"The people who stand to benefit the most are the least aware of the changes that are coming," said Rachel Klein, executive director of Enroll America, a nonprofit that's trying to generate consumer enthusiasm.
"My biggest fear is that we get to Oct. 1 and people haven't heard there is help coming, and they won't benefit from it as soon as they can," she added. "I think it is a realistic fear."
Even the term "exchange" could be a stumbling block. It was invented by policy nerds. Although the law calls them "American Health Benefit Exchanges," Sebelius is starting to use the term "marketplaces" instead.
Polls underscore the concerns. A national survey last October found that only 37 percent of the uninsured said they would personally be better off because of the health care law. Twenty-three percent said they would be worse off in the Kaiser poll, while 31 percent said it would make no difference to them.
Insurers, hospitals, drug companies and other businesses that stand to benefit from the hundreds of billions of dollars the government will pump in to subsidize coverage aren't waiting for Washington to educate the public.
Blue Cross and Blue Shield plans, for example, are trying to carve out a new role for themselves as explainers of the exchanges. Somewhere around 12 million people now purchase coverage individually, but the size of the market could double or triple with the new approach, and taxpayers will underwrite it.
"Consumers are expecting their health insurance provider to be a helpful navigator to them," said Maureen Sullivan, a senior vice president for the Blues' national association. "We see 2013 as a huge year for education."
One goal is to help consumers master the "metals," the four levels of coverage that will be available through exchange plans — bronze, silver, gold, and platinum.
Blue Cross is also working with tax preparer H&R Block, which is offering its customers a health insurance checkup at no additional charge this tax season. Returns filed this year for 2012 will be used by the government to help determine premium subsidies for 2014.
"This tax season is one of historical significance," said Meg Sutton, senior advisor for tax and health care at H&R Block. "The tax return you are filing is going to be key to determining your health care benefits on the exchange."
Only one state, Massachusetts, now has an exchange resembling what the administration wants to see around the country. With six years in business, the Health Connector enrolls about 240,000 Massachusetts residents. It was created under the health overhaul plan passed by former Republican Gov. Mitt Romney and has gotten generally positive reviews.
Connector customer Robert Schultz is a Boston area startup business consultant who got his MBA in 2008, when the economy was tanking. Yet he was able to find coverage when he graduated and hang on to his insurance through job changes since. Schultz says that's freed him to pursue his ambition of becoming a successful entrepreneur — a job creator instead of an employee.
"It's being portrayed by opponents as being socialistic," Schultz said.. "It is only socialistic in the sense of making sure that everybody in society is covered, because the cost of making sure everybody is covered in advance is much less than the cost of putting out fires."
The Connector's executive director, Glen Shor, said his state has proven the concept works and he's confident other states can succeed on their own terms.
"There is no backing away from all the challenges associated with expanding coverage," Shor said. "We are proud in Massachusetts that we overcame what had been years of policy paralysis."
EDITOR'S NOTE _ This is the first story in a two-part series that provides an overview of the major changes in health insurance facing Americans under the Affordable Care Act, President Barack Obama's health care overhaul.