Getting those who signed up this year enrolled again for 2015 won’t be as easy as it might seem. And the law’s interaction between insurance and taxes looks like a sure-fire formula for confusion and as I’ve pointed out before, the Affordable Care Act (ACA) and all its ramifications are enough to confuse even the smartest of healthcare purchasers.

— For the reported roughly 8 million people who signed up this year, the administration has set up automatic renewal. There is a however, because the real numbers are more like 6 million enrollees. But consumers who go that route with automatic enrollment may regret it. They risk sticker shock by missing out on lower-premium options. And they could get stuck with an outdated and possibly incorrect government subsidy. Automatic renewal should be a last resort, consumer advocates say.

–An additional 5 million people or so will be signing up for the first time on HealthCare.gov and state exchange websites. But the Nov. 15-Feb. 15 open enrollment season will be half as long the 2013-2014 sign-up period, and it overlaps with the holiday season.

— Of those enrolled this year, the overwhelming majority received tax credits to help pay their premiums. Because those subsidies are tied to income, those 6.7 million consumers will have to file new forms with their 2014 tax returns to prove they got the right amount. Too much subsidy and their tax refunds will be reduced. Too little, and the government owes them.

–Tens of millions of people who remained uninsured this year face tax penalties for the first time, unless they can secure an exemption.

“It’s the second open enrollment, but the first renewal and the first tax season where the requirements of the Affordable Care Act are in place,” said Judy Solomon, vice president for health policy at the Center on Budget and Policy Priorities, which advocates for low-income people, and supports the law.

“The fact that it is all going to be occurring within an overlapping and relatively short time frame … means that there will be many issues,” she added.

At Foundation Communities, an Austin, Texas, nonprofit serving low-income people, Elizabeth Colvin says more volunteers will be needed this year to help new customers as well as those re-enrolling. Last time, her organization’s health insurance campaign lined up 100 volunteers. She figures she will need a minimum of 50 more.

“We have less than half the time than last year, and it’s over the holidays,” she said. “We have a concern about trying to get more people through the system without shortchanging education, so that consumers know how to use the insurance they’re enrolling in,”

Some congressional supporters of the law are worried about more political fallout, particularly because of the law’s convoluted connections with the tax system.

“It seems to me there ought to be some way to better educate folks on what they may face in this process,” Rep. Mike Thompson, D-Calif., told Internal Revenue Service Commissioner John Koskinen at a hearing last week.

Thompson wasn’t impressed when Koskinen said the IRS has put information on its website and is using social media to get out the word.

Rep. Bill Pascrell, D-N.J., said in an interview that he disagrees with making people pay back part of their premium subsidy. That would happen if someone made more money during the year and failed to report it to HealthCare.gov.

“Why should individuals be punished if they got a bump in salary?” said Pascrell. “To me, this was not the ACA I voted on.”

Last year the federal website that serves most states crashed the day it went live, and it took the better part of two months to get things working reasonably well. This year, the Obama administration is promising a better consumer experience, but officials have released few details. It’s unclear how well system tests are going.

“This coming year will be one of visible and continued improvement, but not perfection,” said Andy Slavitt, a tech executive brought in by the Department of Health and Human Services to oversee the operation.

Insurers say they continue to worry about connections not fully straightened out between their computer systems and the government’s.

They also are concerned about retaining customers. One quirk troubling the industry is that policyholders who want to update their subsidies and stay in the same plan will have to type in a 14-character plan identifier when they re-enroll online. That’s longer than a phone number or a Social Security number, and customers may not know where to find it.

Administration spokesman Aaron Albright says consumers will have several ways to do that. The number will be mailed to them by their insurer as part of their renewal notice, they can get it from a HealthCare.gov call center or they can select the same plan while browsing other options online.

Alex Stevens, a dishwasher at an Austin pizzeria, got covered this year and said he’s planning to re-enroll. A skateboarding enthusiast in his late 20s, Stevens broke a leg skating with friends this summer. It was a bad break and he had major surgery the next day.  But his insurance paid most of the $55,000 bill, and he only owed $750.

