WASHINGTON — Nearly four years after it was signed and after months of scrambling and uncertainty, President Obama's landmark bid to guarantee Americans health security takes full effect Wednesday as the Affordable Care Act begins delivering healthcare coverage to millions nationwide.
Administration officials reported Sunday that about 1.1 million people had enrolled in health plans using the federal website, HealthCare.gov, the main entry point for coverage in 36 states. Nearly all the enrollments came in the last couple of weeks as the deadline approached for coverage that would take effect Jan. 1.
Several hundred thousand people have enrolled on separate sites run by 14 states and the District of Columbia, with the largest figure coming from California, where more than 400,000 have signed up.
An exact count nationwide is not yet available because not all states have tallied their figures, but the total appears to be about 2 million. That remains short of the administration's original goal of 3 million by this point, but marks a significant recovery from the system's disastrous debut in October.
More than 4 million additional people have been found eligible for coverage under the law's expansion of Medicaid and the Children's Health Insurance Program.
How the law will ultimately work and whether it can endure remain unclear, though the fact that coverage will now be real for several million people will almost certainly change the debate over Republican efforts to repeal it.
While that broader political fight plays out, doctors, hospitals and pharmacies across the country are bracing for more confusion as patients struggle to understand their new coverage.
Some may show up at physicians' offices without insurance cards, victims of the error-plagued enrollment process that bedeviled the initial rollout.
Others may discover that although they're properly enrolled in a health plan, the doctor or hospital they visit or the prescription they want to fill won't be covered by the plan they have selected.
Still other patients, including many who have never had insurance before, may be shocked to learn they have to pay thousands of dollars out of pocket before their coverage kicks in. Like employer-provided health plans, many insurance plans set up under the health law come with low premiums and high deductibles.
Surveys indicate that many Americans have little understanding of basic insurance concepts such as co-pays and deductibles.
"We still have a lot of education to do for the average man on the street who doesn't really understand the Affordable Care Act," said J. Mario Molina, chief executive of Molina Healthcare Inc., a California-based insurer that is selling policies in nine states.
Relatively few healthcare providers are likely to encounter significant numbers of patients with problems related to coverage under the new law. The number of people covered by the law is dwarfed by the more than 270 million people who already have some form of health insurance through an employer or a government program such as Medicare.
Jeff Goldman, vice president for coverage policy at the American Hospital Assn., said most hospitals already had systems to help patients sort out their insurance, something that consumers often struggle with, particularly at the beginning of the year.
"We are pretty confident that people are prepared," he said.
Still, the health law remains a political lightning rod, and providers and others anticipate every problem will be magnified.
"The fact that not everything will go exactly as was intended by the ACA when most of its biggest changes start to go live … should surprise no one," the American College of Physicians warned its members in a recent newsletter outlining potential headaches after Jan. 1.
"In a less political environment, the mantra as problems arise with ACA implementation would be fix it, not nix it. Until we get to that point, we'll have to muddle through."