Many of the major provisions of the federal health law known as Obamacare take effect today. Insurance companies will no longer be able to deny anyone coverage because of a pre-existing condition. Nearly everyone in the country will be required to have health insurance (although if you don’t have it today, you still have time to buy a plan before the penalty kicks in). And there are new requirements for what insurance plans must cover.

But many of the implications of those and other changes the law requires won’t be clear overnight. Here are some of the key things to watch as Obamacare rolls out in 2014.

1. How will the early days of 2014 go?

More than 60,000 state residents are slated to get new health care coverage today, either as part of Medicaid or a private health plan purchased on the state’s exchange, Access Health CT.

Access Health CEO Kevin Counihan has already warned that people should expect a bumpy start. But what that means exactly remains to be seen. Will everyone who signed up for private insurance by the deadline get their bills in time to pay them and be covered in January? Will those who paid their first month’s premiums have their insurance cards by today, or get them soon? Will the doctors listed as accepting patients in each exchange plan take the new patients? And will people who signed up for Medicaid be able to see doctors or fill prescriptions without any trouble?

And in the cases of people who are getting subsidies to help cover their premium costs, will the federal government have the technology in place to pay its share of the costs?

Any potential glitches could be short-term if addressed quickly. But as with the rollout of the federal exchange website in October, any problems could have a more enduring impact on public opinion of the health law.

2. How many people will remain uninsured in 2014?

The Affordable Care Act aims to get millions more Americans access to health care coverage, but it won’t cover everyone, particularly in the first year.

An analysis published in the journal Health Affairs estimated that by 2016, Connecticut would still have 162,000 uninsured residents. That’s compared to about 310,000 to 350,000 people who are currently uninsured — about 9 percent of state residents.

Some people aren’t eligible for any or all of the new coverage options available as part of Obamacare. One recent projection estimated there are about 64,200 low-income Connecticut residents aged 19 to 64 who are either not in the country legally or who immigrated legally within the past five years. Those not here legally aren’t eligible for any of the expanded coverage options, while recent immigrants are ineligible for Medicaid until they’ve been in the U.S. for five years (there are exceptions for children and pregnant women). But recent legal immigrants could qualify for tax credits to buy insurance as part of the health law.

Even some people who qualify for Medicaid or discounted insurance coverage are likely to remain uninsured, experts say, either because they’re unaware of their new options, can’t afford the insurance premiums or out-of-pocket costs for getting care, or otherwise opt against getting covered, even if that means paying a penalty. Advocates also worry that technological limitations at the state Department of Social Services could mean that the enrollment process in Medicaid won’t be as easy as they’d like.

The number of people remaining uninsured has implications for many parts of the health care system, including hospitals, whose state funding to help cover the cost of uncompensated care is being slashed. And the balance of people who sign up for insurance — whether there’s a mix of ages and healthy and sick people — matters for the financial health of the exchange plans.

3. Will emergency rooms get even more packed?

Proponents of the health law hope that getting more people covered will mean better access to primary care and preventive services, and that it will translate to fewer people relying on emergency rooms for non-urgent care.

But it remains to be seen whether that happens. When Massachusetts implemented its 2006 universal coverage law, many people went to emergency rooms to get care, noted Dr. Mary Cooper, chief quality officer for the Connecticut Hospital Association.

“Our hospitals are prepared for that, were it to happen,” she said. But Cooper said officials are hoping to avoid the ER surge Massachusetts experienced by trying to make sure the newly insured know how to access primary care and can get appointments with health care providers in the community.

Research indicates that the highest rate of emergency room use occurs in people with Medicaid, not the uninsured. So reducing the number of uninsured and increasing the number of people with Medicaid, as Obamacare is expected to do, might not by itself ease pressure on crowded emergency rooms.

People with Medicaid have historically struggled to find doctors to treat them, although state officials are trying to change that by encouraging more doctors to participate in the program. And as part of the health law, Medicaid rates paid to primary care doctors in Connecticut have increased significantly, although the pay bump is only slated to last two years.

4. Will the newly insured be able to find doctors — or other types of health care providers — to treat them?

It’s a big question in a state like Connecticut, where primary care providers are already stretched thin. A survey released in 2010 by the Connecticut State Medical Society found that more than a quarter of internists and family physicians weren’t accepting new patients.

“We’ve got an aging physician population,” noted Dr. Thomas A. Raskauskas, an ob-gyn and CEO of St. Vincent’s Health Partners, a Bridgeport physician hospital organization. “Who’s going to take care of all these [newly insured] people, and are we going to see an increase in the use of physician assistants and nurse practitioners?”

An increased reliance on those “midlevel” providers could be one solution. Community health centers, which treat many people who are uninsured or covered by Medicaid, are also expected see many of the newly insured.

Another possibility, Counihan said, is an increase in care provided in settings like CVS’ Minute Clinics, which see patients with routine conditions like sore throats, ear aches and flu.

5. What kind of medical needs will the newly insured have?

Some of those getting coverage will have gone for years without medical care. Raskauskas thinks there will likely be some who require a lot of treatment in their first year or two with insurance.

In addition, he expects more people to get screenings like mammograms and pap smears, since insurance plans must now cover preventive services at no charge.

“We may see an uptick in cancers because of that,” he said. “They’re not new cancers, it’s just they’ve never been screened for.” It will add costs to the system in the short-term, Raskauskas said, but would ultimately be beneficial if it leads people to get treated before their cancers become lethal.

Dr. Steven Wolfson, a cardiologist, is less sure that there will be an influx of patients seeking large amounts of care for pent-up needs.

“What we’re really talking about are the working poor. They don’t have time to take off for care,” said Wolfson, who serves on the board of Project Access-New Haven, which arranges for low-income uninsured people to receive donated specialty medical care.

“I hope that they will seek care a little bit earlier than they have in the past,” Wolfson said. “But I’m not sure that there’s going to be a groundswell of people looking to get care.”

6. How will the state Department of Social Services handle thousands of new Medicaid clients?

DSS has faced scrutiny in recent years for its handling of the Medicaid application and renewal process. In some cases, clients have inappropriately lost their Medicaid benefits, despite sending in the information needed to maintain coverage, advocates say.

The department changed how it handles paperwork over the summer, moving to a system that officials say will improve efficiency and accuracy. Commissioner Roderick L. Bremby has acknowledged that it hasn’t gone as smoothly as he’d have liked and has asked for patience while the problems are being resolved. Advocates say that so far, the system has made things worse, leading more clients to inappropriately lose coverage when it’s time for their eligibility to be renewed. And they’re worried about how DSS will handle the added client volume coming its way because of Obamacare. An estimated 55,000 state residents are expected to become eligible for Medicaid today as part of the health law.

DSS spokeswoman Kathleen Kabara said the department has contracted with Xerox State Healthcare to enter client data into the department’s eligibility management system for residents enrolling in the expanded Medicaid program through Access Health. The company will also do data entry for eligibility renewal, she said.

Go to for a more complete report on Access Health CT and the Affordable Care Act’s implementation in Connecticut.

Arielle Levin Becker covered health care for The Connecticut Mirror. She previously worked for The Hartford Courant, most recently as its health reporter, and has also covered small towns, courts and education in Connecticut and New Jersey. She was a finalist in 2009 for the prestigious Livingston Award for Young Journalists, a recipient of a Knight Science Journalism Fellowship and the third-place winner in 2013 for an in-depth piece on caregivers from the National Association of Health Journalists. She is a 2004 graduate of Yale University.

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