Nearly four years after it was signed and after months of uncertainty, President Barack Obama's landmark bid to guarantee Americans health security takes full effect Wednesday when the Affordable Care Act begins delivering health coverage to millions of the nation's uninsured.
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 debate plays out, doctors, hospitals and pharmacies across the state and country are bracing for more confusion as patients struggle to understand their new coverage.
Some likely will show up at physicians' offices without insurance cards, the victims of the error-plagued enrollment process that bedeviled the rollout of Maryland's exchange website and the federal HealthCare.gov starting Oct. 1.
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 at the local drug store 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 but high deductibles.
Surveys indicate that many Americans have little understanding of basic insurance concepts such as copays 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.
Dr. Mark Lamos, president and medical director of Greater Baltimore Medical Associates and internal medicine physician at Greater Baltimore Medical Center in Towson, predicts people won't know what their plans cover.
"I think the misunderstanding will be great," Lamos said.
Kaiser Permanente of the Mid-Atlantic States, which is selling plans on Maryland's exchange, said it has increased staffing at its call center and will reach out to new members through telephone calls and welcome kits mailed to their homes. The kits include information about Kaiser's health care system and the many ways people can access it, including online and mobile.
Kaiser also is trying to ensure members get identification cards before January, but said as long as patients are in the computer system they can get care without one.
CareFirst BlueCross BlueShield said members can access their medical ID cards online or through the insurer's mobile app. Members don't have to wait to get the ID card in the mail.
Jeff Goldman, vice president for coverage policy at the American Hospital Association, said most hospitals already have systems in place to help patients sort out their insurance, something consumers often struggle with, particularly at the beginning of the year. "We are pretty confident that people are prepared," he said.
Mary Lynn Carver, a spokeswoman for the University of Maryland Medical System, said hospitals have been helping explain to patients the ins and outs of their insurance plans for years and they will use the same strategies with the newly insured.
"This is yet another service that hospitals have to staff for that is not reimbursed," Carver said.
The issues created by high-deductible and high-copay plans also is nothing new, Carver added. Hospitals are facing increasing levels of bad debt as patients are not prepared to pay these charges, she said.
About 1.1 million people have signed up for new health plans using the federal government's health exchange website.
A late-December surge in sign-ups — combined with rising enrollment on similar marketplaces operated by 14 states and the District of Columbia — means that about 2 million people nationwide appear to have signed up for health coverage since Oct. 1.
Not all states have reported their enrollment numbers through Dec. 24, so an exact tally is not available.
More than 4 million have been found eligible for coverage under Medicaid and the Children's Health Insurance Program.
In Maryland, which set up its own health exchange, Gov. Martin O'Malley said last week that 42,589 people had signed up for insurance as of Dec. 21 — a jump of almost 13,000 people in a week. More recent numbers will be released this week, and state officials said they expect them to once again break records.
The state set a goal of enrolling 150,000 people in private plans and 110,000 in Medicaid during open enrollment. Of those signed up for coverage so far in Maryland, about 11,700 have signed up for private plans, with the rest on track for Medicaid, according to O'Malley.
Most Americans, including Marylanders, already have some form of health insurance through an employer or a government program such as Medicare. As a result, few health care providers will likely encounter significant numbers of patients with problems related to Obamacare coverage.
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 problems 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."
HealthCare.gov and similar sites run by 14 states and the District of Columbia are the primary portals created by the health law to help Americans who don't get health coverage through work to select a health plan.
Plans sold on these marketplaces must meet new consumer standards. For instance, they are prohibited from turning away customers with pre-existing medical conditions.
Enrollment in these plans started Oct. 1 and is slated continue until March 31. A surge in enrollment in the last few weeks has intensified anxieties about potential mix-ups early next year and prompted administration officials and insurers to take step to try to head off potential problems.
In Maryland, technical glitches that made its exchange rollout one of the worst in the country prompted insurers to extend enrollment deadlines.
Consumers had until midnight Friday to buy plans offered by CareFirst BlueCross BlueShield and UnitedHealthcare. Kaiser Permanente and Evergreen Health Cooperative Inc. are giving people until Tuesday to buy plans. After that, a second enrollment period starts and people have until March 31 to buy coverage without paying a penalty.
Obama administration officials also have asked insurers to initially cover some out-of-network care and prescriptions to help consumers who are moving from one provider network to another. That could be particularly important for patients with complex conditions such as cancer or AIDS. Industry officials said doing so may be difficult.
CVS Caremark executive vice president Helena Foulkes said the pharmacy giant may provide some patients with a "transitional supply" of prescriptions if their insurance is temporarily interrupted in January.
These kinds of interruptions dogged the first few weeks of the Medicare prescription drug benefit in 2006, prompting the George W. Bush administration to step in to help seniors who couldn't get their medications, according to former Health and Human Services Secretary Michael Leavitt. Speaking to a group of insurance industry officials in Washington recently, Leavitt cautioned something similar may again be necessary.
Despite the challenges of dealing with newly insured patients, however, many medical providers fear that the uninsured still pose a far greater challenge. That's particularly true in the states, including Texas and Missouri, whose lawmakers oppose the health law and have declined to expand their Medicaid programs next year. Millions of poor Americans will lack coverage next year in those states.
"The much bigger issue is uncompensated care," said Dave Dillon, a spokesman for the Missouri Hospital Association. "That is what we are most concerned about."