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This could be the year that things finally turn around for President Barack Obama's health care law. Yet it could start with another round of glitches that vex consumers and leave Republicans crowing, "We told you so."
The law's major benefits take effect with the new year, along with an unpopular insurance mandate and the risk of more nerve-racking coverage disruptions.
Big improvements are in store for some, including Howard Kraft of Lincolnton, N.C. A painful spinal problem left him unable to work as a hotel bellman. But he's got coverage because federal law now forbids insurers from turning away people with health problems.
"I am not one of these people getting a policy because I'm being made to," Kraft said. "I need one to stay alive."
What's good for millions like Kraft is secured through what others see as an imposition: requiring virtually every American to get covered, through an employer, a government program or direct purchase of a plan.
But the biggest health care headlines early this year could come from continued uncertainty over the insurance program's messy rollout.
The consumer-facing side of the HealthCare.gov website appears to be largely fixed — with 2.1 million enrolled through federal and state websites. But on the back end, insurers say they are still receiving thousands of erroneous sign-ups from the government.
That means early in the year insured patients could go for a medication refill — or turn up in the emergency room — only to be told there is no record of their coverage.
One of the main worries is over certain error-tainted enrollment records that insurers call "orphans" and "ghosts."
"Orphans" are sign-ups that the government has a record of, but they do not appear in insurer systems. Insurers say those customers never left the government's "orphanage" to "go and live" with the carrier they selected.
"Ghosts" are new customers that the insurer does have a record of, but whose information mysteriously does not appear in the government's computers.
The Obama administration says the rate of such errors has been reduced dramatically, and insurers agree. The catch is that the volume of sign-ups has surged in the meantime, which means even with a lower error rate the number of problem cases keeps growing. And there is no automated way to clear up mistakes quickly.
"There are going to be problems for any number of people who thought they had signed up, and it won't work right off the bat," said Mark McClellan, who oversaw the rollout of Medicare's prescription drug benefit — a program that also had its share of issues. "It would be particularly disruptive for people in the midst of treatment."
Anticipating disruptions, major drug store chains like CVS and Walgreens have announced they will help customers who face coverage glitches, even providing temporary supplies of medications without insisting on up-front payment. Many smaller independent pharmacies are also ready to help.
White House health care adviser Phil Schiliro told reporters the administration was working with insurers and health care service providers to minimize disruptions "as we deal with what are always going to be unexpected problems where there is a transition."
Obama had envisioned that the arrival of the Affordable Care Act's major benefits in 2014 would be like a national seminar, showcasing his philosophy that government can and should smooth the rough edges off an unforgiving economy for struggling working people.
The goal was that in a midterm election year, Democrats would be able to point to millions of newly insured Americans, thanks to subsidized private plans and an expanded version of Medicaid. Media reports would feature compelling cases of people handed a lifeline.
That's indeed happening, but it seems to be only part of the story. The Republican portrayal of "Obamacare" as government inept and out of control appears to be unfolding right alongside.
Legal challenges still lie ahead for the health care law. Supreme Court Justice Sonia Sotomayor, acting Tuesday night on a request from an order of Catholic nuns in Colorado, blocked implementation of portions of the law that would have forced some religion-affiliated organizations to provide health insurance for employees that includes birth control. Several other Catholic groups won similar stays in the lower courts.
Although the stated goal of the law was to cover the uninsured, at least 4.7 million insured people had individual policies canceled because they didn't measure up to new requirements. That forced an apology from the president, who had famously promised that if you like your health plan, you can keep it. The administration says it believes most of those people have secured new coverage.
Americans with job-based health plans are also worried. A recent Associated Press-GfK poll found that most people who've seen their employers scale back coverage blame that on Obama's law, even though businesses were shifting health costs to workers before the law passed.
The nation's divisive debate over health care could go on for years. Having failed to repeal the entire law, Republicans may start targeting pieces of it, such as a Medicare cost control board, or various taxes.
For now, administration officials say they are just focused on getting through the March 31 end of open enrollment. People who enroll by that date will not face the law's tax penalty for remaining uninsured.
The administration and its supporters are also planning a big push to get younger, healthy uninsured people to sign up, key to the law's long-term success.