“I was shocked,” said Hauser. “I thought: ‘What the heck? How did that happen?’ I now tell everyone, including my colleagues, not to let their guard down after the vaccine.”

As more Americans every day are inoculated, a tiny but growing number are contending with the disturbing experience of getting covid despite having had one shot, or even two.

In data released Thursday, the Centers for Disease Control and Prevention reported that at least 5,800 people had fallen ill or tested positive for the coronavirus two weeks or more after they completed both doses of the Pfizer-BioNTech or Moderna vaccine.

A total of about Americans are now fully vaccinated.

These so-called breakthrough infections occurred among people of all ages. Just over 40% were in people age 60 or older, and 65% occurred in women. Twenty-nine percent of infected people reported no symptoms, but 7% were hospitalized and just over 1%, 74 people, died, according to the CDC.

Public health officials have said breakthrough infections were expected, since manufacturers have warned loudly and often that the vaccines are not 100% protective. The Pfizer and Moderna versions have consistently been shown to be above 90% effective, most recently for at least six months. Studies have also shown they are nearly 100% effective at ensuring that the small fraction of vaccinated patients who do contract the virus will not get severe cases or require hospitalization.

Still, people are usually shocked and befuddled when they become the rare breakthrough victim. After months of fear and taking precautions to avoid contracting covid, they felt safe once they got their shots.

Hauser, 52, had stayed home from work to care for her kids, ages 21 and 16, both of whom had contracted the virus. She was confident she was protected. She was also taking care of her father, who has cancer.

“It’s a minor miracle that I didn’t infect him before I realized I, too, was sick,” Hauser said. In keeping with the virus’s fickle behavior, Hauser’s husband, Brian, who had not yet been vaccinated, also never got infected.

Masha Gessen, a staff writer for The New Yorker, completed the two-shot process in mid-February. A month later, Gessen fell ill and tested positive after both Gessen’s son and partner, Julia Loktev, had weathered bouts of covid. The experience was “unsettling, even a bit traumatic,” Gessen said. Loktev’s illness occurred six days after her first dose.

“The psychological effect of getting the virus after a year of being very, very careful and getting vaccinated got to me,” Gessen, 54, said in an interview with KHN. “It took me about three weeks to feel back to normal.” Gessen wrote about the experience this month in .

Dr. Kami Kim, director of the infectious disease and international medicine division at the University of South Florida in Tampa, said physicians are equally disturbed when these cases crop up.

“All this, while anticipated, is definitely confusing and frustrating for people, both doctors and patients. We are all learning on the go and making judgments about what’s best for our patients — and ourselves,” Kim said.

Vaccine manufacturers said the number of breakthrough cases reported by the CDC was not surprising.

Moderna’s latest analysis of its vaccine clinical trial data shows 900 people got covid after being vaccinated, consistent with 90% or more efficacy for the vaccine, company spokesperson Colleen Hussey said.

Pfizer spokesperson Jerica Pitts said the company would monitor trial participants for two years after their second dose to learn more about the Pfizer vaccine’s protection against covid.

In their reporting, the CDC is defining a breakthrough case strictly as illness or a positive test two weeks or more after full vaccination. But tens of thousands of people who have had a first shot or are short of two weeks after their second shot are also getting infected.

Pfizer and Moderna report data showing up to 80% protection from infection two weeks or so after the first shot. But most experts believe protection ranges widely, from 50% to 80%, depending on the length of time after the shot and the individual variation that exists with any vaccine.

The second shot boosts immunity further but not for a few days, at minimum, and then builds over two weeks. And again, this could vary from person to person.

Leslie Fratkin, 60, a freelance photographer in New York City, got her second Pfizer dose March 12. So she was surprised when clear symptoms of covid showed up March 24 and she was quite sick at home for three days.

“You can’t print the words I uttered at the time,” she said.

The CDC advises people who get covid after a first shot to get the second dose soon after recovery, with no minimum wait time specified. That’s a change from prevalent advice back in December and January, when some state health departments advised people to wait 90 days after a bout of covid to get a first or second shot, and especially a second shot.

Driving this important change is mounting evidence from studies and experience indicating that immunity to infection conferred by the vaccines is stronger and possibly more “stable” over time than immunity derived from covid infection.

Michael Osterholm, director of the at the University of Minnesota in Minneapolis, said further research and better public health guidance are urgently needed. For example, is a second dose even needed for people who get covid after the first dose, or does the infection itself serve as enough of an immune system booster? And if a second shot is recommended, what’s the optimal waiting period before getting it?

“These are important practical questions that need to be prioritized,” Osterholm said. “We are sort of flying blind now.”

Other countries have handled the second dose rollout differently.

In the U.K., health authorities delayed it up to 12 weeks, to stretch vaccine supply and prioritize getting at least one shot into more people’s arms more quickly. In Canada, a government vaccine advisory committee recommended April 7 that second doses be delayed up to four months.

At two press briefings this month, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and a covid adviser to President Joe Biden, said that the number of breakthrough cases in the U.S. so far is not cause for alarm and that the administration will continue to monitor these instances closely.

One important line of investigation is how big a role variants or mutated versions of the initial coronavirus play in these breakthrough cases. Research suggests the current vaccines may be somewhat less effective against some new variants.

Martha Sharan, a CDC spokesperson, said the agency is now urging states to use genetic sequencing to test virus specimens from patients with breakthrough cases to identify variants. In Washington state, for instance, eight variants were detected in the genetic sequencing of nine breakout cases reported through April 3.

Today the Biden administration in spending would be directed from the covid relief bill to help the CDC, states and other jurisdictions more effectively detect and track variants by scaling genomic sequencing efforts.

The CDC also has launched a national covid vaccine breakthrough database in which state health departments can store and manage data.

“We are behind on sequencing samples,” said Osterholm. “That will give us valuable information.”

KHN senior correspondent JoNel Aleccia contributed to this story.

Steven Findlay, a KHN contributing reporter, came down with covid 30 days after his first dose and 24 hours after his second dose.

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“The pandemic has given us possibly the best chance we’ve ever had of getting on the right track to shore up our public health resources,” said Jeffrey Levi, a professor of health management at the George Washington University School of Public Health. “Tens of millions of us have directly experienced what happens when our country is not prepared.”

Even so, Levi and other public health advocates worry that momentum will wane once the pandemic abates, as it has after past crises and natural disasters. They also say that more sustained funding will be needed over the next decade and beyond to address long-festering problems.

“We heartily support this new law,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “But many of its provisions are for one-time and time-limited increases in funding for covid-related needs and financial distress. What we hope is that this will be a down payment on a long-term commitment to enhancing public health infrastructure and hiring more public health workers at the federal, state and local levels.”

He pointed to long-term public health issues that existed before the pandemic, such as high rates of obesity and uncontrolled diabetes, that compounded covid-related hospitalization and deaths in the U.S.

The law steers $49 billion toward enhancing coronavirus testing, contact tracing and genomic sequencing, to help identify and track virus variants. Even if the number of infections declines, the money assures these efforts continue for the rest of this year and into 2022 if needed.

