"If the first obligation of a health care system is to take care of the sick, we are failing that test," said Dr. Drew Altman, founding president and CEO of KFF.

Trust is built over time, and payroll is one of the clearest places where employees see whether that trust is deserved.

"People are worried that it is the opening salvo into promoting junk plans that don't meet the ACA requirements," said Katie Keith, director of the Center for Health Policy and the Law at the Georgetown University Law Center.

Producer groups are not sure what kinds of producers a mysterious new batch of guidance might affect.