Illustration by Tom Bachtell

Last Tuesday, at a forum put together by the Wall Street Journal, President Barack Obama told a group of C.E.O.s that he was relatively sure that healthcare.gov would be “functioning for the majority of people who are using it” by November 30th, two months after its disastrous launch. He acknowledged that the process had been “rough, to say the least,” and added that, once the site does work, “we’re going to have to obviously re-market and re-brand.”

That’s not all he’ll have to do. In a CBS News poll released the next day, the President’s approval rating fell to thirty-seven per cent, the lowest it has ever been. The flawed rollout has put the rest of his policy agenda at risk and, with it, progressive ideas about what government can attempt and what a President can achieve—at a moment when an unprecedented expansion of health-care coverage could validate them. According to a new Gallup poll, only forty-two per cent of Americans now agree that the government should guarantee access to health care. In 2006, the number was sixty-nine per cent. The technical inadequacies of healthcare.gov may prove less of a burden than the political damage that has been done.

By November 2nd, fewer than twenty-seven thousand people had managed to sign up for plans through the federal exchange, while seventy-nine thousand had done so in the fourteen states that set up their own sites with federal funds. A week ago, at a press conference at the White House, reporters asked Obama if he had been less than honest with the American people about the readiness of the program. Even in the face of hostility, the President seemed to think, as he often does, that his intelligence vouchsafes his integrity. He replied, “You know, I’m accused of a lot of things, but I don’t think I’m stupid enough to go around saying, ‘This is going to be like shopping on Amazon or Travelocity,’ a week before the Web site opens, if I thought that it wasn’t going to work.”

But there were also the cancellation notices, sent out by insurance companies to hundreds of thousands of people who had heard the President repeatedly tell them, “If you like your plan, you can keep it.” His defense was that companies drop people every year; that the cancelled plans were shabby; and that, once people saw the great deals on healthcare.gov, they wouldn’t want their old ones anyway. That just seemed to make people angrier, though he was no doubt right about the plans. He came as close as he ever has to losing the wholesale support of congressional Democrats, and was forced to devise something between a fix and an alibi, giving state insurance commissioners the power to choose whether people can hold on to existing plans for another year.

The problems with the rollout are alternately maddening and tragic. America’s health-care system has long been profoundly broken. It has shortened lives, distorted the economy, left families bankrupt after illnesses. The hundreds of bugs on the site—slapped-together code that has to draw on multiple agencies’ databases, some decades old, built by dozens of contractors—have obscured a pretty good law, one that finally protects people with preëxisting conditions and those who could never afford insurance. There are other benefits, too, such as cost controls and coverage for reproductive health. Obama doesn’t have to run for office again, but other Democrats do, and the big question for the 2014 midterms may be how each party handles Obamacare.

Not for the first time, Obama has been slow to realize the effect, at every stage, of his knockdown fight with the Republican Party over policy. The passage of the Affordable Care Act, in 2010, was followed by court challenges, dozens of votes to repeal or defund it, and a systematic state-by-state effort to impair it, using every tool in the political system and some outside of it. In 2012, when the Supreme Court upheld most of the law, it also allowed states to opt out of the Medicaid expansion. The federal government would have paid almost the entire cost. Who wouldn’t like such a plan? Republicans, as it happens: only four states with both a Republican governor and a Republican-led legislature took the money. (In all, twenty-five states did.) In Texas alone, this will leave a million people in a “coverage gap.” In a concerted effort facilitated by conservative interest groups—such as Generation Opportunity, funded by the Koch brothers—Republican-led states have undermined the law in ways that range from making it harder to enroll to declining to enforce rules when insurance companies break them.

Healthcare.gov has been getting better; visitors are now generally able to log on and start an application. And by last week enrollment had more than doubled on the state-run Web sites, which continue to work reasonably well, notably in California and Kentucky. Where Obamacare is broadly available and unobstructed, it appears to be bearing out its promise. But there isn’t a lot of time: the deadline to sign up for plans that go into effect on January 1st is December 23rd, just three weeks after the November 30th target date to have the system repaired. Then money starts changing hands, in the form of premiums and subsidies. Henry Chao, the deputy chief information officer of the Centers for Medicare and Medicaid Services, testified last week that parts of the site that will be needed for that—“the back-office systems, the accounting systems, the payment systems”—have not even been built.

Since the rollout, Obama has treated it as a given that the Web site will be fixed, and that everyone will remember how bad the present system has been and how much better the new one is. “I am confident that, by the time we look back on this next year, that people are going to say this is working well, and it’s helping a lot of people,” he said at last week’s press conference. After five years in the White House, Obama still believes that he can go into a corner, tinker with something until it’s better, and win on the merits. The long view can serve him well, but it can also leave him unprepared when the other side won’t give up on an all-out battle. Health-care reform is the President’s signature legislative achievement, and a historic one. To preserve it, he needs to fight for it politically, state by state. This time, the Obama brand alone isn’t enough. ♦