Another $50 billion goes to the Federal Emergency Management Agency to support vaccine distribution and logistical and social support in areas hardest hit by pandemic-related job loss and financial strain. This includes such activities as food distribution.

States and local government agencies are allotted $350 billion to make up for lost tax revenue amid the pandemic-caused recession. Some of that money is expected to be spent on pandemic response and public health programs, but it comes with a deadline. It must be spent by Dec. 31, 2024.

The law also set aside $7.6 billion for hiring more public health workers, but experts said that won’t be enough over the long term.

The Biden administration touted this element of its pandemic plan in January, recommending that 100,000 nurses and other workers be hired as part of a new “U.S public health service corps.”

The proposal, mentioned often in media coverage in January and early February, stipulated that the new corps would initially provide support for vaccine distribution, contact tracing and the nation’s network of more than 1,000 public-funded community health centers. After the pandemic ended, those hired would retain their jobs and serve as an enduring upgrade to local public health services and preparedness, the administration indicated.

The concept of the corps is not in the final law, however, which instead specifies that the $7.6 billion be spent on “establishing, expanding, and sustaining a public health workforce, including by making awards to state, local, and territorial public health departments.” That language, public health experts said, permits the federal government more flexibility while it determines who should be hired for what and in which states.

But the language could bog down the program in red tape.

“Some state and local public health departments will need and be better able to absorb new workers than others,” said Levi of George Washington University. “The flexibility makes sense, but we will need to carefully monitor how this unfolds.”

The Biden administration initially estimated that hiring 100,000 workers would triple the size of the public health workforce. But it’s unclear how many people work in the field nationwide now, including public health nurses, disease intervention specialists, epidemiologists, contact tracers, community health workers, lab technicians, IT specialists and support staff.

A White House spokesperson said the new law “will allow us to build our long-term public health capacity, particularly in low-income and underserved communities,” in part “by hiring workers from the communities they serve.”

Dr. Umair Shah, Washington state’s secretary of health, said more “boots on the ground is definitely part of what we need,” but he added that “recruiting new people takes time.”

Shah also noted that many public health leaders and workers are burned out after the past year, in part because they often were vilified for messaging on mask-wearing, physical distancing and restrictions. Some left their jobs because of that intimidation.

Adriane Casalotti, chief of government affairs at the National Association of County & City Health Officials, which represents the nation’s nearly 3,000 local health departments, said “the backlash was harmful. I hope we can move beyond it now and that lawmakers and the public see more clearly that what we do is critical.”

Determining what the U.S. spends on public health is not straightforward. Federal and state spending for emergency programs, disaster relief, preventive health and social services commonly overlap with public health funding. Also, public health programs are spread across dozens of federal and state agencies.

Trust for America’s Health, a nonpartisan public health advocacy group, estimates that about 3% of all health spending in the U.S. goes to public health and disease prevention in 2020 — more than $100 billion.

Not content with the funding in the new law, public health advocates Congress for an additional $4.5 billion a year in annual funding for public health.

Sen. Patty Murray (D-Wash.), chair of the Senate Health, Education, Labor and Pensions (HELP) Committee, has introduced legislation to provide funding at that level. “It’s critical we end the cycle of crisis and complacency when it comes to funding for public health,” Murray said in a statement. “The simple fact is: public health saves lives.”

Carolyn Mullen, senior vice president for government affairs at the Association of State and Territorial Health Officials, concurred: “The money tends to increase in times of crisis and natural disasters, then declines after the crisis abates. That’s not the way to sustain preparedness.”

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Biden proposes hiring 100,000 people nationwide as part of a . They would help with contact tracing and facilitate vaccination. Experts said it’s not clear that would be enough tracers to keep up with another surge in covid cases, even if the vaccination rate increases at the same time.

As with everything covid right now — testing, vaccinations and hospital capacity — ramping up contact tracing has become a race against time as new, more contagious variants of the virus threaten to accelerate transmission of the disease.

In addition, as testing has steadily increased to around , so has the need for tracing. The two go hand in hand. Also, even conservative estimates put the number of people with undetected infection at the number with reported positive test results.

Such estimates translate to 75 million to 100 million infections in the U.S. Officials in California’s Los Angeles County reported Jan. 14 that an estimated , the nation’s largest, was likely infected.

I have experienced the urgency of the pandemic up close. With a leap of faith, I became a foot soldier in the covid fight last June as a contact tracer in Maryland. Talking by phone to dozens of infected and exposed people every week, I hear about the impact of the virus on families in often sobering detail.

We tracers, for example, are often the first to reach people with their positive test results since labs and health systems frequently get backed up. For people already experiencing symptoms, our calls usually confirm what they suspected. For people without symptoms, though, we are the bearers of unwelcome news. That’s not an easy part of the job.

Still, almost everyone we interview takes it in stride. They agree to isolate and provide us with the names of people they’ve come into “close contact” with — generally, within 6 feet for more than 15 minutes — in the previous week or two. Those contacts then get a call, too. The aim is to reach as many people as possible within 24 hours, to break the chain of transmission by urging them to stay home and quarantine.

Of course, not everyone cooperates. Some decline to quarantine or give the names of close contacts. Most states do not report the number of uncooperative people. But a Pew survey of adults conducted last July found that if told they had the virus. A third, however, said it would not be easy to do so — usually because of work — and a quarter said they would not be comfortable telling tracers about places they had been or people they’d been in close contact with.

As such, contact tracing has inherent limitations, and quarantining isn’t enforced in the U.S. Tracing also becomes far less effective as the number of cases grows.

An analysis by researchers at Johns Hopkins University in Baltimore concluded that contact tracing in the U.S. can be fully effective in mitigating spread of the virus only when new cases are at or below 10 a day for every 100,000 people. The case count now exceeds that in most states. The national seven-day average as of Monday was .

“Tracing programs nationwide are overwhelmed right now,” said Crystal Watson, a senior scholar at Hopkins’ Center for Health Security. “States just don’t have enough people to keep up.”

Even so, Watson added, “every contact traced still means lives potentially saved. We can’t let up.”

Every state has a tracing program, but they vary widely. The Centers for Disease Control and Prevention has comprehensive covid tracing guidelines, but the Trump administration had neither data nor performance requirements for states to meet. 

A White House spokesperson told KHN that the administration views contact tracing as “critical to efforts to reduce spread of the virus.” 

Staffing is the most significant challenge. Researchers at George Washington University in Washington, D.C., evaluated contact tracing needs and how states and counties performed.

Their bottom line, based on the most recent surge in cases: The nation would to keep up with the current number of cases — or 281 per 100,000 people.

But that projection, which takes many factors into account, is widely viewed as unrealistic. The current number of tracers, according to data from Johns Hopkins, is 70,500. 

“If we could get close to half the ideal number, it would help greatly,” said Dr. Amanda D. Castel, a professor of epidemiology at George Washington University. “With luck the vaccine will begin to reduce the need.”

Most states aren’t even close to 140 tracers per 100,000 people. With 530 active tracers, the District of Columbia has 75 per 100,000 people, more than any state. Fifteen states have 12 or fewer per 100,000. And the number of people who have received two doses of the vaccine is not yet large enough to appreciably reduce the rate of infection.

