On March 23, 2010, amid much fanfare, President Obama signed the Affordable Care Act – a law aimed at taking the nation a long way toward universal health-care coverage.

Three years later, “Obamacare” remains a work in progress. At least 13 states have opted not to accept federal money to expand access to Medicaid, federal health insurance for the poor, after the Supreme Court’s ruling last June that made participation in the expansion of Medicaid optional.

And about half the states are declining to set up electronic health-insurance markets, or “exchanges” that provide consumers with health-insurance options, leaving the federal government to do it for them.

The mixed approach by the states, combined with continuing strong opposition to the law by congressional Republicans, has left some Democrats frustrated.

“You’re already seeing the propaganda machine on the Republican side gearing up stories about how Obamacare is going to be a failure,” said Rep. Chris Van Hollen (D) of Maryland, speaking at a breakfast with reporters Friday sponsored by Third Way, a Democratic think tank. “From a political perspective it’s important that the White House be ready to counter a lot of these false claims.”

Public confusion about the law remains high, and has even worsened since it was enacted. A Kaiser Family Foundation poll found that 57 percent of Americans say they don’t know enough about the law to judge how it will affect them personally. Among the uninsured who are under age 65, the figure is 67 percent. Among those with household income under $40,000, it’s 68 percent.

Forty percent of those surveyed had an unfavorable view of the law, 37 percent had a favorable view, and 23 percent had no opinion.

“Though opinion on the law overall remains nearly evenly divided, opponents’ attacks seem to have taken a toll on the public’s expectations,” the Kaiser report says.

In addition, Americans are now likely to think the law will make things worse for their families rather than better.

So when the exchanges begin open enrollment on Oct. 1, it’s unclear how widely the uninsured will respond. The law includes an individual mandate to purchase insurance, effective Jan. 1, 2014, but in the first year, the penalty for noncompliance is as little as $95. If most healthy uninsured people opt to pay the penalty rather than buy insurance, that would produce a risk pool weighted toward people with expensive medical bills – an unhappy outcome for insurers.

The political debate has also reignited.

Congressman Van Hollen, the ranking Democrat on the House Budget Committee, cites as an example of “false claims” about Obamacare assertions that the law has caused a spike in health-care premiums.

“Health-care premiums have gone up every year for decades,” he says. “The issue is the rate of increase. And the reality is they have gone up much more slowly recently, but that hasn’t stopped Republicans from saying they went up, and that they went up because of Obamacare.”

But the future of health-care premiums may be another story, according to an article in Friday’s Wall Street Journal.

“Health insurers are privately warning brokers that premiums for many individuals and small businesses could increase sharply next year because of the health-care overhaul law, with the nation's biggest firm projecting that rates could more than double for some consumers buying their own plans,” write Anna Wilde Mathews and Louise Radnofsky.

But the article also cautions that the future is murky because of the role of government subsidies.

“The effects of the law will vary widely, and insurers and other analysts agree that some consumers and small businesses will likely see premiums go down,” the authors write.

Van Hollen says it’s important to consider the different segments of the health-care market. People who have been buying insurance in the individual market, and will now be part of a pool, “will benefit significantly from Obamacare,” he says.

Congressional Republicans, meanwhile, are still taking votes to repeal Obamacare, even though Obama’s reelection makes that impossible for now.

On Friday, the Democratic-controlled Senate voted down an amendment to repeal Obamacare. But Republicans say they’re not giving up.

“Obamacare’s full repeal remains our ultimate goal,” said Sen. Marco Rubio (R) of Florida.

On Thursday, Senate Democrats joined the chamber’s Republicans in voting 79-20 to repeal a provision in Obamacare – a tax on medical devices that opponents say causes an undue burden on that aspect of health care. The amendment was part of the Senate’s budget resolution, and therefore does not have the force of law. But Republicans like Senator Rubio hailed the amendment’s passage as a moment of bipartisanship.

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In a commentary, the president and CEO of the Kaiser Family Foundation suggests that governors have the potential to bring more bipartisanship to the Affordable Care Act. Several Republican governors have opted to take part in Medicaid expansion, which is funded 100 percent by the federal government in the early years. That, writes Drew Altman of Kaiser, could change the politics of the law.

“To be clear, it is the federal money and the potential to provide coverage for their citizens which is moving the Republican governors, not some overnight conversion to Obamacare,” Mr. Altman writes, “but the longer term result could be a much more bipartisan complexion for the law.”