“Four weeks you rehearse and rehearse
Three weeks and it couldn’t be worse
One week will it ever be right?
Then out of the hat, it’s that big first night!”
— Cole Porter

While many Americans may not know it yet, the health insurance market has begun to shift in critical ways in the three years since the Affordable Care Act was signed into law on March 23, 2013.  First, a number of important consumer protections have been put into place – from giving young adults the option to stay covered under their parents’ policies no matter what state they live in, to setting limits on health insurance companies’ administrative expenses, to putting in place processes that curb excessive rate increases and shine an unprecedented spotlight on the reasons behind them.  These new protections – along with other provisions, like prescription drug discounts for seniors in the Medicare donut hole – were designed to deliver early results to the American public while the core provisions of the ACA were in progress.

State and federal officials, stakeholders, employers,  and many others across the country are working furiously to prepare for the main attraction: the significant coverage expansion that will come with the opening of new health insurance marketplaces on October 1, 2013, as well as an expanded Medicaid program in those states that take up that option.  Taken together, these reforms are designed to create a fairer, more affordable, and more user-friendly private health insurance market for consumers.

The extent to which they do so, of course, depends on some critical questions.  Here are just a few key issues to watch between now and open enrollment:

• Will all the declared state-based exchange states be ready? And if not, then what? It’s the question on everybody’s mind – and it’s not yet easily answered.  But given the fact that some states got a much later start on implementing their state-based exchanges than others, some are questioning the ability of all 18 states that opted for a state-based exchange to be ready on time.  The question then is, will HHS step in and fulfill these functions behind the scenes, decline approving the states’ plans, or take some other steps?

• Will enough people – especially enough young, healthy people – become aware of the new marketplaces and sign up for coverage? With nearly two-thirds of uninsured adults still unsure how the ACA will impact them, much remains to be done between now and October to educate the public about the new coverage options under the ACA.  Federal outreach efforts are scheduled to kick into high gear this summer, while coalitions like Enroll America are planning their own, complementary outreach campaigns.

• Once people know coverage is available, then what? All this education and outreach will need to be accompanied by hands-on, in-person assistance to help people understand what they’re eligible for, compare coverage options, and enroll in a plan.  According to a recent Enroll America national survey, 75% of respondents prefer getting in-person help before making what is a critical financial decision. Unfortunately, it is unclear at this time whether there will be sufficient federal and state resources to support this critical function.  Moreover, the ease with which individuals can enroll will depend on the speed and usability of complex IT systems that have yet to be unveiled to the general public.

• How will states and the federal government work together (or not) to implement market reforms?  State enforcement of the ACA’s market reforms has been lacking – and the federal government recently announced it will enforce these rules in four states.  But the role of state regulators will continue to be critical when it comes to implementing the law’s consumer protections both outside and inside the health insurance exchanges, and taking steps to ensure a level playing field between plans inside and outside the exchanges to minimize adverse selection.  How this plays out – especially in states with a federally facilitated exchange – remains to be seen.

• Speaking of enforcement… will regulators be able to stop insurers and employers from exploiting loopholes to impede the consumer protections in the law? As Christine Monahan pointed out this week, new loopholes such as an “early renewal” loophole in which carriers begin their next plan or policy years on December 31, 2013 rather than January 1, 2014, could result in consumers missing out on important consumer protections as well as premium tax credits or cost-sharing subsidies available on the exchanges  — and lead to risk segmentation as younger, healthier consumers stay in “early renewal” plans while older, sicker consumers are pooled in plans subject to the 2014 reforms.

Despite the significant remaining questions, it’s important to take a step back and remember that the ACA laid out an ambitious vision – one that lays out unprecedented new rules of the road for private health insurance, dramatically expands coverage options, and includes substantial new provisions for delivery system reforms and public health.  The first three years of the ACA have been marked by significant political, legal, and technical uncertainty, but also by significant forward progress on many of these fronts.  And as anybody who has ever been onstage knows, no matter how much you’ve rehearsed something, there is going to be an element of unpredictability when the curtain goes up.  How consumers experience the law will depend not only on the decisions made today, but also on how well implementers respond to those unexpected plot twists.