The latest TIME magazine laments “The Unfulfilled Promise of Obamacare,” featuring a subheadline that ends “As the law takes effect, the reality looks far different than the promise.”

The Affordable Care Act (ACA)–or Obamacare–was designed to provide coverage for two-thirds of the nearly 48 million U.S. residents like Cooksey without health insurance. But as the centerpiece of the law takes effect–the marketplaces where people can buy health insurance, called exchanges, launched on Oct. 1–the reality looks far different, and not only because of the congressional drama over efforts to kill the law altogether. Twenty-seven states declined to set up exchanges or cooperate with the federal government to run them. And many are finding other ways to prevent the law from working as planned. The day before a federally operated exchange launched in Missouri, the state’s lieutenant governor urged residents not to sign up. In Florida, a directive from Governor Rick Scott blocks navigators–consumer-assistance workers paid through the ACA–from working with county health departments. And Georgia’s insurance commissioner has said his department will do “everything in our power to be an obstructionist.” Such efforts guarantee that a federal law may look very different depending on what part of the country you’re in.

Obamacare suffers from other startup snafus. Confusion is widespread: a recent survey by the Commonwealth Fund found that those most likely to benefit from the new insurance exchanges and subsidies to purchase coverage know the least about them. Meanwhile, parts of the law have been delayed–a requirement that employers with at least 50 workers offer health insurance was postponed until 2015 after pressure from business groups. And then there are the glitches: on the first day of enrollment, most exchange websites had technical problems caused by overwhelming demand and computer-system malfunctions that rendered them unusable.

The cumulative effect of political opposition, public confusion and the sheer complexity of launching the largest new entitlement in almost 50 years means many Americans who stand to benefit from Obamacare don’t realize it, while millions of others who are uninsured will get no relief at all. And it may be years before anyone can measure success or failure.

Beyond the implementation problems and the political games, John Hood recently explained for us why Obamacare “is going to collapse.”