It has been 3 years since Congress passed thelaw that has become known as Obamacare. Implementation of thePatient Protection and Affordable Care Act (ACA) has been underwaysince the ink dried on the bill.

But if anyone thought that Congress passing, and then the U.S.Supreme Court sustaining, ACA meant that the fight over it had atlast been settled, they would be mistaken. In the hyper-partisanpolitical landscape that has prevailed in the U.S. for at least thelast two decades, big issues may settle down for a time but theydon't remain settled for long.

Most of ACA's provisions don't kick in until 2014. The public'sexperiences with the law will be grist for off-year Congressionalelection campaigns. It would be comforting to believe that becausethe major challenges to the new healthcare law have beenadjudicated, everyone would just get about the task of making thebest of the situation. That may be hoping for too much.

Related: Read "Major Misfire"

Healthcare is among a small group of issues that stir intensepassions from both ends of the political spectrum. ACA ranks rightup there on the passion index with gun control and abortion, withone big difference: everyone will feel some impact from healthcarereform, while there are millions of people who will never own a gunor have an abortion. But everyone has opinions and everyone canvote.

Most people are in the middle on most issues, but advocacy onissues of passion comes from activists on both the left and theright. And the money to fuel the activists, whose motives areusually ideologically pure, often comes from those with a vestedmonetary interest in the outcome and thus are anything but pure intheir motivation.

Another Healthcare Battle

If you want a preview of what could become one of the majorissues of Campaign 2014, spend some time reading the latest newsregarding ACA. Implementation of ACA could either go reasonablywell, or be an unmitigated disaster. One thing is certain: Thosewho still dream of repealing ACA—despite being repudiated by thevoters and the Supreme Court—will no doubt try to foster theimpression that it has been the disaster they predicted.

Related: Read "From e-Cards to Cats"

How could ACA go wrong? Here are four ways:

• Rate Shock: When state insurance commissionersarrived in Houston April 4 for the spring meeting of the NationalAssn. of Insurance Commissioners (NAIC), they received a paperdrafted by an NAIC panel entitled "Rate Increase MitigationStrategies."

Commissioners are concerned that many consumers will experience"rate shock" when major provisions of the ACA go into effect inJanuary 2014. This is a problem, because ACA has been sold, atleast in part, as a way to make healthcare more affordable.

The paper indicates that state officials have serious concernsabout ­possible rate increases, despite assurances from federalofficials. It then laid out some options to mitigate rateincreases, including regulating premiums more tightly; forcinginsurers to cut costs or operate at a loss; financial assistance toconsumers, above the subsidies that will already be provided; andprograms to ensure that the costs of the sickest patients areshared by all insurers.

If forcing insurers to operate at a loss is being raised as aserious option, it indicates that something is very wrong here.

• "Where Do You Get Those Navigators?": InMarch, a controversy erupted regarding plans to check thebackgrounds of some 20,000 unlicensed "assisters" set to berecruited in California to help consumers enroll in healthinsurance plans. Inexplicably, there were howls of protest aboutthe background checks from some California consumer activists.California Insurance Commissioner Dave Jones said he was "justshocked that groups that represent the consumer interest summarilydismiss what I think is a very real probability of immense consumerfraud."

All it would take is just one consumer being the victim offraud, then going public on social media or in the press, toundermine public confidence.

PIA testified before the NAIC in April, saying people who workas navigators in health insurance exchanges should be subject tobackground checks and licensing, to protect consumers.

The list of individuals that can become navigators is lengthy,which leads to an increased concern that many navigators will havelittle to no experience with insurance. As both the states andfederal government establish navigator parameters, there is abetter option for consumers: agents and brokers.

Agents and brokers are licensed, regulated, experiencedprofessionals that educate consumers on complex insurance productsand enroll them in policies that best fit their personal needs.Agents and brokers have a deep familiarity with insurance marketsand products; they service plans throughout the year, assist withrenewals, and are held to strict compliance standards.

