Despite a U.S. Supreme Court decision upholding the Affordable Care Act, the law remains divisive, even as its main provisions begin to go into effect.
For all the wrangling in Congress about health care reform and a government shutdown, none of it has stopped online insurance exchanges from going live on Tuesday, offering millions of Americans a place to shop for coverage.
Starting Tuesday, consumers are able to access their state's exchange and enter their age, where they live and their household income. Then they are free to peruse an array of available plans, and find out whether they are eligible for tax credits or other subsidies.
The new system, created and funded by the 2010 Affordable Care Act, gives new options to people who don't currently have insurance and those who buy their own on the private market. For those who get care through their employers, or those who received Medicaid, not too much will change.
The goal is to slash the rolls of the uninsured — which total about 48 million — by requiring most Americans to obtain insurance by Jan. 1, 2014 or face financial penalties. The path to that goal is to make coverage more accessible and less expensive. Health care costs in the United States are higher, per-person, than any industrialized country, although the quality of care isn't necessarily better.
Since insurance markets are managed by state regulators, each state exchange will have a different menu of choices. Many states, including those where officials oppose the Affordable Care Act, have declined to help, leaving it up to the federal government to develop their exchanges.
Last week, the federal government released limited data on what its premiums would look like. The numbers looked less expensive than what many had predicted. But the cheaper plans actually carry higher back-end costs, in the form of larger deductibles and co-pays. And they often offer a more limited choice of doctors.
Because of the continued opposition to the reform measure — some conservative lawmakers have tried to use the shutdown talks as a way to prevent the act from going into effect — the success of the exchanges carries heavy political stakes for President Obama. He wants to enroll 7 million people in 2014, and he needs the new system to run relatively smoothly to keep people coming.
Obama's largest obstacle appears to be a general lack of understanding of what the Affordable Care Act does. A study by The Commonwealth Fund, released this week, found that about 40 percent of Americans — including 32 percent of people who went without health insurance in the past year — were aware of the state exchanges.
Glitches will be all but impossible to avoid.
"I do think it's going to be rocky, because how can it not be?" said Christine Eibner, a senior economist at the RAND Corporation. "You have 50 states, all this uncertainty, and people trying to block it."
Although the Affordable Care Act became law in 2010, many states waited until relatively late to begin to figure out how to implement it, Eibner said. Much of that had to do with an attempt to have the law declared unconstitutional. The U.S. Supreme Court upheld the law in June 2012, but said it went too far in trying to force states to expand Medicaid to more poor Americans. Since then, about half the states have refused to expand Medicaid.
Already, there are signs of what the early problems will be, Eibner said. Some federally developed exchanges won't be ready with Spanish language versions. Some states are opening their exchanges only to brokers and "navigators" who will in turn walk consumers through the process. There could also be confusion about the subsidies, which come with complicated eligibility rules.
And so, the next weeks will likely be filled with two basic, and conflicting, narratives of the Affordable Care Act's rollout: stories of bureaucratic chaos and consumer dissatisfaction, and tales of previously marginalized Americans who found a way to get health insurance.
Which narrative wins the day depends not on the early reports, but what happens after bugs have been eliminated and the Jan. 1 deadline passes, Eibner said.
Only then will analysts be able to get a picture of how many people have signed up, and what they're paying.
She said if she were shopping on the exchanges, she'd wait a bit.
"I wouldn't want to be the first one and go through the glitches," she said.