market exchange that lets people get accurate calculations of any premium assistance for which they qualify may not be available until early November, although consumers still can sign up and compare the costs of plans before subsidies.
She said enrollment on the D.C. exchange likely will be heaviest during the first two weeks of December and the last two weeks of March.
"We're using the month of October to really educate people," she said.
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