WASHINGTON - Millions of Americans will begin receiving health insurance coverage under the Affordable Care Act on Wednesday after years of contention and a rollout hobbled by delays and technical problems. The decisively new moment in the effort to overhaul the country's health care system will test the law's central premise: that extending coverage to far more Americans will improve the nation's health and help many avoid crippling medical bills.
Starting Wednesday, health insurance companies can no longer deny coverage to people with pre-existing conditions and cannot charge higher premiums to women than to men for the same coverage. In most cases, insurers must provide a standard set of benefits prescribed by federal law and regulations. And they cannot set dollar limits on what they spend on 'essential health benefits' for a policyholder.
'I feel a huge sense of relief,' said Katie R. Norvell, a 33-year-old music therapist in St. Louis, who has been uninsured for three and a half years and has a pre-existing gynecological condition, endometriosis. She signed up Dec. 22 for a midlevel silver plan offered by Coventry Health Care, now owned by Aetna, and has already begun making doctor's appointments.
'With coverage,' she said, 'I can be my best self. Health insurance won't control my job choices.'
Though this is an important milestone for the law, it is unlikely to end the constant partisan battles that began even before its passage nearly four years ago. And doctors, hospitals and pharmacists say consumers could initially experience some delays and difficulties as they try to use their new insurance.
A series of last-minute changes in rules and deadlines for people to sign up and pay premiums have left less time for insurers to activate coverage and issue identification cards, adding to the uncertainty caused by the troubled rollout of the health exchange.
'There will be a lot of confusion,' said Brian D. Caswell, a former president of the Kansas Pharmacists Association, who owns a drugstore in rural Baxter Springs. 'Many people will get insurance cards, but will not have a clue what's covered, what's not covered and what they are supposed to pay.'
Others may find their insurance companies have no record of their enrollment because the information was not sent by the online marketplaces where they signed up for coverage. Even if they are properly enrolled, some of the newly insured may have trouble finding doctors who accept their health plans, many of which are restricting the number of providers in their networks to hold down premium costs.
And as newly insured consumers sort through details of their coverage, others will find that they are no longer insured by their old plans, which were canceled or discontinued because they did not comply with minimum coverage requirements of the law. Of several million who received cancellation notices, most should be able to obtain other coverage, the Obama administration says.
Toby Mitchell, a self-employed recruiter in Napa, Calif., said she considered forgoing insurance when Kaiser Permanente canceled her longtime plan because it did not meet the requirements of the new law. But in the end, Ms. Mitchell, 60, decided to buy a bronze plan that will cost almost twice as much. Her monthly premiums will now be $575, compared with $288 on her old plan.
'I was really shocked,' she said. 'It's just painful because there are other things I'd rather do with that money, especially when it's hard to see the value is there for me personally.'
Kathleen Sebelius, the secretary of health and human services, said Tuesday that more than 2.1 million people had selected private health plans, about half of them through the federal insurance exchange and half in marketplaces run by states. In addition, hundreds of thousands of Americans have enrolled in Medicaid, the government health insurance program for low-income people, which about half the states have decided to expand under the law.
Federal officials said they did not know how many subscribers were replacing insurance policies canceled because they did not meet coverage standards.
Subscribers will be entitled to coverage starting Wednesday if they pay the first month's premium by the due date, Jan. 10 for many insurers.
Ana Yngelmo, a 37-year-old immigration lawyer in Kearny, N.J., said she would use her new insurance to start seeing a primary care doctor and to get her first mammogram. Ms. Yngelmo, who said she had been uninsured for 16 months, chose a platinum plan with generous coverage - 'the best they had,' she said - and no deductible. She qualified for a tax-credit subsidy that will lower her monthly premium to $350 - still expensive, she said, but worth it for peace of mind.
'For me, insurance is about those tragic situations where you need some terrible surgery or get cancer,' said Ms. Yngelmo, who recently started her own law practice. 'I just want to make sure that in those situations, I can go to whichever doctor I want and it will be covered.'
In some states, doctors are preparing for an influx of newly insured patients. Dr. Michael J. Pramenko, a family doctor who is executive director of Primary Care Partners in Grand Junction, Colo., said his group had opened a satellite clinic, added several doctors and extended office hours in the expectation that 'we will be seeing more patients.'
Cynthia Taueg, a vice president of the St. John Providence Health System in Warren, Mich., near Detroit, said she expected a gradual increase in patients because 'a majority of the uninsured in our service area will be eligible for Medicaid' or for subsidized private insurance through the exchange.
Scott Keefer, a vice president of Blue Cross and Blue Shield of Minnesota, voiced a concern expressed by many insurers: Some consumers will go to doctors, hospitals and drugstores believing they have enrolled in a health plan, only to find that the company has no record of them.
That is what happened in January 2006 when a prescription drug benefit was added to Medicare. Many low-income people left pharmacies empty-handed after being told they would be responsible for co-payments of $100, $250 or more. Pharmacists extended credit to some customers. To help their residents, states paid drug claims that should have been paid by Medicare.
The Affordable Care Act is far more complicated, as it relies on a larger number of providers to deliver a much wider array of benefits.
Since the federal exchange opened Oct. 1, officials have grappled with problems in the quality of enrollment data. Insurers said the government initially provided them incorrect or incomplete information on some enrollees, and no information at all about some who enrolled online.
Insurers and government officials are taking steps to reduce confusion. Aetna, for example, has posted information on its website answering questions likely to bedevil consumers in the next few weeks. The insurance exchanges in California and Connecticut are about to run advertisements explaining the Jan. 10 premium deadline.
Peter V. Lee, the executive director of California's insurance exchange, said that while logistical problems would surely pop up as the new coverage took effect, they would matter less and less as people started using their benefits.
But John G. Lee, an insurance agent in Fredericksburg, Va., said that health insurance was a complicated product and that people did not always understand what they were buying online. He said he worried that consumers would be upset when they discovered that certain medicines were not covered by their plans, or that their doctors were excluded from the approved providers.
William Hannah of Cleveland, Ga., who has been uninsured for about 20 years, said he was looking forward to using his new coverage to see a specialist for lower back problems and numbness in his limbs. But Mr. Hannah said he had canceled the first plan he signed up for, from Blue Cross and Blue Shield of Georgia, after realizing it would not pay for treatment at the medical center closest to his home. He switched to a silver plan from Alliant Health Plans and qualified for a tax subsidy that will lower his premium costs to $56 a month.
'It's very affordable to me, thanks to the tax credit,' said Mr. Hannah, 63, who said he had retired early to care for his ailing mother. 'On the other hand, there's the limitation of what the insurance companies are actually paying for and what institutions they are paying for.'
Noel Vasquez/Getty Images
PHOTOS: INSIDE KIM KARDASHIAN AND KANYE WEST'S ROMANCE
