Let's be honest. In the history of American health care, theyear 2013 won't exactly go down as a time that went as smoothly asone of President Barack Obama's campaign speeches.

At mid-year, most observers could see some of the downsides:rising premiums and dropped policies. Deadlines had to be pushedback, and some parts of the law demanded rewrite.

And by October — when the exchanges rolled out — there were(are) “glitches” with state websites and www.healthcare.gov, whichprompted calls for Silicon Valley to rescue the $600 million mess.Tea Party Republicans partially closed the government in an attemptat political blackmail, while Democrats quickly distancedthemselves from the program's failures. It was difficult for anygood news about PPACA — such as reduced premiums for some consumersand the ability for people with pre-existing conditions to buycoverage again — to cut through the media morass.

But even though PPACA implementation has been bumpy, it willcontinue — and 2014 will prove to be a pivotal year. Much of thelaw's major provisions take effect next year, and yes, there arelikely to be more delays or problems. Brokers can count on clients,employees and HR managers turning to them for advice on coming intocompliance with the law and helping make decisions in the uncertainbusiness environment ahead.

“In some respects, someone who's new to insurance and islearning the new scheme — they'll have an advantage because thestuff we used to know doesn't apply anymore. It's all new,” saysPamela Mitroff, director of state affairs for the NationalAssociation of Health Underwriters. “I answer the bulk ofcompliance questions from our members. I get 20–30 a day, andthey're not just one simple question. Many of them will have a pageof questions.”

Here's a look at what's ahead in 2014 for Obamacare.

The individual mandate

Beginning Jan. 1, 2014, Americans must buy health insurance froma private insurance provider or through a public program. While theglitch-marred exchange website debuted in October 2013, individualsmust have insurance by Jan. 1 in order to comply with the newregulation. The penalty for failing to do so is either $95 or 1percent of a person's income — whichever is higher.

Market reforms

PPACA includes a bevy of market reforms — the most notable beingthat carriers will have to cover people with pre-existingconditions. Others include prohibiting lifetime limits, definingsmall employer groups as between 1–100 employees (some states candefine as 50 employees until 2016), and limiting annual deductiblesto $2,000. Brokers and agents point to PPACA's edict on modifiedcommunity ratings as a major factor in potential increases in thecost of plans. PPACA mandates a 3:1 community rating, while somestates are as high as 8:1. Carriers also will not be able to chargemore for women.

“You'll see younger people with plans that go up in price, andthe older folks, in all likelihood, stay where they were,” saysZach Zinser of Zinser Benefit Service in Louisville, Ky. “They'regoing to raise the bottom up.”

Tax credits begin

Because of the individual mandate, Obamacare also includes taxsubsidies for individuals to help them afford the cost of healthinsurance. However, the tax credits are dependent on annual incomeand access to private plans. Brokers have answered a lot ofquestions from employees about whether they qualify for a taxcredit and will continue to do so.

“The No. 1 question I get is, 'Am I eligible for a subsidy?'”says Trish Freeman of Trish Freeman Insurance Service in Gonzalez,La.

“When people hear Affordable Care Act or they hear comments from[The Department of] Health and Human Services or the president,they're expecting something affordable,” says Darlene Tucker, ownerof Darlene Tucker Insurance and Financial Planning in Scotts Hill,Tenn. “And they may or may not find it affordable. We're going tosee a lot of people where the premium is not affordable. And Ithink we'll still see people who can't afford the premium whoaren't eligible for the subsidy.”

New tax No. 1

To help pay for it, architects of the law built in several newtaxes and fees on carriers. Perhaps the most expansive is calledthe Health Insurance Tax, which is expected to generate $8 billionin 2014 and more than $100 billion over 10 years, according toAmerica's Health Insurance Plans. Several groups—and unions thathave negotiated top-shelf plans for their members—have startedlobbying to repeal the tax.

New tax No. 2

Another tax comes in the form of the “transitional reinsurancefee.” A fee of $63 for each life covered on a health insurance planwill be collected yearly from carriers. The fee will be first becollected in 2014, and it will continue being collected through2016. The fee is supposed to offset the extra cost of coveringpeople with pre-existing conditions.

Brokers and agents credit these two new taxes and others ascontributors to premium increases across the country.

“Those are all taxes that will be built into the price now,”Zinser says.

Medicaid expands

Medicaid — the state-federal program that provides healthcoverage for the poor —will expand to cover individuals whoseincomes are 133 percent of the federal poverty level. Some stateshave opted not to take part in the Medicaid expansion.

Health care co-ops

Co-ops will be allowed to compete for consumers on theexchanges. An Oct. 22 story in the Washington Post, however,reported some co-ops are in trouble and might not have enoughfunding to adequately begin operations. In some states, though,co-ops have launched.

“Unfortunately, when everyone in Michigan had to submit theirrates, it was a guessing game, and [the co-op's] rates are higher,”says Denise Van Putten, an account executive with the Grand Rapids,Mich.-based Lighthouse Group. “I think a co-op is a good idea if wecan get the rates to be competitive.”

Freeman pointed out the relative youth of the co-ops — many ofwhich were created during the time since Obamacare's passage —could affect consumers' perception about their quality andaffordability.

“In Baton Rouge, there are two companies on the exchange — wehave Blue Cross and the Louisiana co-op,” Freeman says. “People area little leery about companies they don't know anything about.”

Minimum standards

All health insurance policies must adhere to standards set forthunder PPACA. People who've lost policies in 2013 and those who willcontinue to lose coverage in 2014 will do so because their existingplans don't meet 10 minimum standards mandated under PPACA.

Those standards include:

• ambulatory patient services
• emergency services
• hospitalization
• maternity and newborn care
• mental health and substance use disorder services, includingbehavioral health treatment
• prescription drugs
• rehabilitative and habilitative services and devices
• laboratory services
• preventive and wellness services and chronic diseasemanagement
• pediatric services, including oral and vision care

Waiting periods defined

Also starting Jan. 1, the waiting period for people to sign upfor health insurance will be set by PPACA. Waiting periods of morethan 90 days will be prohibited for all health plans. Brokers andagents say this provision mainly affects businesses and industriesthat experience high turnover.

Wellness worth more

PPACA also allows employer-sponsored wellness programs toincrease the value of incentives. After Jan. 1, employers canincrease the value of incentives to 30 percent of premiums. Forreducing tobacco use, employers can increase the maximum reward upto 50 percent.

Factor in the new regulations with parts of the law that arealready in effect, and brokers and agents agree that there has beena profound impact on the individual and small-group markets. Somewarn that the market could disappear, while others say the marketcan withstand Obamacare's regulations.

“For brokers that work in the small-group arena, the vastmajority of groups with under 50 employees are going to look atdropping their coverage,” Tucker says. “That's been my opinionsince the law passed, and nothing has happened to change mymind.”

Van Putten says that among the more than 500 small groups hemanages, less than 10 percent will drop their coverage.

“The rates out there for individuals are high,” she says, “sothey're completely different from the group plans.”

So as 2014 looms, brokers around the country are continuing toadvise clients. But they're also looking around for newopportunities and developing strategies to keep their ownbusinesses afloat. Some have advised a wait-and-see approach, whileothers have been more aggressive.

Freeman says at the end of the day, it's about helpingclients.

“I can't bail on them,” she says. “I can't leave them with anavigator — someone who's had 20 hours of training when I've had 20years of training. I will get my clients through this, and as longas I don't lose money in the future, I'll be here.”