The Affordable Care Act is complicated?we all knew that, right? And we?ve all had two-plus years to read it, read about it, talk about it, make rules and plans and whole political campaigns about it.

Yet after all that time, many Americans remain uninformed or misinformed about the ACA and what to expect as it rolls out, and the American news media and the government have not made any great strides in explaining it to the public.

To borrow a phrase from Cool Hand Luke, what we?ve got here is a failure to communicate.

The first case in point, of course, is the cancellation by private health insurers (which have been known to discontinue policies before) of those individual plans that don?t meet ACA requirements for comprehensive coverage.

Certainly, average people were taken aback to get cancellation letters, but the media treated the cancellations as a shocking development, seemingly not bothering to understand that the president's blanket statement that we could all keep our existing policies meant policies that followed the law and were still on the market. The truth of the matter is that individuals can now replace these policies with comprehensive coverage that has no benefit caps or exclusions of pre-existing conditions.

As a result of the uproar, the president has responded by allowing insurers to continue selling those policies for a year, dependent upon approval by state regulators.

But this episode begs the question: What other completely predictable ?surprises? await us as the ACA careens toward its full enactment? What other headlines will come rolling out as the reforms unfold? Here's what we can expect coming down the pike:

Bumpy startup/glitches/bureaucratic problems. This has already happened on a grand scale with the failures of the website, but that's not likely the end of it. Inevitably, there will be problems for the newly insured as they attempt to access healthcare for the first time under their new policies. There will be trouble with billing, subsidies, and any number of other pieces. Such snafus happen at every large-scale Medicaid managed care rollout, they happened with the dawn of Medicare Advantage, and they will happen again in January?but on an unprecedented scale. Carriers, hospitals, and providers expect the disruption and are preparing to take it in stride: everything from missing or inaccurate insurance cards to bungled reimbursements. 

High deductibles.  High up-front deductibles in bronze and silver plans will surprise many of the newly enrolled, some of whom might not know how a deductible works. They also will not know to ask what medical services are exempt from the deductible or about the existence of disease management programs that waive deductibles so members can get the preventive care they need. Health plans and pharma will need to educate the newly insured about these features.

Narrow networks will exclude desired physicians, hospitals. Most exchange-plan shoppers have no clue they?re buying a plan with a restricted network, and cannot easily research the provider networks of their plan options before they buy. When the limitations of these networks become known, we may see an outcry reminiscent of the 1990s-era backlash against HMOs.

Providers will see a lot of bad debt. The high deductibles mean that physician practices and hospitals will deal with bad debt and billing issues while members work through their deductibles. And in in states that are not expanding Medicaid, hospitals will be hurt by the decrease in charity-care funding (in the form of lowered disproportionate share hospital funding) that was worked into ACA as a tradeoff for having more insured patients. This has been foreseen by providers, but that won?t make the experience any more pleasant.

Some are left out. In states like Texas, Florida, and Tennessee that have not expanded their Medicaid programs, millions of Americans will remain without coverage, unable to access Medicaid or the insurance subsidies.

Many will fail to sign up. Between the broken website and the negative press, there will be many fewer people signing up for exchange coverage than previously expected. Those signing up will likely be those more in need of medical care, creating the unbalanced risk pool that insurers and policy experts rightly fear. And this, in my view, is the worst potential outcome?for health insurers, for pharma, and for providers, and for all those who?ve re-tooled their practices and businesses to prepare for the ACA.

Even if the Obama administration is able to fix a workable website and get the premium subsidies applied correctly to each individual's purchase, the foreseeable friction points and problems in the ACA's implementation are legion. It's time for a more serious effort to educate the public about the ACA and its rollout in the months ahead.

Follow Paula Wade on Twitter @PaulaWadehli

Six healthcare policy questions hanging in the balance as the United States votes

View Now