Knowing that the major changes under health reform wouldn’t kick in until 2014, Democrats made sure to frontload the legislation with provisions that would take effect immediately. But among these “early deliverables,” one has had a particularly tough time catching on. Low enrollment continues to plague the new high-risk insurance pools for Americans with preexisting conditions: Only 18,313 have signed up as of March, light-years behind the 200,000 people that the Congressional Budget Office estimated would sign up by 2013.

The flagging numbers have prompted Obama’s Health and Human Services Administration to take big steps to make the high-risk pools more enticing. Insurance rates in many of the pools were already below market rates, but HHS will now dip even further into the $5 billion dedicated to the program to reduce premiums by as much as 40 percent, as the Wall Street Journal notes. Perhaps more significantly, the administration will also relax the enrollment requirements, dropping a provision that required participants to show a denial from an insurance company or an offer of insurance at twice the regular rate.

While changes could help boost enrollment, Democrats acknowledge that it’s more than just the parameters of the program that might be deterring participation. On Wednesday morning, I caught up with Minority Leader Nancy Pelosi, who maintained that low enrollment was due to a lack of information about the high-risk pools, rather than the brass tacks of the program. Pelosi told me:

I think that people have to know about it, and one of the things that we have to spend time doing now is making sure that people know about it. They knew quickly that you could stay on your parents policy until you're 26 years old. That was easier to understand. … This is harder for people to understand — not that it exists, but that they qualify for it. I think we have to be more pro-active. … We have a responsibility to make sure that people do know what is available to them now.

Shortly after passage of health reform, in fact, Democrats asserted that outreach and education would become their central focus, kicking off a wide range of awareness-building campaigns in conjunction with outside allies. Though the pools are temporary — ending in 2014, when all insurance companies will be prohibited from discriminating against people with preexisting conditions — President Obama has also made them a priority, even referencing the provision during his 2011 State of the Union Speech. In certain regards, the high-risk pools might have even had a head start, at least in theory: They were already in place on a state level in a handful of places, and many Republicans embraced them in the recent past: Sen. John McCain featured high-risk pools in his 2008 campaign proposal, and John Boehner included them in a 2009 House GOP health proposal.

But the political controversy surrounding health reform has quickly overshadowed the specific questions and issues surrounding its implementation. Coming into the new Congress, Republicans put the repeal of the Affordable Care Act at the top of their agenda, putting Democrats on the defensive and drawing out the debate over whether the legislation should exist in the first place. In recent weeks, moreover, Democrats have been consumed by their offensive against Republican Rep. Paul Ryan’s plan to overhaul Medicare, again taking the focus off putting the ACA into effect.

Perhaps as a result, many Americans remain clueless about what’s in the Affordable Care Act — and even whether it still exists. As recently as late February, a poll conducted by Kaiser Family Foundation found that nearly half of Americans thought that health reform had been repealed or said they didn’t know whether that was the case. Within that context, it’s not surprising that so few Americans are rushing to sign up for a special insurance program that, up until recently, had relatively stringent requirements for participation.

The obstacles that these early deliverables have encountered have prompted even some reform supporters to wonder whether the Dems were overly ambitious about what they could accomplish immediately. In addition to the high-risk pools, for example, a new insurance regulation banning some bargain-basement insurance plans has prompted HHS to issue 1,370 waivers to businesses and other policyholders to exempt them from the program, as I recently reported. “It was a huge lift — it was always going to come out of the gate more slowly than they thought,” Peter Harbage, a health-care consultant and former Clinton administration official, told me, referencing the high-risk pools. “It’s like turning around an aircraft carrier.” Nevertheless, having made big promises about the immediate benefits of health reform, Democrats might be under growing pressure to deliver.

Suzy Khimm is a staff reporter in the Washington bureau of Mother Jones.