State and county health departments are keenly aware of the deficit and have moved to hire more tracers or deploy existing state or county employees to the task. Maryland, for example, has hired several hundred tracers in the past three months and is up to 1,550, said Katherine Feldman, director of contact tracing for the state. That’s still just 26 tracers per 100,000 people.

Nationally, states have hired about 17,500 tracers since October, according to Johns Hopkins data.

Biden recommended hiring contact tracers and other public health workers as part of his proposal for a $1.9 trillion covid relief and stimulus package.

Those hired would keep their jobs once the pandemic eases, to enhance the nation’s permanent public health corps and readiness. The president’s proposal does not stipulate, however, how many of those hired would be initially deployed to contact tracing. Administration officials did not respond to requests for comment on this point.

Last week, a group of Republican senators proposed a scaled-back $618 billion covid relief package that includes resources for vaccine distribution, testing and tracing but makes no mention of a public health service corps.

David Cotton, vice president for public health research at NORC, the University of Chicago  survey and research organization that assists Maryland with its program, said that while tracers don’t need medical or public health experience, hiring and training the right people and nurturing their skills is not something to be taken lightly.

“The success of tracing depends on having people in that job who can gain people’s trust,” he said. “Plus, the work can be quite emotionally draining.”

States are also adjusting programs.

In Maryland, we have shortened the questionnaire and prioritized geographic areas with high positivity rates. People are also being texted to prompt them to answer our initial calls. These steps have sharply reduced a backlog of cases, said Feldman.

Nationally, traditional tracing programs successfully reach about 65% to 75% of people who test positive and 55% to 60% of contacts. Those numbers are likely trending lower over the past six weeks after the recent surge in cases, experts and state officials said.

But no one knows for sure. That’s because there is no national reporting requirement or strategy for tracing metrics, and only 14 states make full data on their tracing programs public.

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So to help the kids and keep them safe — especially their oldest child — Jonathan opted to take 12 weeks of paid leave from his teaching job under a program authorized by an emergency federal law enacted in March.

“Qualifying for paid leave was a huge relief and has worked out really well,” said Jonathan, who lives in Concord, New Hampshire.

But the family has learned about a new wrinkle: The 11-year old needs surgery in January. The operation is expected to require a month or two of recovery. Unfortunately, Jonathan’s leave will be used up by then; what’s more, the emergency federal paid leave program it is based on lapses Dec. 31.

Unions and workers’ rights and consumer advocacy groups are this week waging a last-ditch effort to get Congress to extend the program into 2021. They argue that the program is a critical component helping to prevent the spread of the virus and providing financial assistance to struggling families.

They also assert that a number of unwise exemptions — plus a lack of enforcement and public awareness — have limited the program’s effectiveness.

“The emergency paid-leave provisions have been one important step in helping American families deal with this crisis,” said Sen. Kirsten Gillibrand (D-N.Y.). “Congress must extend the provision until this crisis is over. Paid leave is critical as the economy recovers.”

The program is among two dozen pandemic-related relief measures set to expire at the end of the year. Those include unemployment benefits, protections against evictions, student loan relief and payments for COVID testing.

The Democratic-controlled House twice approved bills extending most of those, including paid leave. But Republican leaders in the Senate have until this month refused to consider new relief and stimulus legislation. This week, negotiations have intensified on a compromise bill that extends some of the expiring measures. But an extension of paid sick days and paid leave is not included in that bill.

Capitol Hill staffers and workers’ rights advocates say a paid-leave extension could still be added to the relief bill or a government spending bill that Congress must pass this month.

“It’s outrageous that paid leave is not in this legislation,” said Vicki Shabo, a senior fellow for paid-leave policy and strategy at New America, a Washington think tank. “The evidence is very clear paid sick days and leave help prevent spread of the virus, and it’s a benefit families overwhelmingly want and need.” 

Neither the Trump administration nor President-elect Joe Biden responded to requests for comment, and neither has announced a position on the issue.

Paid Sick Leave ‘Is in the Public Interest’

The current law requires businesses with fewer than 500 workers to allow their employees to take up to 10 days of sick leave at full pay and up to 50 more at two-thirds pay to care for a child when schools or day care centers are closed because of COVID-19.

The federal government covers the cost via tax credits to employers. The benefit covers mandatory 14-day quarantine periods for those exposed to the virus, whether they get sick or not.

Larger firms were exempted on the theory that most already provide paid sick days and some forms of extended paid leave — and don’t need federal subsidies.

But an analysis after the law was enacted found that the exemption leaves about 70 million workers in large businesses — roughly half the nation’s workforce — without the full protections offered under the COVID law.

The law and subsequent Department of Labor rules also permit firms with 50 or fewer employees to opt out of providing paid sick days or leave if they think their business will be adversely affected.

About 34 million people work for those small businesses — and the majority offer fewer than 10 paid sick days, if any. Few have extended paid leave.

In addition, the law has no guarantee of paid sick days or leave for the nation’s 13 million health care and emergency response workers.

The justification for that when the measure was enacted: Hospitals, clinics, nursing homes and emergency response companies needed to ensure that these essential workers would show up in a time of crisis.

“This was extremely shortsighted and bad policy,” said Pronita Gupta, director of job quality at the Center for Law and Social Policy in Washington, D.C. “We have seen the harmful outcome — the high number of coronavirus cases in health care facilities, especially among low-wage nursing home workers.”

Nor does the law offer extended paid leave for people who have COVID-19 or need to care for a family member with the disease beyond 10 days. Republicans opposed a broad-based benefit beyond at-home child care, advocates for the benefit noted.

“The problem is we now know that thousands of people who have COVID are sick for more than two weeks, some for months,” said Shabo. “These people need to be able to stay home and recover; that’s in the public interest as well.”

this month, a coalition of nine national public health groups urged Congress to extend the paid-leave benefits. “Paid sick leave can reduce the spread of COVID-19 in workplaces and communities by removing the barrier to employees staying home if they might have the virus,” the groups wrote. “Even one infection can set off an outbreak.”

Business groups are sympathetic, but some still oppose extending paid leave. Chief among them is the National Federation of Independent Business, a lobbying powerhouse that represents small businesses. Beth Milito, the group’s senior executive counsel, said that while small-business owners have been “highly sensitive” to their workers’ needs during the pandemic, mandating paid sick days and extended leave puts an undue burden on them.

“Figuring out who qualifies, monitoring who takes leave and then applying for the tax credit is all too much red tape,” Milito said. “It’s the hassle factor at a time when many businesses are barely making ends meet.”

Estimates of the Program’s Costs Vary Widely

Surveys show a majority of the estimated 70 million private- and public-sector workers covered under the law — after all the exemptions and carve-outs — don’t know about their right to paid sick days or leave.

“The lack of awareness has limited the potential of this benefit,” said Dawn Huckelbridge, director of the Paid Leave for All campaign, which is supported by a coalition of unions and employees and other groups. The Department of Labor, which administers the benefit, “simply fell down on the job,” she said.

Estimates last spring of the use and cost of the benefit varied widely — from around $20 billion to $105 billion.

