What’s next for ObamaCare?

Eight million people have signed up for ObamaCare. So what now?

As ObamaCare enters its fifth year, big questions remain about how the law is working and whether it will live up to promises of providing affordable coverage and slowing the growth of medical costs.

{mosads}The politics surrounding ObamaCare are equally uncertain.

The botched rollout of HealthCare.gov emboldened critics and stoked Democratic fears that the law would be an albatross in the 2014 midterm elections. But last month’s late enrollment surge pushed the coverage numbers above expectations, and recent polls indicate that voter disapproval of the law is waning.

Republican leaders have made clear that their campaign strategy this year will center on attacking ObamaCare, but Democrats say that plan will backfire.

Here are five things to watch as the next chapter of the ObamaCare debate unfolds.

Will premiums rise on the exchanges in 2015?

Health insurers are analyzing their risk pools right now in order to calculate premium prices for next year. If prices on the exchanges skyrocket in some states, Democrats could pay a heavy price.

Republicans have long predicted that few young and healthy people would sign up for ObamaCare, creating an actuarial “death spiral” that would doom the marketplaces in 2015. So far, the Obama administration appears to have avoided that outcome.

Adults between ages 18 and 34 now account for 28 percent of enrollments on the marketplaces, the White House said. While that percentage falls short of the 4-in-10 minimum that some experts see as ideal, it is roughly the equal to the share of young adults that signed up for coverage in the first year of Massachusetts’s healthcare reform law.

Actuarial groups and the Congressional Budget Office (CBO) are also optimistic. The CBO said Monday that the average 2015 premium for the second-lowest-cost “silver” plan would rise slightly next year and by 6 percent each year for the rest of the decade.

Even if insurers seek dramatic rate hikes, the price changes must be approved by regulators in 37 states, according to the Kaiser Family Foundation.

Still, some companies have warned that they are considering pronounced cost increases. If enacted, the higher prices will bolster the Republican argument that the law isn’t working for consumers.

Is the law getting more popular?

For much of its existence, ObamaCare has registered low public approval ratings as Republicans made the case that the law will increase healthcare costs and erode patient choices. Those attacks helped fuel the GOP’s takeover of the House in 2010.

Recent polls indicate that public sentiment on the law might be changing. A Gallup survey released last week found that 32 percent of voters fear ObamaCare would make their own healthcare situation worse — down from 40 percent a month ago — while a combined 66 percent say the law will either help them or won’t affect them at all, up from 57 percent in the previous poll.

Meanwhile, the percentage of voters who think the law will negatively impact the nation’s healthcare system on the whole ticked down 3 points, Gallup found, while those who think it will improve that system ticked up.

Obama and other Democratic leaders have long argued that the popularity of the reforms would increase as the law matured and more people reaped the benefits. Obama on Thursday said that prediction is coming true.

“The longer we see the law benefiting millions of people, the more we see accusations that the law is hurting millions of people being completely debunked … and the more the average American who already had health insurance sees that it’s actually not affecting them in an adverse way, then it becomes less of a political football, which is where I want it to be,” Obama said during a White House press briefing.

Will the shakeup at HHS have an impact?

Health and Human Services (HHS) Secretary Kathleen Sebelius is set to depart once the Senate confirms her replacement, White House budget director Sylvia Burwell. The shakeup coincided with a burst of positive news about ObamaCare and raised questions about whether a change in leadership could help improve the law’s image.

Sebelius became a political lightning rod during her tenure. Republican lawmakers frequently accused her of misleading Congress, and at one point, threatened to investigate her for perjury.

Burwell, in contrast, is practically unknown to the public as she prepares to take the reins at HHS. While a few Republicans criticized her nomination, an equal number have praised her performance at the White House. Former colleagues say she’s a seasoned manager who will earn lawmakers’ respect in her new role. 

If Burwell can avoid political missteps, it’s unlikely she will confront the level of opposition Sebelius did. This alone could help calm the waters around the healthcare law.

Will the Supreme Court throw a curveball?

A potential wildcard in the debate is a case before the Supreme Court challenging ObamaCare’s requirement that larger, for-profit businesses give workers access to birth control as part of a cost-free package of preventative care services.

The mandate has sparked an outcry from Republicans and other conservative-leaning critics, who contend the provision violates the constitutional rights of employers who are opposed to certain forms of contraception on religious grounds.

Democrats and other supporters of the mandate counter that the requirement does not violate religious freedom because employers are under no obligation to use the birth control they reject.

The hot-button case has galvanized advocates on both sides of the issue, and the Supreme Court’s ruling, no matter the outcome, will be sure to energize each party’s ideological base a few months before the elections.

The court is expected to announce its decision in June.

Are more delays coming?

After the botched rollout of HealthCare.gov, the administration enacted a series of delays and changes to the healthcare law that angered critics and added to the perception of a White House adrift.

Combined with other policy delays — like the twice-deferred employer mandate —critics charged that Team Obama was manipulating the law in order to protect Democratic incumbents and cover up its own errors. Republicans have used the argument that Obama is not following the law to justify inaction on bipartisan priorities like immigration reform.

If the administration announces further ObamaCare delays before November, its choices could feed criticism from the right and undermine the administration’s message on healthcare reform. At the same time, further delays could pacify industry groups that would otherwise target Democrats in the midterms.