National health reform has survived two presidential elections, a year-long debate in Congress, a summer of Tea Party uprisings, a Republican counteroffensive in the 2010 elections, more than 30 repeal votes in the U.S. House and a U.S. Supreme Court ruling last summer.
And it's still not the law of the land.
In Minnesota, the November election produced an all-DFL government that is full-speed ahead on implementing the provisions of the Affordable Care Act, AKA Obamacare, including the central feature of the law for consumers -- an insurance-buying marketplace known as a health insurance exchange.
But in states where Republicans hold sway, resistance remains strong.
Gov. Scott Walker of Wisconsin joined 15 other states in declining to organize an state exchange -- allowing the federal government to do so.
Conservative groups such as FreedomWorks for America and the American Legislative Exchange Council, or ALEC, continue to urge states and GOP legislators to resist. ALEC says 15 states have passed versions of the "Freedom of Choice in Health Care Act," which "protects the rights of citizens to pay directly" for health care and is aimed at stopping penalties against those without insurance. A version was introduced in Minnesota but not acted on.
When Republican Gov. Tim Pawlenty was in office, he vowed to "keep Obamacare out of Minnesota" and succeeded, even refusing a federal offer to extend Medicaid to poor, childless adults. When DFL Gov. Mark Dayton took office in 2011, he immediately accepted the Medicaid offer and began planning for the health exchange.
Now that the DFL has control of the Legislature, it has the votes to extend Medicaid to cover more families and to write the exchange into state law.
But Twila Brase of the Citizens Council for Health Freedom, which opposes the act as a "federal takeover of health care system," says the battle isn't over. "The Achilles heel of Obamacare is the exchange," she said during a meeting of Minnesota's health exchange task force last month.
Health-care reformers like to recall that it was Ronald Reagan who greeted the arrival of Medicare in the 1960s as the end of personal freedom in the United States. They say the current opposition is equally over the top, considering that this plan relies on private insurers and a private health-care system.
But opposition runs deep. In a rumination last month on the "deeply American" practices of states seceding from the union, outgoing Texas Rep. Ron Paul -- the favored presidential candidate of Minnesota GOP activists this year -- cited Obamacare and marijuana enforcement as examples of federal overreach that could provoke such a reaction.
Considering the pushback, the outlook for national health reform is for an uneven national rollout, depending not on a state's need, but on its politics. The map of states that are signing onto Obamacare and states that are resisting bears a striking resemblance to blue-red electoral college map.
For the moment, Minnesota is Democratic "blue" in both.