What Did You Say?

Supporters face an array of political, financial and legal challenges in the coming months. Democrats and insurance industry officials are already seeking ways to blunt what may be the next big controversy: an expected increase in monthly insurance premiums next year for the health plans sold through the federal and state marketplaces.

Combatants on both sides debated the administration’s report last week that 6 million people had signed up for private plans. “The law’s working,” White House senior adviser David Plouffe said on ABC’s “This Week.” He added: “And this was a seminal achievement.”

But Republican Sen. John Barrasso (Wyo.) expressed skepticism about the figure. “They are cooking the books on this,” he told “Fox News Sunday.”

In the months and years ahead, other questions will loom: How will Americans react when they get fined next year for not having insurance? Will more states expand Medicaid under the law? And will the federal courts make future changes to the law, including barring the use of government subsidies to help pay for coverage in the federal marketplace?

The unresolved issues mean it is far too soon to know how President Obama’s signature domestic achievement — and one of the most polarizing pieces of U.S. social policy — will turn out. So far, the action has been “a warm-up act for what lies ahead,” said Larry Levitt, senior vice president of the nonprofit Kaiser Family Foundation.

Here’s a road map of what comes next:

Premiums’ trend

Monthly insurance premiums almost always go up, because costs typically rise. So the big questions are: How much will premiums increase for next year, how widespread will the increases be, and how will consumers be affected?

Many plans “low-balled” prices for 2014 to attract customers. “It’s like opening day at the hardware store, and you’re going to have a special,” said Joseph Antos, a health policy analyst at the American Enterprise Institute.

Although some plans may continue to keep rates low to build market share, others probably will raise prices — perhaps to bolster profits or to compensate for getting a higher-than-expected percentage of older, expensive enrollees, analysts say.

During the first five months of open enrollment, younger people signed up for health plans at a lower rate than older ones. But some insurance experts say they are getting more young people than they expected; in any case, final demographic data are not in. The law provides some financial help for plans that end up with too many unhealthy customers.

Some industry officials are predicting double-digit increases in premiums in some states, but information about the new rates won’t emerge until later in the spring, the summer or later. Increases in premiums are likely to vary by health plan and location.

Even if premiums rise substantially, consumers who get federal subsidies to help buy insurance may not feel the blow. The subsidies, available to people with incomes between 100 percent and 400 percent of the federal poverty line, limit premium bills to a proportion of income.

That doesn’t help people who aren’t eligible for subsidies. Insurers say adding a cheaper level of coverage, as some Democratic senators have proposed, would help to attract healthier people who might not otherwise be motivated to buy coverage.

The political impact

The political challenges for Obama and the Democrats may be even more daunting than the policy dilemmas — and have a bigger effect on the health law’s long-term future. If the GOP does well in congressional races in the fall, winning control of the Senate — and then the White House in 2016 — the law could be dismantled.

Republicans and their allies already are using the health law as a dominant theme. The conservative group Americans for Prosperity is spending more than $30 million on ads alleging that the law will increase what consumers pay for insurance and deprive them of access to the doctors they trust.

Several Democratic senators who voted for the law and will face the electorate this fall — including Mark Begich (Alaska) and Mark R. Warner (Va.) — have suggested ways to improve the law. But congressional Republicans have shown no interest in legislative remedies, and National Republican Senatorial Committee spokesman Brad Dayspring said Democrats have a major liability.

“Obamacare is a vehicle that drives home a bigger problem Democrats have with voters: Either they didn’t understand the law that they championed, which makes them inept, or they blatantly lied about what this law would do, which makes them dishonest,” he wrote in an e-mail.

In an interview, Begich said he thinks the law will be a “neutral” factor in his race, in part because “Alaskans are not necessarily one-issue voters,” and he added that the debate is shifting as more people buy health plans.

Still, Democrats may be disappointed if they expect the newly insured to emerge as a politically powerful constituency, as senior citizens did for Medicare. Robert J. Blendon, a professor of health policy and political analysis at the Harvard School of Public Health, said polls suggest that nine of 10 people who vote in midterm elections are insured. Thus, they are unlikely to benefit from the law.

There are some silver linings for Democrats. Polls show that a majority of Americans do not favor repealing the law — rather, they want it to be improved. Also, the enrollment process has resulted in the training of a slew of new organizers who will help turn out the Democratic vote in November. One is Dee Lila Peterson, a Service Employees International Union chapter president at a nursing home in Doylestown, Pa.

Before she started, she said, “I wasn’t really political.” But now, she plans to encourage Democrats to vote in November. “You need to let them know what’s actually going on,” she said.

Rising enrollment

For the enrollment period that is coming to a close, health experts are eager to find out more information about the 6 million people who signed up for private plans. It’s unclear, for example, how many have paid for policies — a necessary step in getting coverage.

“It’s going to be quite a while before we know the real meaningful numbers,” Blendon said.

Looking ahead, congressional budget analysts expect enrollment through the federal and state exchanges to rise to 13 million people by early next year, and to 24 million people by two years after that. That estimate is based on what happened in programs like the Children’s Health Insurance Program, for which enrollments started slowly but then accelerated rapidly. But some health policy analysts say the pattern might be different because the health law is so controversial.

In any case, there is wide agreement that outreach efforts — such as the “navigators” and others who assist with enrollment — will be vital. And there are concerns that there might not be enough government funding to do an adequate job of reaching people.

“To really ramp up enrollment and make inroads into the uninsured, they need to figure out how to reach hard-to-reach low-
income people,” Kaiser’s Levitt said.

One problem is that many people don’t realize they are entitled to subsidies. When they are told, they often embrace the law, according to those who are assisting in enrollment.

Efia Joseph, a 35-year-old home care worker in Fairfield, Conn., who was uninsured for two years, got a plan through the state’s exchange. Because her subsidy is close to $300 a month, she pays only $122 in premiums. After seeing three doctors in January and scheduling an MRI, she is traveling around the state promoting the insurance marketplace. “People are calling back and saying, ‘I love you!’ ” she said.

Penalties kick in

Monday is the day by which most Americans are required to have picked a health plan or face a fine. This mandate has long been the most unpopular part of the law, and it’s likely to affect millions of people, though at this point it’s not clear how many. (The administration decided last week to extend the deadline for some.)

The fine is $95 per uninsured adult or 1 percent of income, whichever is higher, for the first year. It gradually rises through 2016 to $695 per uninsured adult or 2.5 percent of income. The fine will be collected at tax time, when the Internal Revenue Service will deduct the amount from tax refunds.

Some people have made up their minds to defy the requirement. Paul Alexander Clark, 35, an entrepreneur in Nashville, said he has decided to pay the fine this year rather than pay $132 a month for an insurance policy with an annual deductible of more than $6,000. “It was simple math combined with the knowledge and confidence of being able to navigate the health system,” he said.

Lena H. Sun contributed to this report