Obamacare: What Could Go Wrong Next?

vaeenma/Thinkstock(WASHINGTON) — After an unprecedented, last-minute surge, the Affordable Care Act open-enrollment period closed last week, topping out at more than seven million enrollees.

But even as the White House celebrated surpassing its enrollment goal, Republican strategists were downplaying its significance.

Though Obamacare undoubtedly hit a major milestone on March 31, the path ahead could still be a rocky one.

Here’s a look at the challenges that remain for the president’s signature health care reform law:

1. DEADBEAT ENROLLEES

The 7.04 million number the White House has been touting includes individuals who have signed up to purchase health care but have yet to pay the premium.

If they don’t pay, they’ll be dropped from their plans.

Predictions about the number of enrollees who have actually completed the process by paying the premium run the gamut. One major insurer estimated that as few as 80 percent of enrollees had coughed up the cash. Department of Health and Human Services Secretary Kathleen Sebelius suggested that the number may be as high as 90 percent.

Based on those estimates, only about 5.63 to 6.34 million people are currently fully enrolled with health insurance — which means that, as of right now, the risk pools are 10 to 20 percent smaller than the Obamacare team had originally hoped.

Of course, the most recent enrollees, whose coverage won’t kick in until May 1, haven’t received their bill, so it’s likely that at least some of the people who haven’t yet paid still will.

The White House seemed confident that the overwhelming majority of enrollees will follow through on their decision to purchase health insurance.

“Long before the Affordable Care Act…a lot of people bought health insurance and the overwhelming majority paid for their health insurance on time. There will be nothing different about this,” White House press secretary Jay Carney told reporters.

Republican lawmakers were less optimistic.

“Those numbers are a bit of funny math,” Sen. Ted Cruz, R-Texas, said on Fox News. “At this point, it is abundantly clear this thing isn’t working.”

According to the White House, the current total does not include enrollees who signed up through the state-run exchanges or individuals who purchased insurance directly from insurance companies. It also excludes people who will sign up during the special enrollment period, a second chance for those who encountered glitches on the site or underwent major life events like divorce or the birth of a child.

2. GEOGRAPHIC LOPSIDEDNESS

Political pundits have long pointed to the total number of young people enrolled — and that number as a percentage of the entire marketplace — as important indicators of the law’s success.

The thing is, the total number doesn’t really matter. Risk pools are aggregated on a state-by-state basis, so what really matters is the mix in each state.

It’s possible that some states may have a disproportionately high percentage of healthy, young people while others will have a disproportionately low percentage.

Since premiums are also calculated geographically, next year’s premiums could skyrocket in some areas and plummet in others.

3. UNHEALTHY YOUNG PEOPLE

We all know that for the plan to work, Obamacare needs young people. But actually, that’s “young people” with an asterisk.

The percentage of young Americans, even when broken down geographically, doesn’t mean much if they aren’t, by and large, healthy.

Of course, young people, on the whole, are less likely to develop costly medical conditions.

But it’s possible that the overwhelming majority of the so-called “young invincible” demographic who have actually enrolled in the law did so because they know they’re not invincible — because they’re already sick.

The Affordable Care Act forbids insurers from rejecting patients based on pre-existing conditions, which means that it’s possible even younger enrollees already have costly medical problems.

Next year’s premiums will be calculated, in part, based on average medical bills per person — the total cost of care divided by the number of people in the risk pool. If the pool doesn’t have enough healthy people (young or not), premiums will rise.

4. A FLOOD OF ROUTINE MEDICAL PROCEDURES?

Some previously uninsured patients (or those with sub-standard plans) have been putting off routine tests — such as colonoscopies and pap smears — that they will now be able to obtain at a fraction of the price.

(The Affordable Care Act’s essential health benefits requirement stipulates that all non-grandfathered plans must offer preventative care.)

An unusually high number of routine medical procedures could artificially inflate the per-person health care costs — but only for this year.

Still, because average medical bills are used to calculate next year’s premiums, higher-than-average health care costs in 2014 could result in premium hikes next year.

5. TECH TROUBLES

Just when we thought HealthCare.gov’s tech woes were over, the site crashed for a short period on the final day of enrollment. But that wasn’t the only — or even the most-serious — technical issue facing the site.

Fortunately for most consumers, the remaining roadblocks are likely to affect insurers, not the insured.

The mechanism to pay insurers the government subsidies — the difference between the plan cost and the patient’s payment — has yet to be completed.

It’s not yet clear when the so-called “back-end” mechanism will be completed. In the meantime, insurers have reportedly been manually billing the government for the subsidies.

But some believe manual billing will be riddled with errors and is likely to result in yet another administrative headache.

Copyright 2014 ABC News Radio