But more recent estimates suggest it may be less. According to a Government Accountability Office report citing IRS data, as of the end of October about 150,000 employers had filed for paid family and sick leave tax credits, totaling $1.3 billion. The report noted, however, that many employers will likely wait until filing their taxes in the spring to claim the credit and recoup their costs.

The congressional Joint Committee on Taxation last month released fresh projections on the cost of an extension of paid leave — $1.4 billion if extended for two months and $1.8 billion for three months.

Although it’s too early for any full assessment of the paid-leave program’s impact, advocates point to a, published online in October in the journal Health Affairs. Researchers at Cornell University and the KOF Swiss Economic Institute found that in states where workers gained the right to paid sick leave under the emergency law, 400 fewer confirmed COVID cases were reported per day.

The researchers conclude: “Our findings suggest that the U.S. emergency sick leave provision was a highly effective policy tool to flatten the curve in the short run.”

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The Orlando, Florida, resident sought treatment in May. After a series of tests, doctors told Moen she had a rare kidney condition that would require months of treatment.

“Losing the coverage ended up being worse than losing the job,” said Moen, 36, a dancer who had worked for both Walt Disney World and Universal Studios. “It was very stressful.”

Moen rushed to find replacement coverage. With help from a social service agency, she enrolled in a plan through healthcare.gov, the federal Affordable Care Act insurance marketplace. Because she and her husband, Brett, were not working — he had been laid off by Disney, too — they qualified for federal subsidies, so the coverage cost her just $35 a month. Most of her medical expenses, which involve traveling frequently to Jacksonville for specialty treatment, are covered.

Moen’s husband recently found a job, however, and the increase in the couple’s income likely means her subsidy will fall and she’ll have to pay more for health insurance. Moen said she’ll evaluate her options and may switch plans during this year’s ACA open enrollment period, which began Nov. 1 and ends Dec. 15 for coverage starting Jan. 1.

“A priority is to continue seeing my medical team in Jacksonville,” Moen said.

Moen is one of millions of Americans who have been dropped from their jobs and their employer-provided health insurance since March, when the coronavirus first ravaged the economy. Although no official tally exists, that at least 10 million workers lost their insurance but that about two-thirds of them found alternative coverage — through a new job, Medicaid, a spouse’s or parent’s plan, or the ACA marketplaces.

That leaves at least 3 million people without coverage, the most added in a single year since accurate record-keeping began in 1968. And experts are worried that, as the virus continues to play havoc with the economy, new rounds of business closings and layoffs could add to that number.

Navigators Want More Resources

The unprecedented situation has health insurance counselors (called navigators), ACA marketplace staff members and insurers scrambling to assist a possible surge of people looking for health insurance during open enrollment.

For the 36 states that rely on the federal ACA enrollment platform — healthcare.gov — the Trump administration awarded grants totaling $10 million for marketing and outreach this year, the same level as in 2019. In 2016, the last year of the Obama administration, navigator grants totaled $63 million.

Many navigator organizations say they don’t have the resources from the federal government to do the job as they would like.

“I’m trying not to panic,” said Jodi Ray, executive director of Florida Covering Kids & Families. “We’ve seen substantially more people needing coverage and help in recent months compared to last year, and more are new to being uninsured.”

Ray said her team is booked with appointments well into November. But she bemoans the fact that she has a third of the counselors she had a few years ago — 50, compared with 150 — and only a tiny ad budget.

Like Ray, Jeremy Smith, program director at First Choice Services in Charleston, West Virginia, said his team is expecting “tens of thousands more people” needing help compared with last year — but no bigger budget to serve them. First Choice provides telephone-based enrollment assistance in West Virginia, New Hampshire, Iowa and Montana with a federal grant of $100,000 per state.

“We are talking to a lot more people who have had job-based coverage for years,” Smith said. “This is the first time they are having to find insurance elsewhere. They don’t know what to do or who to trust.”

In Wisconsin, the governor shifted $1 million into health insurance outreach, in part to make up for a lack of federal funds, said Allison Espeseth, managing director at Covering Wisconsin, the state’s navigator agency. She said the money will go to radio and TV spots, billboards, bus ads and small grants to community organizations.

“A lot of people who lost jobs and insurance didn’t know they could enroll before open enrollment, so we are hoping to see them now,” Espeseth said.

Toula Barber, 60, is happy to be among those who got clear and useful help. “I’m not that savvy with computers and figuring all this stuff out,” said Barber, who lives in Manchester, New Hampshire. After she lost her job as a waitress in August, Barber’s health insurance lapsed at the end of September. A First Choice Services navigator helped her find a plan with coverage that started Oct. 1. She pays $200 a month after subsidies.

Because that plan has a $6,000 deductible, however, Barber said she would look for something better during open enrollment, in consultation with the same navigator.

An published last summer found evidence of a shortage of enrollment assistance. It also pointed out that people who turned to insurance brokers rather than independent navigators for help sometimes were presented with the option of plans (such as short-term policies or cancer-only policies) that don’t meet ACA standards.

“The bottom line was that nearly 5 million people who sought help during the last open enrollment could not find it,” said Karen Pollitz, a senior fellow at Â鶹ŮÓÅ and one of the authors of the study. “I’m concerned that people will face barriers to finding help this year, too.”

Some States Are Pushing Harder

In contrast to the states that use the federal website, healthcare.gov, many of the 15 states that run their own ACA marketplaces are committing more resources to outreach and marketing this year to meet the higher demand.

“We market aggressively,” said Peter Lee, executive director of Covered California, that state’s marketplace. “We want everyone who needs coverage to get it.” Of Covered California’s $440 million budget this year, Lee said $140 million will go for marketing and outreach. In addition, California is inserting information about the marketplace and subsidized coverage in all unemployment checks.

Just short of 300,000 Californians have enrolled since the pandemic began, and about half did so because they lost employment-based coverage, said Lee.

At the same time, however, about 1 in 4 Covered California enrollees dropped out this year, higher than the normal turnover as some newly qualified for Medicaid and an unknown number could no longer afford the premiums. Still, enrollment was at an all-time high of 1.5 million as of June.

In New York, state officials and private groups have been helping people enroll in Medicaid, marketplace plans or other state-supported programs.

“We’ve been super busy since April,” said Elizabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, an independent advocacy group for low-income residents. “Our governor prioritized this, so it’s going well.”

One challenge Benjamin noted are the fears that a case currently before the Supreme Court might overturn the law. “Our clients keep asking whether the ACA will still be around next year,” she said. “We reassure them it will.”

Madeline McGrath, 27, sought insurance help from the service society in May after her coverage through the Peace Corps expired. The corps laid off all its overseas staff in March. Madeline was in Moldova. She returned home to Chazy, New York. She qualified for Medicaid, and just in the nick of time: A few weeks earlier, she had been diagnosed with Crohn’s disease, a chronic digestive disorder.

“I’ll stick with Medicaid since my copayments are very low,” said McGrath, who is pursuing a graduate degree.

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New studies, from both federal and private research groups, generally indicate that when the country marked precipitous job losses from March to May — with more than 25 million people forced out of work — the loss of health insurance was less dramatic.

