Welcome to Health Reform Watch, Jason Millman's regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Jason with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition, or sign up here to receive it straight from your inbox. Read previous columns here.

Obamacare's opening act was hard enough, and the health care law's second year isn't looking much easier.

Directors of the state-run health insurance marketplaces, who spoke on a panel in Washington Friday, are worried about keeping the customers they already have. And they know it'll be a challenge to boost enrollment in 2015, when the Congressional Budget Office projects that the marketplaces will cover 13 million people across the country.

"The low-hanging fruit, we picked," said Peter Lee, executive director of California's exchange, which surpassed initial targets by signing up 1.4 million people this year. "It is going to be an issue getting people who were not historically insured across the finished line."

Lee, joined by exchange directors from Kentucky and Maryland, talked Friday about the challenges they see ahead as the health-care law moves past its start-up phase, as well as their plans for making the exchanges easier places to shop for coverage.

They frequently came back to their concerns around retention, which I've written about previously. The issue is this: Once people have enrolled in coverage, how do you make sure they keep paying premiums to stay enrolled?

The directors see low health insurance literacy, particularly among the previously uninsured, as a hurdle. For example, they may not expect their out-of-pocket costs to be as high as they turn out to be, especially under the high cost-sharing design in many Affordable Care Act health plans.

"We have an education challenge of what it means to be an informed consumer of an insurance product," Lee said. "We don't have many good models out there."

The exchange directors are reconsidering the role of in-person assisters, including navigators, whose main job was to help people get enrolled in the first place. The directors think the navigators may also be able to help the new exchange customers as they start to use their insurance coverage.

Directors are also looking to other improvements for the 2015 enrollment period, scheduled to start in November. Kentucky’s exchange, which was held up as an early Obamacare success, sees one major area where it failed in 2014: the small business exchange, also known as SHOP.

Just 54 Kentucky businesses signed up a total of roughly 500 employees in the state’s SHOP, according to exchange director Carrie Banahan. Other successful states have seen lackluster enrollment in the SHOP exchanges for several reasons – they offer limited advantages over the current insurance market for small businesses, and many employers renewed their health plans early last year. Banahan blames Kentucky’s low SHOP turnout on some clunky software.

“The [insurance] agent community did not like the SHOP functionality, so they steered everybody away,” said Banahan, adding that the state has hired Deloitte to build a better enrollment platform next year.

Covered California, meanwhile, wants to let people pay their premiums at the point of completing an application instead of waiting for a bill from their insurer. And the troubled Maryland exchange, which is dumping its enrollment system, has one major goal in mind for 2015.

"Have a better Web site," said interim exchange director Carolyn Quattrocki.

Top health policy reads from around the Web:

Hospitals trying to attract rich immigrants. "When it comes to ordering meals at Houston's Memorial Hermann Southwest Hospital, immigrant patients can choose from dishes similar to those they might eat at home: dumplings or noodles for Asian palates, curry to accommodate Indian tastes. These and other choices at medical facilities nationwide reflect intense competition to attract one of health care's most desirable demographics — affluent, foreign-born patients with generous insurance coverage or cash to pay out of pocket." Ramit Plushnick-Masti in the Associated Press.

Obamacare's helping former inmates. "When inmates in California and around the country are released, most leave prison or jail with no health insurance and little access to medical care, but that’s beginning to change. The federal health care law encourages states to expand Medicaid to include all poor single adults, not just those who are disabled or who have children. Although Medicaid won’t cover medical care for prisoners, except for longer hospital stays, public health experts say the change in the law represents an unprecedented opportunity for ex-offenders when they get out." Sarah Varney for PBS NewsHour.

Scott Brown's awkward Romneycare history. "The former Massachusetts senator, now running in New Hampshire, has become a walking megaphone of anti-Obamacare rhetoric. ... Yet for all the vitriol, Brown may not be the purest critic. Obamacare is an offshoot of Romneycare, which Brown supported as a Republican state lawmaker in Massachusetts." Kyle Cheney in Politico.