With only weeks to go before health insurance exchanges across the United States open their web portals for business, Health Affairs’ September issue, published today, focuses on who stands to gain, or lose. Will employers stop providing health insurance, forcing their employees to seek insurance through the exchanges? What penalties will taxpayers face if they claim eligibility for an insurance subsidy, only to later discover they had erroneously underreported their income? What is the financial impact of medical loss regulations on insurers and the ramifications of Medicaid expansion? These are a few of the questions discussed in this issue.

Articles include:

Will employers drop health insurance coverage? Since the passage of the Affordable Care Act, policy experts have debated whether or not 2014 will mark the beginning of the end for employer-sponsored health insurance. Thomas Buchmueller and colleagues at the University of Michigan look at theoretical and empirical evidence to put that question in context. The authors describe the economic reasons for employer-sponsored insurance and how relevant portions of the Affordable Care Act may affect these offerings; review various predictions; and discuss the challenges of interpreting early data from 2014. The models they have studied point to a relatively small decline in employer-sponsored coverage as a result of health reform, which the authors believe is likely to be correct.

On a related topic, an article by Daniel Austin, Jay Bhattacharya, and coauthors at Stanford University forecasts what could happen if lower-income Americans now receiving employer-based health insurance, faced with a minor $100 premium increase, would shift their coverage to the exchanges. The authors found that as many as 2.25 million individuals might make that change, increasing federal outlays by $6.7 billion. These findings present a cautionary tale, and the authors recommend that policy makers and analysts pay especially careful attention to participation rates as the Affordable Care Act’s implementation continues.

Income changes and premium subsidies. Subsidies for health insurance premiums under the Affordable Care Act are refundable tax credits. Ken Jacobs of the University of California, Berkeley, and coauthors analyze the degree to which individuals receiving tax credits to help cover the cost of insurance would need to repay all or part of that subsidy to the Internal Revenue Service if they fail to report changes in their incomes during the year. To avoid this problem, the authors recommend that the insurance exchanges educate consumers about the importance of timely reporting of any income changes and suggest other measures to minimize subsidy repayments.

Two other papers address different aspects of the Affordable Care Act:

In emergency care, the cost of overtriage.  Regionalized trauma care in the United States plays an important role in identifying seriously injured patients for transport to major trauma centers. However, little is known about the cost of treating patients without serious injuries at these same centers. Craig Newgard of Oregon Health and Science University and coauthors compared acute care costs for injured patients transported by emergency medical services agencies in several west coast states between 2006 and 2008. They found that 34.3 percent of the low-risk patients — those not meeting triage guidelines for transport to major trauma center — were sent to major trauma centers anyway, accounting for up to 40 percent of the acute injury costs. According to the authors’ findings,  $136.7 billion could have been saved annually if the hospitals in the regions being studied had adhered to the field triage guidelines.

Also of interest in the September issue: