By Richard Knox, NPR
Today marks a milestone on the nation's long march toward universal health coverage: the launch of online marketplaces, called exchanges, designed to help people find insurance they can afford.
It's an idea pioneered by Massachusetts seven years ago. People here call their program a success, and say the state's exchange was an indispensable factor.
Glen Shor, who once ran the Connector and is now the state's secretary of administration and finance, is confident that the nation will follow Massachusetts' lead.
"As the [federal] law begins to be implemented," Shor said, "people will see and feel its positive effects. They'll be able to see through some of the rhetoric and spin."
When the Connector opened for business in late 2006, people signed up much faster than projected. Within a year there were 367,000 newly insured citizens.
"Enrollment was fast," Shor said. "One of the clear lessons of the Massachusetts experience is that people want affordable health insurance."
Today, 97 percent of the state's 6.6 million people have it — the highest coverage rate of anywhere in America.
And Shor says Obamacare will bring another 45,000 new people into the fold — those working in low-wage jobs who will qualify for an expansion of MassHealth, the state's Medicaid program.
That group represents "roughly a quarter of the remaining uninsured," said Shor. "A big deal."
Thousands more will become eligible for premium subsidies because they make under $46,000 a year (for an individual) or $94,000 (for a family of four). That will bring Massachusetts pretty close to advocates' longtime dream of universal coverage.
"It's a fight that's worth fighting, and I think ultimately it will be won," Shor said.
“One of the clear lessons of the Massachusetts experience is that people want affordable health insurance.
- Glen Shor, secretary of the Massachusetts Office for Administration and Finance
But not everybody in Massachusetts is quite so optimistic. Rick Lord is president of Associated Industries of Massachusetts, a prominent business group. He was also a leader in the broad bipartisan coalition of business, consumers, health care providers and insurers that resulted in what some here still call Romneycare.
"I think Massachusetts got health care reform right," said Lord, adding that members of his group are proud that the state is committed to expanding health coverage.
But Lord points out that anything as complicated as health care reform is going to need some tinkering along the way. In Massachusetts, the Legislature passed without controversy three technical corrections after the law was passed. Lord doesn't see how Congress could do that with Obamacare.
"No amendment to the Affordable Care Act will be passed for fear that the whole act will unravel," he says. And that makes him more than a little worried.
"I'm feeling a little pessimistic about how it's going to play out in Washington," Lord said. "If it's not successful at all, I worry that will doom the prospects for revisiting this in the short term, [or] even the medium."
But for now, the fate of Obamacare depends on whether enough Americans vote with their feet in the coming three months, when those who want coverage under the law must choose a plan in order to be covered on Jan. 1.
"That's the big question," said Brian Rosman, research director of Health Care for All, Massachusetts' leading health consumer group.
"Will people jump over the negative publicity and go out and seek health care for themselves because it's in their interest?" Rosman wondered. "Our experience in Massachusetts is that they're going to sign up."
Rosman's colleague Kate Bicego thinks people across the country will too. She manages consumer assistance for Health Care for All.
Bicego has been getting a lot of calls from officials in other states who are scrambling to set up exchanges. She's also hearing from consumers outside Massachusetts. She's heard just about every question, worry and rant about the new exchanges.
"People don't know what Obamacare is," Bicego told Shots, the online health channel from the NPR Science Desk. "Most people have filled their heads with a lot of misinformation about what the law actually requires of people and what the law offers."
Bicego thinks there's only so much anybody can do in advance to dispel misconceptions. She says it's only when people can get their hands on information that matters to them that proponents can cut through the confusion.
In her experience, a lot of people are surprised to hear that there are health plans they can afford; that many people qualify for help in paying the premiums; and that they're not going to be penalized on their taxes for not buying something they can't afford. But getting that across takes time.
"Once I talk to them for about an hour about 'This is actually what the law does,' people are just as excited as I am about what this means," Bicego said.
Brian Rosman predicts that the nation will turn a corner in January when millions of people start to see what it's like to have coverage.
"Once people start getting benefits and it becomes part of the infrastructure of how our health care system works," he said, "the repeal effort will fade away."
That's what happened a generation ago with Medicare and Medicaid. They were pretty controversial, too.