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It’s the final day of the Affordable Care Act’s first enrollment period for people to sign up for health insurance. But the story of the health-care overhaul doesn’t end here.

Since the insurance sign-ups started — or tried to start — back in October, the news has involved stories of website fiascos, canceled-plan notices and people thrilled to have access to health care after years of going without.

More than 6 million people nationwide have signed up for plans through the government-run insurance marketplaces. In Washington, more than 131,000 residents had purchased coverage from the state’s online exchange by last week, and that number will rise by many thousand more by the end of Monday.

So what happens next? Here are four areas to watch.

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Waiting on final tallies

After enrollment officially ends at 11:59 p.m. Monday, some insurance applicants will still be stuck in the system.

As of last week, 11,500 incomplete applications were ensnared in the Washington Healthplanfinder, the state’s exchange. Residents can ask for more time to finish enrolling, and each request will be reviewed to verify that they actually were delayed by a computer error.

People in the 36 states using the federally managed exchanges can get an extension for a variety of reasons, including problems with the website and being victims of natural disasters.

That means there will be delays by state and federal officials in their final tally of how many people bought insurance, the number who are in the sought-after “young invincible,” 18-to-34 demographic, and the race, income and gender of participants.

One of the most eagerly awaited numbers — and one likely to be a long time coming — is how many of the people who bought plans were formerly uninsured, a key benchmark for gauging Obamacare’s success.

Another important piece of the reforms was Medicaid expansion — at least in states like Washington that opted to make more people eligible for free health care. As of March 20, more than 380,000 newly eligible or previously eligible adults had signed up for Medicaid. Medicaid enrollment runs year-round, so those numbers will keep growing for some time.

Next year’s exchange

Last year, state Insurance Commissioner Mike Kreidler got two surprises when insurers turned in their plans for the exchange.

First, premiums were lower than some companies’ original dire predictions. But how insurers got there was the second surprise: narrow provider networks, often excluding some major hospital systems, and, in many cases, very large deductibles.

What will next year’s plans look like?

Kreidler has proposed new rules for the networks, which he wants to apply to the 2015 plans. While he acknowledges that narrow networks can help keep premium costs low, he says his job is to ensure consumers get what they pay for.

To do that, his office needs to know which hospitals and which doctors are included in each plan, he says. And so should consumers, he adds, before they sign on the dotted line.

On the other side are those who say consumers should have the choice to buy a low-cost, narrow-network plan. If they’re willing to accept limits, even severe limits, that should be their choice.

“It’s called the Affordable Care Act, not the Accessible Care Act,” quipped exchange board member Bill Hinkle at last week’s board meeting of the Washington Health Benefit Exchange, which operates Healthplanfinder. Hinkle, a former Republican state representative from Cle Elum, said he is concerned about limiting options.

Insurers say the rules are too complex, will discourage innovation and could increase costs for consumers. Others worry the rules will discourage new insurers — and more choices — from coming into Washington’s market.

Kreidler says he’s confident the new rules won’t increase costs. But insurers will doubtless ask for larger premiums, as is typical. How much larger? In the past, they’ve had history to go on to see how their costs stack up against premiums paid in. This year, they have a scant few months of experience before the May 1 deadline for turning in their proposed 2015 plans and rates.

Enough docs for all?

A prime goal of the Affordable Care Act is health-insurance coverage for nearly all Americans. And with more insurance comes an increased demand for health-care providers.

Does that mean we’re heading toward a doctor shortage? Clinics and hospitals say they are anticipating growing demand, increasing the number of providers and using existing doctors and nurses more efficiently. Plus, access to care often depends on where you live, what coverage you have, and what sort of specialist you need.

“It’s too soon to tell” whether The Polyclinic facilities are getting many new patients, said Tracy Corgiat, vice president of marketing and development. But they hope they will.

Corgiat says they’ve hired more primary-care doctors and specialists. The Polyclinic also formed a partnership with Virginia Mason Medical Center to provide more options to patients with new insurance that covers fewer hospitals, in case they need to move between a clinic and hospital.

Officials with Providence Health & Services, which has facilities across Western states, say they are looking at ways to improve use of their providers. That includes redesigning their clinic workflow, using team-based care, and delivering some services through telemedicine.

Medicaid patients have often struggled to find health care. Insurance through Medicaid pays doctors less than private plans or Medicare, and many providers say they can’t afford the lower rates.

HealthPoint is a nonprofit organization with clinics around King County accepting Medicaid patients. The group, whose focus is primary care, recently added new facilities and is considering opening more.

“I wouldn’t say that we’re maxed out,” said Elizabeth Winders, Medicaid program manager for HealthPoint. “Some clinics are experiencing more capacity issues than others. It’s possibly waiting longer to see someone than before.”

Success or failure

Folks pro and con on Obamacare are eager to render judgment on the program. The overhaul’s most ambitious initiatives include the insurance exchanges and campaign to get people to buy insurance. With the closing of open enrollment for 2014, can we at last have a ruling on the Affordable Care Act?

Not so fast.

“The crucial question is who are you getting in the system and who are you missing? Are you getting young, healthy people in appropriate numbers?” said University of Washington history professor William Rorabaugh. “We don’t know the answers to those questions yet.

“It took about five years for Medicare to reach the level of enrollment that was expected when Medicare was adopted in 1965,” Rorabaugh said. “You are asking a lot of people to change their behavior.”

So far, the public remains largely sour on Obamacare, but most people want to keep the law and try to fix it rather than scrap it and start over.

A recent poll found that 46 percent of Americans had an unfavorable view of the law, while 38 percent viewed it favorably. But the same folks overwhelmingly wanted to keep the Affordable Care Act, with 59 percent saying either keep it as is or keep it and improve it, according to the Kaiser Family Foundation. Some 29 percent preferred repealing it. Other surveys have found similar results.

The law’s supporters expected people who were uninsured because of premium costs or pre-existing conditions to be happy, but perhaps they didn’t expect so many people to be angry over the price of plans and benefits available under the new rules, Rorabaugh said.

With the mandate that everyone get coverage, it’s unclear whether the positive experiences will outweigh the negative over time.

“When the government intrudes in people’s lives by making them purchase something they don’t want to purchase,” Rorabaugh said, “that is a point of resistance, and that won’t go away.”

Lisa Stiffler, a freelance writer in Seattle, can be reached at

Carol M. Ostrom is at or 206-464-2249. This story was produced through a partnership with Kaiser Health News, an editorially independent part of the Kaiser Family Foundation.

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