Related: Read "Ben Nelson to the Rescue"

Agents and brokers must meet continuing education requirementsto maintain their licenses. In addition, they are required tomaintain continuous professional liability insurance coverage inorder to protect consumers.

Rather than recruiting inexperienced, unlicensed people, itwould make sense to rely more on professional independent insuranceagents and brokers to help people navigate the ACA.

At the same time, agents are still trying to ensure that theyare compensated fairly. Fortunately, the Dept. of Health and HumanServices (HHS) recognizes the value of agent and brokerparticipation.

In a proposed rule issued on April 3, HHS it confirms thatagents and brokers can act as navigators in a federally facilitatedexchange, but not receive consideration directly or indirectly froman issuer. However, it notes that "agents and brokers who sellother lines of insurance would not be prohibited from receivingconsideration from the sale of those other lines of insurance whileserving as Navigators, provided they complied with the [new]disclosure requirement."

• Smoker's Penalty: The dwindling number ofsmokers in America are shunted outside while they feed theiraddiction. It seems that the ACA also leaves smokers out in thecold. ACA allows states to impose up to a 50 percent surcharge forpeople who have used tobacco at least four times a week over thelast 6 months. And any subsidy they receive cannot be used to paythe penalty.

Starting next year, federal law will limit insurers' ability tocharge higher premiums based on age; women cannot be charged morethan men because they're women; pre-existing conditions cannot beused to deny or price coverage. What group is left from whichinsurers can recover some costs? The one without any clout:smokers. Still, Rhode Island, Vermont, Massachusetts and theDistrict of Columbia recently voted to bar insurance companies fromcharging higher premiums to smokers. More states may follow.

In the U.S., 43.8 million people—19 percent of the totalpopulation—smoke. A number of these will need to access healthinsurance through the ACA. If they are subject to a 50 percentpenalty, what happens? Chances are they get priced out of coverage.How does this advance the goal of covering more people? Even theAmerican Cancer Society opposes this. Says a spokesman, "This isthe population that needs healthcare the most. We are antismokingfor sure, but we are not antismoker."

• The Confusion Factor: Those of us in theinsurance industry sometimes forget that people who don't work inour industry regard insurance as something to avoid thinkingabout.

Three years after passage of the ACA and months before majorprovisions take effect, two-thirds of Americans say they have toolittle information to know how the law will affect them. A KaiserHealth Tracking poll found that overall, Americans'awareness of key elements of the law has declined somewhat sincepassage when media attention was at its height. The surveyalso found that the public is not tuned into decisions states aremaking today about how to establish the insurance exchangemarketplaces.

That kind of apathy is fertile ground for misinformation.

The survey discovered that 47 percent of those polled mistakenlybelieve illegal immigrants can receive subsidies to purchase healthcoverage, 40 percent incorrectly believe a government panel will becreated to make end-of-life decisions for Medicare beneficiaries,and close to 60 percent were mistaken that health spending rosefaster than usual in recent years, when, in reality, it hasdeclined.

Electoral Politics

Rising rates, massive confusion and the potential for fraud. Allthis could combine to sour the public on the ACA going into nextyear's mid-term elections. Mix in vested economic, electoral andideological interests on both sides who could profit by fightingyet another battle and you have the makings of a politicaldonnybrook.

Still, it might not happen. People are used to keeping theirchildren on their healthcare plans until age 26. By the time thenext election rolls around, they may well be accustomed to havingtheir preexisting conditions covered and not getting cancelled justbecause they get sick. Convincing people that they should supporttaking away the basic fairness that they now enjoy will be a verytough sell.

No matter what happens, the ideological warriors on both sideswill try to spin the implementation of Obamacare to their politicaladvantage. Advocates will call it a success and opponents willproclaim it a failure.

Three years after the final vote for approval in Congress, thedebate about healthcare reform is not over. It may continue for theforeseeable future.