That’s partly because large numbers of mostly low-income workers who lost employment during the crisis were in jobs that already did not provide health insurance. It helped that many employers chose to leave furloughed and temporarily laid-off workers on the company insurance plan.

And others who lost health benefits along with their job immediately sought alternatives, such as coverage through a spouse’s or parent’s job, Medicaid or plans offered on the state-based ACA marketplaces.

From June to September, however, things weren’t as rosy. Even as the unemployment rate declined from 14.7% in April to 8.4% in August, many temporary job losses became permanent, some people who found a new job didn’t get one that came with health insurance, and others just couldn’t afford coverage.

The upshot, studies indicate, is that even with the new options and expanded safety net created by the ACA, by the end of summer a record number of people were poised to become newly uninsured.

What’s more, those losses could deepen in the months ahead, and into 2021, if the economy doesn’t improve and Congress offers no further assistance, health policy experts and insurers say.

“It’s a very fluid situation,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, a New York-based health research group. “The ACA provides an important cushion, but we don’t know how much of one yet, since this is first real test of the law as a safety net in a serious recession.”

Collins also noted that accurately tracking health insurance coverage and shifts is difficult in the best of times; amid an economic meltdown, it becomes even more precarious.

Coverage Was Already on the Decline

Some 20 million people gained coverage between 2010 and 2016 under the ACA’s expansion of Medicaid and its insurance marketplaces for people without employer-based coverage. A gradually booming economy after the 2008-2009 recession also helped. The percentage of the population without health insurance declined from about 15% in 2010 to 8.8% in 2016.

But then, even as the economy continued to grow after 2016, coverage began to decline when the Trump administration and some Republican-led states took steps that undermined the law’s main aim: to expand coverage.

In 2018, 1.9 million people joined the ranks of the uninsured, and the Census Bureau reported earlier this month that an additional 1 million Americans lost coverage in 2019.

The accelerating decline is helping fuel anxiety over the fate of the ACA in the wake of the death of Supreme Court Justice Ruth Bader Ginsburg. The high court is scheduled to hear a case in November brought by Republican state officials, and supported by the Trump administration, that seeks to nullify the entire law.

In July, researchers at the Urban Institute, a Washington, D.C., think tank, forecast that around would lose employer coverage in 2020. But they estimated that two-thirds of them will have found new coverage by year’s end — leaving about 3.3 million uninsured.

A , released Sept. 18, and using 2020 data from the Census Bureau, calculated that of the roughly 3 million people under age 65 who had lost job-based insurance between May and July, 1.4 million found coverage elsewhere — most through Medicaid — and 1.9 million became newly uninsured. Notably, 2.2 million of those who lost their coverage were between 18 and 39 years old; 1.6 million were Hispanic.

Another recent study, using different methods, reported higher numbers for the same period. The last month determined that between April and July 6.2 million people lost employer coverage. The authors didn’t calculate how many found alternative coverage via Medicaid or the ACA, however.

Other findings support the notion that the health insurance loss trend shifted by mid summer. Â鶹ŮÓÅ, for example, Sept. 11 showing that most companies that offered coverage to begin with chose to continue insuring furloughed and temporarily laid-off workers between March and the end of June. But as the virus continued to batter the economy, employers moved to permanently shed those jobs. (KHN is an editorially independent program of Â鶹ŮÓÅ.)

“The issue now is that the temporary layoffs have greatly decreased and permanent job losses, including jobs that came with health coverage, are increasing,” said Cynthia Cox, a Â鶹ŮÓÅ vice president and director for the Program on the ACA.

Many low-income workers who lose their jobs and don’t have coverage through a spouse or parent turn to Medicaid, the federal-state health program for low-income people. The Centers for Medicare & Medicaid Services reported last week that enrollment in Medicaid and the Children’s Health Insurance Program , a nearly 6% increase since the beginning of the coronavirus crisis.

The Impact of the Marketplaces

Gains and losses of coverage in the ACA marketplace are not yet clear, experts say. The Trump administration issued a report in June indicating that 487,000 people had, between January and June, enrolled in an ACA plan via the federal website, healthcare.gov. But that report failed to say how many people dropped an ACA plan in that period — for example, because they could no longer afford the premiums.

A study by Avalere, a health research and consulting firm in Washington, D.C., has estimated that enrollment in the ACA marketplaces since March could have swelled by around 1 million. That includes new enrollees in the 13 ACA marketplaces that states, plus the District of Columbia, operate. Many of those states held a “special enrollment period” when the pandemic hit. Healthcare.gov, run by the Trump administration, did not offer a special enrollment period.

About 11 million were enrolled in an ACA plan in February. Open enrollment for coverage that would start on Jan. 1, 2021, begins Nov. 1.

Jessica Banthin, a senior health policy researcher at the Urban Institute and until 2019 deputy director for health at the Congressional Budget Office, said it’s anyone’s guess how many people who lost their job-based coverage this year will choose this option. She said numerous factors will influence people’s health insurance decisions this fall, and into 2021.

Chief among them is gauging whether they might soon get a new job, or get back an old job, that offers insurance. That may hold some people back from enrolling in an ACA plan this fall, Banthin said. Plus, buying insurance may be too expensive, especially for families more concerned with paying for housing, food and child care while going without a paycheck.

“Health insurance may not be their immediate concern,” Banthin said. “Many people’s lives have been disrupted as never before. There’s a lot of trauma out there.”

Collins of the Commonwealth Fund said that, even before the pandemic, a growing proportion of families were vulnerable to loss of coverage and care.

In a survey of more than 4,000 adults early this year, Collins and colleagues found a “persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues.”

In large part, that’s because 1 in 5 respondents who had coverage were “underinsured.” Underinsurance reflects the extent to which coverage leaves people at risk of high out-of-pocket costs — a situation exacerbated by widespread job loss.

“Now is absolutely not be the time for the ACA to be further undermined, let alone killed outright,” said Stan Dorn, director of the National Center for Coverage Innovation at Families USA.

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Charbonneau, 43, his two partners and 10 staff members are struggling to keep their rural practice alive. Patient volume is slowly returning to pre-COVID levels. But the large Seattle-area company that owns his practice is reassessing its operations as it adjusts to the new reality in health care.

Charbonneau has been given until September to demonstrate that his practice, Lifespan Family Medicine, is financially viable — or face possible sale or closure.

“We think we’re going to be OK,” said Charbonneau. “But it’s stressful and pushes us to cut costs and bring in more revenue. If the virus surges in the fall … well, that will significantly add to the challenge.”

Like other businesses around the country, many doctors were forced to close their offices — or at least see only emergency cases — when the pandemic struck. That led to sharp revenue losses, layoffs and pay cuts.

Dr. Kevin Anderson’s primary care practice in Cadillac, Michigan, is also scrambling. The practice — like others — shifted in March to seeing many patients via telemedicine but still saw a dramatic drop in patients and revenue. Anderson, 49, and his five partners are back to about 80% of the volume of patients they had before the pandemic. But to enhance their chances of survival, they plan to overhaul the way the practice gets paid by Medicare.

