Charles Dharapak, File, Associated Press
WASHINGTON — It took only a year to set up Medicare. But if President Barack Obama's health care law survives Supreme Court scrutiny, it will be nearly a decade before all its major pieces are in place.
And that means even if Obama is re-elected, he won't be in office to oversee completion of his signature domestic policy accomplishment, assuming Republicans don't succeed in repealing it.
The law's carefully orchestrated phase-in is evidence of what's at stake in the Supreme Court deliberations that start March 26.
The Affordable Care Act gradually reorganizes one-sixth of the U.S. economy to cover most of the nation's 50 million uninsured, while simultaneously trying to restrain costs and prevent disruptions to the majority already with coverage.
Despite the political rhetoric about what "Obamacare" is doing to the nation, only a fraction of the law is in effect.
"We really haven't seen the main game," said Drew Altman, president of the California-based Kaiser Family Foundation, a nonprofit information clearinghouse on the health care system. "The major provisions that will affect the most people and cost the most money don't go into effect until 2014 or later."
What has taken effect in the two years since the law was enacted has produced both successes and clunkers, and some surprises.
Few expected a relatively minor provision tacked on late in the legislative process to be its biggest success so far. But allowing young adults to stay on their parents' insurance until age 26 has added nearly 2.5 million people to the coverage rolls, at no cost to taxpayers.
Despite Republican pledges to repeal the overhaul, it's arguably the Obama administration that has done more to scale it back.
Health and Human Services Secretary Kathleen Sebelius decided to pull the plug on a long-term care insurance program seen as a budget drain. She also decided that Washington would not dictate a basic health benefits package for the country, allowing each state to set its own, within limits.
Medicare recipients gained more protection from high prescription costs and better preventive coverage, but older people remain the age group most opposed to the law, concerned that cuts to the program to finance benefits for the uninsured eventually will compromise their own care.
If the Supreme Court overturns the law entirely, that would present an immediate dilemma about popular early benefits such as coverage for young adults and prescription savings for seniors.
"These provisions give immediate relief to a small percentage of people, but it's a lot of relief," said economist Len Nichols of George Mason University in Virginia.
Other early benefits have been a mixed bag.
Millions of people are getting preventive care that now must be provided at no additional cost to patients. Birth control for women soon will be on that list. Insurance premium increases are getting more scrutiny.
But a program of tax credits for small businesses has seen little acceptance. The administration is in the awkward position of asking congressional Republicans to help fix it.
A highly promoted program that provides a lifeline to people denied coverage because they already had medical problems has probably saved lives. But enrollment in the Pre-Existing Condition Insurance Plan has been disappointing, with only about 50,000 people nationwide.
Glenn Nishimura, a consultant from Little Rock, Ark., checked it out and found his premiums would come to about $6,300 a year.
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