A year on, Obama's healthcare reforms are still a work in progress

(EPA)

Just as Rome wasn't built in a day, that monumental piece of policy architecture – US healthcare reform – is only gradually being turned into bricks and mortar and Americans still aren't sure what to make of it.

Across the country, the Obama administration and its supporters are holding events to mark the first anniversary of its proudest single achievement, the Patient Protection and Affordable Care Act, that became law on 23 March 2010. It was the biggest overhaul of the US health care system in half a century, re-organising a $2.5trn sector that accounts for one sixth of the entire national economy.

But little triumphalism will mark the occasion. The speeches and conferences are part of a continuing sales campaign for a project about which public feelings remain mixed – and which will be a central theme of the 2012 election campaign. Health reform is very much a work in progress. Some of its more appealing elements have already kicked in. Insurance companies can no longer withdraw coverage, or deny coverage for children with pre-existing conditions, or impose caps on benefits. Children can also now stay on their parents' policy until they are 26. Some preventive treatments such as mammograms are now free.

The government also now provides temporary subsidies for small businesses to fund coverage for their workers. Given that in the US, health insurance is mainly provided by employers, this provision should also make a dent in the total of 45 million Americans without coverage – many of them because their employer cannot afford it. But two of the largest pieces of "Obamacare" will only fall into place in 2014. One is the network of state insurance exchanges, part-financed by the Government, which should enable individuals and small businesses to pool their buying power and drive the price of insurance down.

The other – the most important and most controversial element of all in "Obamacare" – is the so-called 'individual mandate', obliging virtually everyone to buy insurance or face a fine. Only if all Americans, including the healthy, buy insurance, the Government argues, will the cost of coverage for those who are sick come down. Otherwise, the stricter conditions imposed on the companies will merely drive premiums higher. The latest polls reflect the public uncertainty. Most show a narrow majority opposed to the plan, but also a majority opposed to repeal of the 2010 act. The administration argues that as more individuals personally experience the benefits, reform will become more popular.

But Republicans are likely to remain as hostile as ever.

In January, the new right-wingcontrolled House voted to repeal the 2010 reform, as one of its very first actions. The step, of course, was purely symbolic, with no hope of surviving the Senate, where Democrats have a majority, let alone a presidential veto.

But the large Tea Party presence on Capitol Hill, coupled with a widespread concern that health reform is "big government" run amok, means the issue will not go away. It will feature large in key Senate races in 2012 as well as the contest for the White House.

If the Republicans were to recapture the Presidency and win control of the Senate next year, then "Obamacare" would be doomed.

It could also yet be doomed by the courts. Federal judges in two states – Florida and Virginia – have ruled the individual mandate is an abuse of power by Congress.

Courts in other states have, however, upheld it and the issue will have to be resolved by the Supreme Court. Were the latter to deem the mandate unconstitutional, healthcare reform would be forced back to the drawing board.