Jodi Faustlin, CEO of the for-profit Center for Primary Care in Evans, Georgia, manages 37 doctors at eight family medicine practices in the state. She’s confident all eight will emerge from the pandemic intact. But that is more likely, she said, if the company shifts from getting paid piecemeal for every service to a per-patient, per-month reimbursement.

One of those 37 doctors is Jacqueline Fincher, the president of the American College of Physicians. Fincher said the pandemic “has laid bare the flaws in primary care” and the “misguided allocation of money and resources” in the U.S. health care system.

“It’s nuts how we get paid,” said Fincher, whose practice is in Thomson, Georgia. “It doesn’t serve patients well, and it doesn’t work for doctors either — ever, let alone in a pandemic.”

Physicians and health policy experts say the pandemic is accelerating efforts to restructure primary care — which accounts for about half the nation’s doctor visits every year — and put it on a firmer financial footing.

The efforts also aim to address long-festering problems: a predicted widespread shortage of primary care doctors in the next decade, a rising level of physician burnout and a long-recognized underinvestment in primary care overall.

No data yet exist on how many of the nation’s primary care doctors have closed up shop permanently, hastened retirement or planned other moves following the COVID-19 outbreak. by the American Academy of Family Physicians in late April forecast furloughs, layoffs and reduced hours that translated to 58,000 fewer primary care doctors, and as many as 725,000 fewer nurses and other staff in their offices, by July if the pandemic’s impact continued. In 2018, the U.S. had about 223,000 primary care doctors.

“The majority [of primary care doctors] are hanging in there, so we haven’t yet seen the scope of closures we forecast,” said Jack Westfall, a researcher at the academy. “But the situation is still precarious, with many doctors struggling to make ends meet. We’re also hearing more anecdotal stories about older doctors retiring and others looking to sell their practices.”

Three-quarters of the more than 500 doctors contacted in an . said they expected their practices would not make a profit in 2020.

A study in the journal Health Affairs, published in June, put a hard number on that. It estimated that primary care practices would , or 13%, in gross revenues per full-time physician in 2020. That works out to a loss of about $15 billion nationwide.

One main problem, said Westfall, is that payment for telehealth and virtual visits is still inadequate, and telehealth is not available to everyone.

Re-Engineering Primary Care Payments

The remedy being most widely promoted is to change the way doctors are reimbursed — away from the predominant system today, under which doctors are paid a fee for every service they provide (commonly called “fee-for-service”).

Health economists and patient advocates have long advocated such a transition — primarily to eliminate or at least greatly reduce the incentive to provide excessive and unneeded care and promote better management of people with chronic conditions. Stabilizing doctors’ incomes was previously a secondary goal.

Achieving this transition has been slow for many reasons, not the least of which is that some early experiments ended up paying doctors too little to sustain their businesses or improve patient care.

Instead, over the past decade doctors have sought safety in larger groups or ownership of their practices by large hospitals and health systems or other entities, including private equity firms.

A 2018 survey of 8,700 doctors by the Physicians Foundation, a nonprofit advocacy and research group, found, for example, that only , down from 48.5% in 2012.

Fincher, the American College of Physicians president, predicts the pandemic will propel more primary care doctors to consolidate and be managed collectively. “More and more know they can’t make it on their own,” she said.

A 2018 survey by the American Medical Association found that, on average, that year came from fee-for-service, with the rest from per-member, per-month payments and other methods.

The pandemic has renewed the push to get rid of fee-for-service — in large part because it has underscored that doctors don’t get paid at all when they can’t see patients and bill piecemeal for care.

“Primary care doctors now know how vulnerable they are, in ways they didn’t before,” said Rebecca Etz, a researcher at the Larry A. Green Center, a Richmond, Virginia, advocacy group for primary care doctors.

Charbonneau, in Montana, said he’s “absolutely ready” to leave fee-for-service behind.

However, he’s not sure the company that owns his practice, Providence Health System — which operates 1,100 clinics and doctors’ practices in the West — is committed to moving in that direction.

Anderson, in Michigan, is embracing a new payment model being launched next year under Medicare called Primary Care First. He’ll get a fixed monthly payment for each of his Medicare patients and be rewarded with extra revenue if he meets health goals for them and penalized if he doesn’t.

Medicare to Launch New Payment System

The Trump administration — following in the footsteps of the Obama administration — has been pushing for physician payment reform.

Medicare’s program is a main vehicle in that effort. It will launch in 26 areas in January. Doctors will get a fixed per-patient monthly fee along with flat fees for each patient visit. A performance-based adjustment will allow for bonuses up to 50% when doctors hit certain quality markers, such as blood pressure and blood sugar control and colorectal cancer screening, in a majority of patients.

But doctors also face penalties up to 10% if they don’t meet those and other standards.

Some private insurers are also leveraging the pandemic to enhance payment reform. Blue Cross and Blue Shield of North Carolina, for example, is offering financial incentives starting in September to primary care practices that commit to a shift away from fee-for-service. Independent Health, an insurer in New York state, is giving primary care practices per-patient fixed payments during the pandemic to bolster cash flow.

Meanwhile, two of the nation’s largest primary care practice companies continue to pull back from fee-for-service: Central Ohio Primary Care, with 75 practices serving 450,000 patients, and Oak Street Health, which owns 50 primary care practices in eight states.

“Primary care docs would have been better off during the pandemic if they had been getting fixed payments per month,” said Dr. T. Larry Blosser, the medical director for outpatient services for the Central Ohio firm.

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So why is the industry looking to Congress for help?

Insurers say that while that falloff in claims for non-COVID care is offsetting for now many insurers’ costs associated with the pandemic, the future is far more fraught.

Costs could remain modest or quickly outstrip savings. A recession could drive revenue down. Or the coronavirus could resurge next winter and spike treatment expenses.

All that uncertainty for the companies could trigger far higher premiums for consumers, if insurers hedge their bets. Then again, the current savings insurers are seeing — along with cautions from state regulators about pushing cost-sensitive customers away during an economic downturn — might result in minimal premium increases.

“Insurers are nervous, to be sure,” said Mike Kreidler, Washington state’s insurance commissioner. “But so far they are telling me they are in good shape. Coronavirus claims have not been that high — yet.”

Backing that assessment was a report out last week by credit rating agency Moody’s, which looked at a range of pandemic scenarios — from mild to severe — and concluded “U.S. health insurers will nonetheless remain profitable under the most likely scenarios.”

Earlier this month, UnitedHealth Group CEO David Wichmann told analysts that cost reductions so far are outstripping expenses for COVID-19 and that revenue is up compared with the previous year. He expects — barring a worsening situation — the rest of the year’s earnings to match projections. Other insurers, including Centene, Anthem, Humana and Cigna, are scheduled to release earnings reports this week.

If these results are repeated across the insurance industry, there will be pressure on insurers to hold down rate increases for next year and do more for policyholders, such as constrain the growth in deductibles and other out-of-pocket costs, said consumer advocates, regulators and policy experts.

“The last thing we need is insurers pricing their coverage unnecessarily high at a time like this,” said Peter Lee, executive director of Covered California, the health insurance marketplace in that state for people who buy their own coverage because they don’t get it through their job.

