After surviving a Supreme Court decision and a presidential election, the Obama administration's health care law faces another challenge: a public largely unaware of major changes that will roll out in coming months.
States are rushing to decide whether to build their own health exchanges, and the administration is readying final regulations, but a growing body of research suggests that most low-income Americans who will become eligible for subsidized insurance have no idea what's coming.
Part of the problem, experts say, is that people who will be affected don't realize the urgency because the subsidies won't begin for another year. But policy decisions are being made now that will affect tens of millions of Americans, and the lack of public awareness could jeopardize a system that depends on having many people involved.
Low enrollment could lead to higher premiums, health policy experts say. Hospitals worry that, without widespread participation, they will continue getting stuck with patients' unpaid medical bills. Advocates say the major purpose of the Affordable Care Act -- extending health insurance to more Americans -- will go unmet if large numbers of vulnerable people don't take advantage of it.
But because "Obamacare" has been so controversial, and its fate caught up in the presidential campaign, there has been little public discussion about the specifics of putting it into action.
States such as Texas and Florida, where opposition was strong, have been slow to embrace the law, and critics have been loath to promote it.
Initial White House efforts at outreach caused congressional Republicans to accuse the administration of using taxpayer money for political gain. In mid-November, Ways and Means Committee chairman Dave Camp, R-Mich., subpoenaed Health and Human Services Secretary Kathleen Sebelius, demanding information about how her agency has used federal money to promote the Affordable Care Act.
"People hear it's going to come in 2014, which makes it not very relevant to their lives," said Tevi Troy, a top Health and Human Services official under former President George W. Bush. "If you don't have an understanding of the law, that's when you're going to have real take-up problems."
Seventy-eight percent of the uninsured Americans likely to qualify for subsidies were unfamiliar with the new coverage options in a survey by Democratic polling firm Lake Research Partners. That survey, sponsored by the nonprofit Enroll America, also found that 83 percent of those likely to qualify for the expansion of Medicaid, which is expected to cover 12 million Americans, were unaware of the option.
In separate October polling data from the Kaiser Family Foundation, 41 percent of voters described themselves as "confused" about the health care law.
Even as Congress was finishing debate that led to the law, a coalition of health care advocates formed to help promote it. Led by Families USA co-founder Ron Pollack, the group started Enroll America, a nonprofit largely funded by health care industry and philanthropy groups.
In coming months, the group will begin an ad campaign meant to encourage Americans to sign up for the health care law's subsidized insurance coverage. Still in its planning stages, it is likely to start in the summer or fall of 2013, just before the state-based insurance marketplaces, or exchanges, open for enrollment in October.
The still-unnamed campaign is likely to put more intensive resources toward a handful of key states. Those could include Florida and Texas, which have a combined 10 million uninsured residents, and have made little effort to do such outreach.
The group has raised $6 million from a coalition that includes the American Hospital Association, pharmacy chain CVS-Caremark, physician groups and individual health insurance firms. Although that initial funding has covered survey research and hiring of seven staff members, Mr. Pollack, the board chairman, said the group hopes to raise "tens of millions" more for its campaign.
"We know now that the Affordable Care Act has to be implemented," said Rachel Klein, Enroll America's executive director. "It's imperative that the people who will benefit hear about the new coverage available and learn how to sign up."
Currently, 48.6 million U.S. residents lack health insurance. The Congressional Budget Office estimates that 30 million will gain coverage. That would leave nearly 19 million uninsured.
About a quarter of those are illegal immigrants, who aren't eligible for the law's subsidies. Two million, the CBO projects, live in states that will opt out of the Medicaid expansion. The rest, however, probably are eligible for new benefits. The CBO expects that nearly 6 million of Medicaid's newly eligible just won't sign up for the program.
Even though subsidies for currently uninsured people won't go out until Jan. 1, 2014, the state exchanges that will offer health plans are being set up now, and participants will need to start signing up next Oct. 1.