In the three years since President Obama signed the Affordable Care Act into law, it has survived more than 50 votes in Congress to defund or repeal it, a Supreme Court challenge, a presidential election and, as of Tuesday morning, a government shutdown. Much of the spending for the law is mandatory and won't be cut off.
But now, it must survive its own implementation.
Tuesday is the day that Obamacare goes operational. Americans can begin signing up for health insurance on online marketplaces known as exchanges.
And that begins a new chapter in the nearly five-year-old political battle over Obamacare, says GOP pollster Bill McInturff.
"What happens today is we're going to move from this policy debate about Obamacare to a reality outcome debate: What impact does it have on millions and millions of Americans, and do they judge it to be good or bad?" McInturff says. "And I believe attitudes will shift based on that reality of the outcome of Obamacare."
The Political Costs
The president is confident that attitudes will shift in his direction. Like the Green Eggs and Ham story invoked by Republican Sen. Ted Cruz — Obamacare's chief antagonist in Congress — Obama is certain that when Americans try it, they will like it.
"That's what's going to happen with the Affordable Care Act," the president has said. "And once it's working really well, I guarantee you they will not call it Obamacare."
But Obamacare — as it will be called for the foreseeable future — has already exacted a stiff political price from the president.
Opposition to the health care overhaul fueled the rise of the Tea Party, which led to the Democrats' historic loss of their House majority in 2010. But Republicans paid a political price, too. Their efforts to repeal the law in 2012 failed, and Democrats held on to the White House and the Senate.
Through it all, public opinion has been consistent — consistently negative about the law, even if voters don't want it defunded. Health care historian Jonathan Oberlander says that's why he's not sure even a flawless rollout will change perceptions.
"This is not a program like Medicare or Social Security; it is a program that really is a series of policies and regulations and subsidies," he says. "And that makes it difficult to explain to the uninsured what the benefits are, and I don't think it's going to be easy for Obamacare, regardless of how well or not it does in the next year to overcome that chasm."
Why The Debate Hasn't Gone Away
Both parties think the law helps them politically.
Democratic pollster Geoff Garin says Republicans have overreached by staking everything on stopping the law.
"The Republicans have made the debate about Obamacare a debate about them and their tactics and their wanting to repeal it totally," Garin says, "rather than a debate about Democrats or whether Obamacare is a good or a bad thing."
But Republican economist Douglas Holtz-Eakin says there are good reasons the GOP has planted its flag on Obamacare.
"I've had many people come up to me and say, 'Why do Republicans do this?' And I say, well, the polling tells them to," he says. "It continues to be the single thing that moves independents. So you get the famous swing voters. Nothing generates more political animation than Obamacare, so if you look at intensity and turnout, it still works."
Republicans see independent voters as the key to their two goals in 2014: regaining control of the Senate and expanding their majority in the House. And there's also another dynamic motivating Republicans: Many feel this is their last chance to stop the law.
"If we don't do it now, in all likelihood, Obamacare will never, ever be repealed," Cruz said recently on Fox News. "Why is that? Their plan is to get the American people addicted to the sugar, addicted to the subsidies."
A 'Sort Of Paralysis'
Surrender is unthinkable for either side in this fight. That's because the health care debate reflects the deepest divide in American politics: the core beliefs of the two parties about the role of government. That debate is — for now — at a standoff.
"We ask very simple questions," says McInturff, the GOP pollster. " 'Do you think the government should do more or less?' And that's a 48-48 proposition right now in the country. And it's been that way for about a decade. And guess what, if you've got a country that's poised at 48-48 about whether government should do more or less, and we have a health care issue that is absolutely wrapped around that question, it's not surprising that it's led to this sort of paralysis that has made this a very contentious issue for cycle after cycle."
Obamacare is not only the law of the land. It's also, as of Tuesday, a practical reality for millions of Americans. But as a political issue, it's far from settled — and won't be anytime soon.