That prediction comes as tens of millions of Americans have lost their jobs — and often their health insurance.

Those thrown out of work may be able to stay on employer coverage through a federal law called COBRA, but it’s expensive and workers have to foot the bill. Insurers and employers have asked Congress for relief legislation to fully cover COBRA costs.

Losing a job is also a qualifying event to enroll in an Affordable Care Act plan — and, again, the industry has asked lawmakers to temporarily to help enrollees pay their premiums. Some states that run their own ACA marketplaces have reopened enrollment to help the uninsured get coverage.

The industry also wants Congress to authorize temporary financial support to help cover insurers that face “extraordinary, unplanned costs in 2020 and 2021,” according to a letter sent to lawmakers from America’s Health Insurance Plans and the Blue Cross Blue Shield Association.

To help, some states are giving insurers more time this year to submit their planned premium rates for 2021 — based on their expected costs — hoping things may be clearer by summer. California, for instance, is giving insurers until July to draw up their estimates.

One fear is that insurance actuaries, when faced with an unknown risk like the coronavirus, will price higher than needed, said Lee.

Setting premiums for next year is a balancing act. Insurers that calculate incorrectly and go too low will lose profits and may have to dig into their cash reserves to pay claims. If they set rates too high, they may run afoul of a provision in the ACA that requires insurers to issue rebates to policyholders if they don’t spend at least 80% of revenue on medical care.

And they don’t estimate well even in normal years. Early data for 2019 coverage shows insurers may owe in rebates, which will be paid out this year.

Insurers are not talking about next year’s premiums.

“We do not yet know the full scope, severity or duration of this outbreak. So we cannot know the ultimate cost of our members’ medical treatment or how long the postponement of non-urgent care will continue,” said Justine Handelman, senior vice president at the Blue Cross Blue Shield Association.

Early estimates, including a scary one from Covered California issued in late March, warned that costs associated with the coronavirus could drive premiums up 40% next year without federal help, based on initial models of the number of Americans who might fall seriously ill.

That report, though, did not take into account the effect of the sharp decline in elective care.

Thirty-one states have barred most elective surgeries, part of the effort by governors to promote social distancing to flatten the curve of the epidemic and to help prevent hospitals from being overwhelmed.

“The good news since we published that report is that it looks like efforts to flatten the curve are taking effect,” said Lee, so costs are more likely to be in the median rather than high end of the range.

The cost to insurers “all depends on the severity” of the continuing pandemic, said Dean Ungar, a vice president and senior credit officer at Moody’s. “On the lower side, the industry will do quite well, and also even in a more median scenario, especially when you factor in the offsetting benefit of delayed procedures.”

Moody’s estimates that deferred elective procedures may account for as much as 20% to 40% savings on medical costs per month for many insurers as long as elective procedures are barred or patients are unwilling to seek nonemergency care.

Even so, “I don’t think the insurance industry as a whole has any intention of making money off this,” Ungar said. “There will be rebates or other things to help. Partly that’s the right thing to do and partly it’s good business.”

Former Cigna executive turned industry critic Wendell Potter disagreed. He tweeted earlier this month that UnitedHealth spent $1.7 billion during the first quarter to buy back its own stock — a move that helps the company. “In other words, they’re thriving during a pandemic,” Potter tweeted. Instead, he said, the insurer should plow that money into premium reductions or other help for policyholders.

For its part, UnitedHealth said it has waived patient cost sharing for COVID care — as have most other insurers — as well as accelerated payments for what it owes to doctors, and is helping provide loans to some clinics.

Some physician groups fear they are being left out, saying some of the savings seen by insurers and self-insured employers should be directed to those struggling after seeing their practices dry up as people avoid medical care or governors bar elective procedures.

“It’s a huge hit,” said Tom Banning, CEO and executive vice president of the Texas Academy of Family Physicians.

Lee agreed, warning that struggling front-line physicians, and especially family and primary care doctors, will need financial help.

“A bad outcome of all this will be if thousands of providers can’t make it financially and their practices get bought up by hospitals or private entities — creating more consolidation in health care, which is already driving costs up,” said Lee. “Lawmakers should be thinking about helping primary providers out.”

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“CMS is committed to working with states to provide the flexibility they need to increase choices for their citizens, promote market stability, and more affordable coverage,” a spokesperson for the Centers for Medicare & Medicaid Services, who declined to be identified, wrote in an email to KHN. “We are pleased to see states like Georgia take the lead in health care reform by creating innovative state based solutions.”

Federal officials in recent weeks had requested additional information from Georgia, and Republican Gov. Brian Kemp on Wednesday asked for a delay in the evaluation of a large portion of the proposal.

The state’s plan, which has drawn opposition from ACA supporters, proposes to jettison consumer access to the federal insurance enrollment website — healthcare.gov — and instead send people buying individual policies to private companies to choose coverage.

It would also cap how much is spent on premium subsidies, which could mean some consumers would be put on a wait list if they needed financial help to buy a plan. ACA subsidies are not capped in any state now.

The state’s proposal is the boldest yet under new guidelines the Trump administration issued in 2018 and 2019. Those guidelines widen the opportunity for states to try different approaches to expanding coverage and lowering costs for consumers who buy insurance themselves because they don’t get it through their job or a government program.

Georgia officials say the initiative would help drive down insurance costs — for the state and consumers — by providing more choices, permitting cheaper plans to be offered and capping financial assistance to consumers.

Last year, 450,000 Georgians enrolled in a health plan through the ACA, 88% of whom received a federal subsidy to help pay their premium.

Nationwide, 11 million people got health insurance through the marketplaces in 2019.

Ryan Loke, who handles special projects for Gov. Kemp, said state officials expected that the federal government would need more details as it reviewed the proposal. Georgia’s request “is a first in the nation approach to reforming the individual marketplace, and given the novelty to the approach — we expected that supplemental information would be required, and have worked with our federal partners to begin putting together the necessary information for their review.”

But critics in Georgia and two detailed analyses released in late January have slammed the proposal, initially submitted for federal review Dec. 23.

“If CMS were to approve this waiver in its current form, I would expect lawsuits on behalf of Georgia consumers and families,” said Laura Colbert, , a consumer group based in Atlanta that has called the proposal “.” “The proposal would encourage enrollment in substandard plans and likely cause many Georgians to lose coverage. People with preexisting health conditions would be put at risk.”

Such a lawsuit would add to the mountain of litigation surrounding the ACA, including and an appeals court decision in December that threatens the entire law.

A decision favoring Georgia’s proposal would also add to the continuing high-profile political debate over the fate of the ACA.

“This is the first time a state has tried to take advantage of the Trump administration’s new approach to waivers, to implement some of the ideas the administration’s been pushing,” said Justin Giovannelli, a health policy expert at Georgetown University in Washington, D.C. “Other states and a lot of lawyers are watching closely.”

Georgia is making the request for new marketplace rules under a procedure known as a 1332 waiver. Under the law, states using such a waiver must still hew to strict rules set by the ACA.