“My mom said she was glad that I have insurance,” said Stevens.

As the share of Americans remaining uninsured declines, it’s clear the health care law has filled a need for millions of people like Stevens, who work but don’t have coverage on the job.

That demand was strong enough to overcome a dysfunctional website the first year of the coverage expansion. The second year will show whether the full program is workable for the people it was intended to serve, or if major retooling will be needed.

Here is a part that is confusing; by the educated analyses nearly 6.4 million have obtained health insurance coverage through HealthCare.gov as of Dec. 19. Of that, 1.9 million are new sign-ups while the remainder are manual and automatic re-enrollees, HHS Secretary Sylvia Mathews Burwell announced Tuesday. So, where are the 1.6 million of the other enrollees?

When combined with the more than 750,000 people who have signed up on state-based exchanges over the first month of open enrollment, total sign-ups have surpassed 7.1 million. The federal agency plans to release a complete monthly report with additional state and federal sign-up figures next week, Burwell said during her news briefing.

The administration has been reluctant to release state data because HHS wanted to ensure it is receiving the most accurate and up-to-date numbers even as some state exchanges extended the sign-up deadlines for when people would have to be in a plan for their coverage to be active by Jan.1, Burwell said.

The 7.1 million figure means the Obama administration is quickly closing in on its 9.1 million goal for sign-ups by the time the second open-enrollment period closes Feb. 15, but how accurate are the current numbers of enrollees and is the ACA sustainable?

Consider the following reported problem in Iowa from the Associated Press.

A taxpayer-backed Iowa health insurer created under ObamaCare has been taken over by the state amid deep financial problems, sending policyholders in the Midwest scrambling for new coverage and raising questions about the status of similar outfits across the country.

The Iowa Insurance Division announced Wednesday that Insurance Commissioner Nick Gerhart was taking over CoOpportunity Health, a struggling cooperative that sprouted out of the Affordable Care Act.

A local court had granted Gerhart’s request to be appointed as “rehabilitator” of the nonprofit, after the state warned of its “hazardous financial condition.” Gerhart now has the authority to manage the company — and either restructure it or have its assets liquidated.

Gerhart told customers that those who enrolled before Dec. 15 and make their premium payments can keep their insurance.

But anyone who signed up Dec. 16 or later will not have coverage and now must enroll in other plans to stay insured. Further, if CoOpportunity Health goes under, a government safety net could protect those left holding their policies. However, the coverage “may be limited,” the state warned. And Gerhart is advising that most of the 120,000 CoOpportunity Health policyholders in Iowa and Nebraska “may find it in their best interests” to find new carriers by Feb. 15 — the deadline for open enrollment for 2015 coverage.

CoOpportunity Health will no longer offer its policies through Iowa’s online marketplace, either.

For critics of the law, Wednesday’s announcement was more evidence of the ACA’s problems.

“Here in Iowa, we were promised more [choices] and lower premiums, yet now we learn that one of two [companies] responsible for providing affordable insurance can’t provide what the law promises,” Drew Klein, director of the Iowa chapter of the conservative Americans for Prosperity, said.

With CoOpportunity Health off the exchanges, it leaves plans offered by Coventry Healthcare as the only option for Iowans who qualify for the federal subsidies under the law.

Therefore, are we actually getting the accurate information on the correct information on the success of the supporting insurance companies and the amount of subsidies that the government is supplying to the insurance companies as they fail or in trouble. Consider that the Iowa Company, which formed last year, had been promised $146 million from the Centers for Medicare & Medicaid Services.

How much additional payment has been promised to other insurance and co-insurance companies? Also, with the change in the political environment, will the amount of supportive financial incentives still be available to keep the ACA do what it was designed for…. those who can’t afford healthcare?

Next week I will start with my evaluation of the Sick Care system that we have and my suggestions for a Wellness Care system.