The Patient Protection and Affordable Care Act, often referred to as Obamacare, was signed into law in spring 2010. This ended a tortured fifteen-month legislative process, but it was far from the end of controversy surrounding this major policy reform. The Affordable Care Act (ACA), as it is better known, remained a source of deep controversy in US politics and public life more generally, with its fate a major point of debate in all federal election cycles through to and including the 2018 midterm congressional elections. Hence, the expectation of the Obama administration and congressional Democrats that, once enacted, the law would gain in popularity as its benefits became evident was confounded through the rest of Obama's presidency. Opposition to the law from Republicans was unrelenting, implementation of the law was problematic, and the costs of the new provisions for governing health care arrangements received as much publicity as the benefits.

One consequence was that ‘Obamacare’ remained underwater in terms of public opinion throughout Obama's presidency. Hence, at the start of 2017, with Republicans in control of the levers of government in Washington DC, the demise of Obamacare seemed imminent. Yet again, however, expectations were undone. Republicans had repeatedly voted to ‘repeal’ the ACA when such votes had been sym-bolic under President Obama, but found themselves unable to devise a plan to ‘repeal and replace’ when their actions were to have real-world consequences. Moreover, in the post-Obama era the ACA now had positive approval ratings, and preserving the ACA was an issue that many Democrats campaigned on in 2018.

This chapter will examine the political and policy dynamics underpinning this narrative. Why were the supporters and then the opponents of the law so misguided in their expectations? The chapter will open by briefly outlining the legislative progress of the bill through 2009 and early 2010, noting how hostility towards the emerging reform galvanized conservative opposition to the Obama administration and its wider program so soon after the 2008 election results had seemed to give President Obama and congressional Democrats a political space to push through a bold policy agenda. Next, it turned out that the actual enactment of the law further fuelled rather than diminished that opposition, with efforts at obstruction spreading from the political to the judicial arena.