For example, a state experiment can’t cost the federal government more money (for premium subsidies), raise costs for consumers on average, or result in fewer people gaining coverage than would be the case without the experiment.

Georgia’s proposal is in two parts. The first part seeks to establish a reinsurance program that picks up the tab for the care of high-cost patients using both state and federal funds. That allows insurers to keep costs down so they can offer lower premiums to consumers. The program, if approved, would go into effect in January 2021.

CMS says it will evaluate that part separately, with an eye toward swift evaluation and approval after a 30-day comment period. Final approval would make Georgia the to gain permission to use a reinsurance program.

Kemp has dubbed Georgia’s proposal for more far-reaching changes, starting in January 2022, the “Georgia Access Model.”

Instead of using the federal marketplace, Georgia would require consumers to enroll in coverage directly through insurance companies, brokers or private-sector websites.

At the same time, Georgia proposes to take over the administration of subsidies and cap the amount each year.

Insurers would also be allowed to sell plans that don’t comply with ACA requirements, under Georgia’s request. For example, one proposed type of plan could cover just half of a consumer’s costs for care, as opposed to the 80% to 90% levels of ACA’s silver and gold plans. Such a plan would have lower premiums but sharply higher out-of-pocket costs (such as deductibles and copays) if extensive care was needed.

Insurers and brokers would also be allowed to promote cheaper plans that don’t cover all the benefits required of current ACA plans.

Two studies released late last month concluded that Georgia’s proposal does not meet the guidelines for marketplace experiments set out in the ACA.

“There are very clear errors in Georgia’s proposal,” said Christen Linke Young, co-author of and a fellow at the Brookings Institution in Washington, D.C. “The numbers don’t add up, and the proposal doesn’t meet the standards the ACA established. The plan would harm consumers if approved, and we don’t believe it can or should be approved.”

The , by the left-leaning Center for Budget and Policy Priorities (CBPP), also in Washington, concluded that Georgia’s proposal would “cause thousands of Georgians to lose coverage and … likely also leave many with less affordable or less comprehensive coverage than they would otherwise have.”

If premiums or enrollment rose by 10%, for example, CBPP calculates that Georgia would have to deny subsidies to between 15,000 and 34,000 people under the proposed cap.

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But it might end up harming some workers.

That’s in part because the law, which takes effect Jan. 1, could cut two ways. While inducing many employers to extend health insurance to newly reclassified employees, it might prompt others to shift some workers from full-time to part-time status to avoid offering them health coverage, or — in the case of some small firms — to drop such benefits altogether.

Some companies might trim their workforce to limit cost increases. Benefits typically account for of total employee compensation costs, and health insurance is the largest component of that.

“I think we will see more people classified as employees over time,” said Ken Jacobs, chair of the Center for Labor Research at the University of California-Berkeley. “And that is very likely to expand the number who are offered and take coverage. But the situation is definitely fluid.”

Adding to the fluidity: Some large employers are contesting the new law. Uber, the ride-sharing app company, has said the  and indicated it is prepared to defend its position in court. The company has joined competitor Lyft in broaching the idea of a to challenge the law.

California Gov. Gavin Newsom has indicated a willingness to negotiate changes and exemptions with those companies and others.

Uber did not respond to requests for comment, and Lyft declined to comment.

In addition to shared-ride drivers, the law affects construction workers, custodians and truck drivers, among others.

Some independent contractors prefer the flexibility that comes with setting their own hours, but others are eagerly eyeing health coverage.

Steve Gregg, a resident of Antioch, Calif., is among them. Gregg, 51, is uninsured and makes too much to qualify for Medi-Cal, the state’s version of the Medicaid program. He hopes to be reclassified as an Uber employee in 2020, primarily to gain access to health insurance.

“The only medical care I can really afford right now is to use an online doctor for my blood pressure medicine,” said Gregg, who typically logs 50 hours or more a week driving for Uber in the Bay Area.

Under the Affordable Care Act, companies with at least 50 full-time employees must pay a penalty if they don’t offer health insurance to those who work 30 hours or more a week.

California’s new “gig economy” law requires employers to treat independent contractors as regular employees if the work they perform is central to the core mission of the company and they operate under the company’s direction.

Several kinds of workers are exempt from the law’s provisions, however, including insurance and real estate agents, investment advisers, doctors and nurses, direct sales workers and commercial fishermen.

Jacobs said other states will closely watch what happens in California, given that some tech companies hire large numbers of independent contractors.

New Jersey, Massachusetts and Connecticut have similar labor laws on the books. Lawmakers in Oregon and Washington state are eyeing legislation akin to California’s.

Independent contractors in the Golden State are nearly twice as likely to be uninsured as regular employees, according to by UC-Berkeley’s Center for Labor Research, known as the Labor Center. From 2014 to 2016, just under 70% of workers classified as employees had employer-sponsored health insurance, compared with 32% of independent contractors, the study shows.

An estimated 1.6 million of the state’s 19.4 million workers are full-time independent contractors, according to another analysis by the Labor Center. It is unclear precisely how many contractors are “misclassified,” but sponsors of the new law, led by Assemblywoman Lorena Gonzalez (D-San Diego), put the number at around 1 million.

Whatever the exact number, employers who rely on contract workers will need to make complex health insurance decisions.

A company whose contract workers average 35 to 40 hours a week, for example, could reclassify them as employees for the purpose of complying with the new law but try to limit their weekly hours to fewer than 29, thus avoiding the ACA coverage requirement, said Dylan Roby, an associate professor of health policy and management at the University of Maryland and an adjunct associate professor at UCLA.

A of small companies that are not required by the ACA to cover their employees do so anyway, and the ones that hire independent contractors will also face hard choices.

“If they have to expand that to reclassified employees, the cost could be substantial,” said Christen Linke Young, a health insurance researcher at the Brookings Institution in Washington, D.C.

A small firm with a skilled and relatively high-wage workforce might choose to absorb the cost of expanding coverage to reclassified workers, Young said, because those workers might not qualify for subsidies to buy health insurance on their own through Covered California, the state’s ACA marketplace. Offering insurance is also a retention tool.

Other small companies, however, could choose to drop coverage altogether rather than pay the tab for newly reclassified workers.

And some might be able to place the new employees in a separate category and offer them no health benefits, or less generous ones than the existing employees get. But under federal law, an employer can do that only if the new employees are doing a different kind of work than the current ones, Young said.

Companies of all sizes can wait a year before offering new employees coverage, to establish what their average weekly hours are. That buys firms with 50 or more employees time to decide whether the reclassified workers qualify for health benefits under the ACA.

The uncertainty about how the new law will play out is sowing confusion among many independent contractors.

Vanessa Bain, a resident of Menlo Park, Calif., who works full time as a contract worker for Instacart — a same-day delivery service for groceries — worries about what her employer will do.

Bain and her family are enrolled in Medi-Cal, California’s version of the Medicaid program for people with low incomes. But she would rather get insurance through Instacart.

“What will they offer us?” Bain, 33, wonders. “If the premiums are too high or the coverage crappy, we may be better off buying it on our own through Covered California. We’ll have to see.”

This story was produced by , which publishes , an editorially independent service of the .

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