What's Next for Obamacare

Monday marks the end of open-enrollment for the Affordable Care Act. Now comes the real test for the law.

Obamacare's first enrollment period is ending—and with it, a half-decade of debating the law solely as a vague political abstraction.

How the Affordable Care Act would play out has been mostly a theoretical question until now; Republicans predicted it would collapse in on itself (didn't happen), while Democrats swore the public would embrace it as time went on (also didn't happen).

The end of the first open-enrollment period provides real-world data to measure the law's progress—and those results will help define the challenges the law faces as it grows out of its infancy.

We won't know for a few more weeks exactly how many people picked a plan during the six-month enrollment window, but it's somewhere north of 6 million. And we won't know until much later—if ever—how many people paid their first premium, or how many enrollees were previously uninsured.

Both of those are critical metrics for evaluating the law's performance. Neither answer, however, is likely to move the law back to the other side of the key threshold it has already crossed: signing up enough people to push ahead into 2015 and 2016.

"The ACA has survived an election and a Supreme Court challenge and a government shutdown and a website debacle, and now doubts about its enrollment totals," said Drew Altman, president of the Kaiser Family Foundation.

With millions of people signing up, the law has cleared one long, difficult set of hurdles and has defied the darkest predictions of its critics. But that doesn't mean it's out of the woods entirely—it's just on to the next long, difficult set of hurdles.

What will happen to premiums?

It's too flip to say the national enrollment data "doesn't matter"—the whole point of the law was to cover millions of uninsured Americans, and whether that's happening matters very much. But the national total doesn't say much about of the law's sustainability or what happens to premiums next year.

Premiums will go up, because premiums go up every year. The size of next year's premium increases depends on enrollment and demographics in each state, and even within specific regions of each state.

Some states are faring better than others: California is well-positioned for 2015, with enrollment above expectations and a competitive market. On the other end of the spectrum are states like Mississippi, where there's only one insurance company in the state's exchange and the population is relatively unhealthy to begin with.

The demographic mix is pretty steady across all 50 states. Nationally, young adults—the most coveted enrollees—made up 25 percent of all sign-ups through the end of February. The percentage will probably improve in the final analysis; young people were always expected to sign up at the last minute.

Generally, if the risk pool in a particular market turns out older and sicker than expected, insurers are more likely to raise their premiums. We don't know precisely what insurers expected—they all priced their plans independently, and the law includes several programs designed to absorb any surprises and keep premiums as steady as possible. In competitive markets, insurers likely will try to keep increases to a minimum, but industry insiders caution that hikes are looking likely, at least in some parts of the country.

Will people like their plans?

So, enrollment in the first is decent, and there are tools to try to keep premiums in check, which will help enrollment continue to grow. The administration will probably do pretty well at getting people into the system. The biggest challenge for the Affordable Care Act, healthcare experts say, is whether people like what they find.

"The biggest question by far is how people feel about that coverage, and whether they think it's a good deal … and what is the proportion of winners to losers," Altman said.

The "losers"—people who had their plans canceled and must pay more for an equivalent policy that might not include their doctor—have gotten more attention so far. The "winners"—people with preexisting conditions who were denied or priced out of health insurance until now—will likely get more attention as more of them actually gain coverage.

But what if even the "winners" start to sour on their coverage?

If the people who were supposed to benefit the most from Obamacare find themselves stuck in their deductibles, paying out of pocket even though they have insurance, they could "start to be very publicly unhappy," said Caroline Pearson, senior vice president at the consulting firm Avalere Health.

The risk, Pearson said, is that "you've got the chronically ill people who ... came in with the promise of good coverage and they don't find their coverage to be meaningful."

The Health and Human Services Department is already "worrying about that and trying to figure out, 'How do we give people some goodies?' " she said.

There's also a risk of consumer backlash against narrow networks of doctors and other providers. Many exchange plans have excluded expensive providers as a way to keep premiums low. That's a bigger issue for people who had coverage before than people who are gaining it for the first time, but HHS is also on guard on that front, hinting that it might require broader networks.

Even if people like their benefits, will they like 'Obamacare'?

Republicans are confident the issue will buoy them in November, and Democratic strategists acknowledge that healthcare isn't likely to turn in their favor between now and then. The best they can do is neutralize it.

The turnaround in enrollment from October to March is undeniable, and it's a big win for the White House. But even as the law has found its footing and enrollment has surged, public approval hasn't budged.

In the Kaiser Family Foundation's latest tracking poll, public opinion of the Affordable Care Act was deeply divided, as always. Forty-six percent of voters said they have an unfavorable view of the law, compared with 38 percent who rate it favorably—basically the same breakdown the poll found in September, before the disastrous Healthcare.gov launch.

"We could ask, Will the ACA cure America's energy problems or take us to Mars, and we will get an almost perfect partisan split in the responses," Altman said.

If the public is going to rethink Obamacare, it's going to take a while.

"I think over time, as the law becomes more real for the American people, a judgment based on the reality of the law will begin to supplant the role the law has played as a symbolic dividing line between left and right," Altman said.