The Year in Health Care: Please wait, reform is still loading...

If the Affordable Care Act in 2013 were a Charles Dickens novel, it would probably start off with, “It was the worst of times,” and then stop right there.

After all, 2013 was supposed to be the year in which the wrong that was 48 million Americans without health insurance — Dickensian twist if there ever was one — would finally be righted. It was the year the health insurance exchanges mandated by President Barack Obama’s signature health care law would launch open enrollment for coverage in January 2014, offering reasonably priced insurance plans for everyone, regardless of whether they were healthy or sick, and which could easily be bought online with just a few clicks of a mouse.

Instead, what actually transpired on Oct. 1 — the day the Healthcare.gov website was supposed to go live — was an exercise in vocabulary. Namely, how many times could the word “disastrous” be uttered without sounding repetitive.

Commentators got creative and used the words “botched,” “failed,” “catastrophic” and the resounding favorite, “glitchy,” to describe the fact that when people tried to log on to the site — the federally run marketplace for the 36 states that opted out of setting up their own exchanges — they were greeted with error messages, forever-loading pages or were just plain booted off the system in the midst of signing up.

Due to bug-ridden software and a website that evidently couldn’t even handle 500 users at once in the days leading up to launch, just six people in the entire United States were able to successfully sign up for health insurance on day one, Congress later revealed. On Oct. 2, that number expanded to an also unimpressive 248 people, a tiny fraction of the 20 million hits received by the Healthcare.gov site the day it launched.

The Obama administration was left sputtering to the tune of the Republican chorus of, “I told you so,” all in the middle of the first federal government shutdown in 17 years, an outcome brought on by GOP lawmakers’ refusal to make a budget deal unless the rollout of the ACA was delayed.

Obama, in damage control mode, made a series of speeches acknowledging the website’s faults but urging patience, pointing out that no one told Apple to shut down when its iOS 7 operating system was buggy.

But the damage was already done. The government started up again, but so did public outrage about the technical problems of Healthcare.gov, which managed to eclipse the already-contentious ACA law itself. Congress grilled health care administrators about the IT failures with all the vitriol of the Salem witch trials.

But the 14 states that had opted to run their own exchanges were mostly singing a different tune, perhaps illustrating the key difference between the mostly Democratic states that embraced the law and the other states that hadn’t.

They received ample federal funding to launch and advertise their insurance marketplaces as part of the law. So states such as California saw enrollment numbers surpassing 150,000 people by mid-December.

With the so-called glitches mostly ironed out, though, the nation’s health care battles are still far from over.

The ACA aimed to make health insurance affordable for everyone, and to ensure that no one ever went bankrupt or died because of astronomical health care bills — scenarios that had become all too real for scores of Americans.

But a significant part of the plan relied on expanding state-level Medicaid coverage for low-income adults and children living at or below 133 percent of the federal poverty line, an estimated 17 million people who had previously been considered too “rich” to qualify. The federal government has promised to fund the expansion through 2019, after which states would have to foot 10 percent of the bill.

As of this month, however, some 20 states are forgoing that federal funding to expand Medicaid, saying it’s still too expensive — meaning that they lose out on billions of dollars that could have contributed to health care, according to an analysis by the Commonwealth Fund.

As a result, millions of people who would have newly qualified for Medicaid are just plain out of luck, a loophole disproportionately affecting single mothers and the working poor.

What will happen to those people? Will they continue to ignore their aches and pains, only to rack up emergency room bills when the going gets rough?

While many low-income people will now enjoy insurance coverage for the first time, members of the middle class who are just out of reach of the ACA’s subsidies are reporting that premiums and deductibles are still too expensive for them. And young people, whose enrollment is critical to keeping costs low, have not been signing up at the rates the Obama administration had hoped.

So while the divide between haves and have-nots is less resolute than it was before Affordable Care Act passed — no one can be kicked off their insurance plan if they get cancer, or be denied coverage if they have a pre-existing condition — the issues surrounding health care costs, government involvement and quality of care will continue to play out for years to come, not least when the insurance coverage for early adopters kicks off in January.