Employers are becoming less alarmed about specific healthcare cost threats and more focused on what policy changes they want in response. Both directions are documented in the 2026 Pulse of the Purchaser survey, published by the National Alliance of Healthcare Purchaser Coalitions (National Alliance). The National Alliance itself flags the apparent tension without fully resolving it.
The survey drew on 408 employer and purchaser responses fielded in May and June through National Alliance member coalitions. It is a non-probability sample of employers engaged through coalition membership, which means the findings represent a self-selected and relatively sophisticated segment of the market.
Drug prices, high-cost claims, and hospital prices have ranked as the top three affordability threats in every year of the survey. In 2026, they held those positions again. But their ratings as threats have fallen across the board.
Drug prices peaked as a threat at 93.1 percent in 2024 and dropped to 76.7 percent in 2026. Hospital prices fell from their 2023 peak of 82.4 percent to 68.1 percent. Health system consolidation fell from 64.7 percent to 49.7 percent over the same period.
The National Alliance report offers three possible explanations without assigning weight to any. The first is genuine improvement: employers may be getting better at managing these costs and feel less threatened. The second is normalization: high costs have become so routine that employers no longer mark them as exceptional threats. The third is attention shifting to other pressures, meaning the category of "threat" has been crowded out by a larger field of concerns.
The survey design cannot distinguish between these explanations. The report does note that employer views on workforce concerns (attracting talent, cost shifting, wage trade-offs) have remained essentially flat since 2023, with no meaningful change across any of five statements tested.
That stability argues against a broad shift in priorities. It is more consistent with normalization: the threat ceiling has been reached and alarm has plateaued, even as the underlying conditions persist.
While threat ratings fell, support for policy reform rose across every category tested. Support for PBM reform grew from 68 percent in 2023 to 87.6 percent in 2026. Hospital price transparency went from 75 percent to 84.6 percent.
Drug price regulation went from 72.9 percent to 83.8 percent. Hospital rate regulation went from 65.6 percent to 82.6 percent. HSA reforms went from 45.8 percent to 69.6 percent, the largest absolute gain at 23.8 percentage points.
The National Alliance report describes this as frustration hardening into targeted policy asks. Falling threat ratings and rising reform support are not contradictory if employers have moved from cataloguing problems to pursuing specific solutions.
That framing is consistent with the policy engagement data. More than half of employers (51.3 percent) now report active engagement in federal or state healthcare legislative activity, up from 42.5 percent in 2025. The most common barrier among those who had not participated was limited staff capacity (47.9 percent), not a lack of interest.
The sharpest single movement in the policy data concerns the 340B Drug Pricing Program. In 2024, half of employers said they did not know enough about 340B to have a view on whether shrinking the program would help their plan. By 2026, 56 percent said it would be helpful, a 36-percentage-point shift in two years.
The 340B program was created in 1992 to allow safety net hospitals and federally qualified health centers to purchase outpatient drugs at discounted prices. Covered entities were intended to use the savings to stretch resources for low-income patients.
The program has since grown substantially. Drug Channels Institute, citing IQVIA data, reported in July 2026 that discounted purchases under the 340B program reached $100 billion in 2025, up 23 percent year-over-year.
The employer concern with the program is specific. Because pharmaceutical manufacturers do not pay rebates on drugs dispensed under 340B, employer-sponsored plans can end up paying higher net prices for those drugs.
IQVIA estimated in 2024 that 340B program dynamics increased pharmacy costs in employer-sponsored health plans by $5.2 billion, or 4.2 percent, according to an American Benefits Council brief published in February 2025. That figure has not been independently verified by the National Alliance survey, but it provides context for why employer views shifted as familiarity with the program increased.
The survey also tracked support for hospital-specific reform. Hospital rate regulation, a policy that would set or cap hospital prices in some markets, was supported by 82.6 percent of employers in 2026, up 17 percentage points from 2023. Hospital antitrust enforcement registered 72.2 percent support. Healthcare global budgets, a more expansive price-setting mechanism, drew support from 45.6 percent in 2026, up from 31.2 percent in 2023 but still below a majority.
The combination of declining threat alarm and rising reform support carries a practical implication for benefits brokers. An employer that rates hospital prices as less of a threat than it did three years ago has not necessarily stopped paying higher hospital prices. It may simply have learned to expect them.
For a broker advising a plan sponsor on hospital purchasing strategy, that normalization is worth naming. The threat perception gap does not indicate that the underlying cost problem has resolved. It may mean the employer needs external context to understand how its own hospital cost experience compares to peers.
