The most ambitious and sweeping social legislation in a half-century moves into its final stage Tuesday, as enrollment opens at the state-run consumer marketplaces that are central to President Barack Obama's campaign to remake the nation's health insurance system.
Hiccups virtually are assured as tens of millions of people try to understand and comply with new rules and bureaucracies. But undoubtedly, once new insurance policies begin Jan. 1, the process already will have brought about dramatic changes.
"This is revolutionary. This law is going to change everything about health insurance in the United States," said consultant Bob Aita of Aita & Associates Insurance Marketing in Sebastopol.
The keystone of the law commonly called Obamacare — fondly by its fans, pejoratively by its critics — is that nearly everyone will be required to have insurance or else pay a penalty. And it provides a range of subsidies to help many people pay for coverage.
That means a huge change in circumstances for about 10 percent of Sonoma County's population: 50,000 people who are now uninsured and who, for the most part, are considered the law's biggest winners. The roughly 20,000 undocumented immigrants in the county are not eligible for coverage.
For those eligible, the impact of the Affordable Care Act is that they will be required to get insurance — but they also will have greater access to health insurance and in ways they didn't have before.
Access to Medi-Cal, the insurance plan for low-income people, will broaden as the upper income limit is raised. As it stands, only people earning at or below the federal poverty level are eligible. The new upper limit will be 138 percent of the poverty line.
Others without insurance who earn too much to qualify for Medi-Cal will be offered a sliding-scale subsidy pegged to their income to help make insurance affordable as long as they purchase it through the state's health insurance marketplace.
"The access to the insurance is access to care," said Rita Scardaci, director of the county's Department of Health Services. "It really is an exciting opportunity for us to move as a community toward being healthier."
Meanwhile, those above the income cutoff of four times the poverty level — which annually for a single adult would be $46,000 and $94,200 for a family of four — will not qualify for a subsidy, but nonetheless will face a penalty unless they get insurance.
Things will change less for people who already are insured, especially those who get coverage through their employer. But even for them, the world of health insurance will be remade as big shifts take place, some of which already have begun to kick in.
Some of those include:
Beginning next year, insurers will no longer be able to use someone's pre-existing health conditions, including mental illness, as a reason to deny them health insurance. Children have had this benefit since Obamacare's first year in 2010.
Insurance policies will be required to include "minimum essential benefits" ranging from pediatric care to emergency services to psychiatric treatment and prescription drug coverage.
Policies that include dependents already are required to cover adult children until age 26.
Older people might pay less for their insurance; younger people might pay more.
Women receive free services including Pap smears, mammograms and contraception.