On Friday, May 10, President Obama ventured into Ohio to give a Mother’s Day defense of the sagging fortunes of his signal achievement, the misnamed Patient Protection and Affordable Care Act. The law, the President assures us, “is here to stay”—a comment that is best regarded as a threat and not a promise. His conclusion was not coincidental; support for the ACA has dropped from 42 percent to 35 percent between November 2012 and April 2013.

This recent drop in popularity is not a function of some detailed analysis of the ACA’s key provisions. Rather, the public seems to feel that the sheer complexity of the program makes it highly unlikely that it will be able to take effect in any form by its ostensible January 1, 2014 start date. The most obvious difficulty in implementation stems from the unwillingness of many states to participate in its two gargantuan initiatives, even with heavy federal support: the private exchanges (now called “marketplaces”) for individuals, and the Medicaid extension to additional individuals.

Growing Pains for the ACA

The most up-to-date report from the Kaiser Family Foundation reveals extensive resistance on both fronts. The ACA’s new marketplaces are said to allow ordinary individuals to shop for their own policies. This modest goal sounds easy, but it is not. As the current rules demand, all enrollment must be possible online, in person, by phone, fax, and mail. In addition to a website, the exchanges must provide “culturally and linguistically appropriate assistance,” along with a navigator program to promote public awareness. They must offer seamless linkage with other public initiatives, and accurate information on premium tax credits and cost-sharing subsidies, all under a program whose key provisions are not yet fully worked out. Already, HHS has distributed over $3.6 billion to states for implementation, with more to come.

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