The gap between employers who talk about controlling healthcare costs and those who actually do something about it comes down to one factor more than any other: whether they can see their own data.
That is the central finding of the 2026 Pulse of the Purchaser survey, released by the National Alliance of Healthcare Purchaser Coalitions (National Alliance). The nonprofit represents employers providing health benefits to more than 90 million Americans. Its online survey of 408 employers, fielded in May and June 2026, finds that those with full access to medical and pharmacy claims data used an average of 11.9 high-value purchasing strategies.
Employers with limited or no claims access used an average of 7.9. Both groups were considering similar strategies. The difference was not ambition. It was access.
"Employers have the concern and the will to act, but too often lack the usable data, contractual rights and staff capacity to do so," said Shawn Gremminger, National Alliance president and CEO. "When those barriers are removed, employers are better able to move from concern to action."
The strategies that open up with full data access include network evaluation, hospital price review, vendor audits, reference-based pricing, direct contracting, and centers of excellence. These are the tools most likely to produce durable savings rather than one-year cost-shifting.
The survey's backdrop is familiar but still striking. Employers project a 7.7% average healthcare cost increase before plan design changes, with one in three expecting increases of 9% or more. Fully insured employers were most likely to anticipate the steepest rises.
More telling is how employers frame the problem. Ninety-two percent say healthcare costs hurt competitiveness, 83% say cost increases trade off directly against wage and salary increases, and 93% expect costs to shift to employees.
That last figure deserves attention. When nearly every employer in a survey of 408 expects to pass costs to workers, the downstream effects run beyond open enrollment. They touch retention, engagement, absenteeism, and financial stress, the same issues driving employer health plan costs to near 15-year highs.
Drug prices (77%), high-cost claims (75%), and hospital prices (68%) are the top threats employers identify. Hospital and facility costs represent the largest share of total spend at 30.5%, followed by prescription drugs at 21.1% and professional fees at 19.1%. Stop-loss data has shown a similar concentration: 1% of members drove a third of all medical and pharmacy spending in 2025.
The survey also captures a meaningful shift in the pharmacy benefit management market. The share of employers contracting with the three largest PBMs fell from 63.4% in 2025 to 54.3% in 2026. Movement was concentrated among employers with fewer than 1,000 employees, suggesting mid-market employers are leading the reassessment.
Among those still with the Big Three, 55.7% said they are considering a PBM change within the next one to three years, compared with 31.1% of employers using other PBMs.
What may explain the restlessness: nearly one in four Big Three clients said they were not sure what was in their PBM contracts, at 23.4%, almost twice the rate of employers using alternative PBMs at 11.7%. Employers cannot act on what they cannot see, and contract opacity appears to be driving market movement as much as price.
PBM reform was rated the most helpful policy change by 87.6% of survey respondents. Hospital price transparency (84.6%), hospital rate regulation (82.6%), and hospital antitrust enforcement (72.2%) followed. Support for every reform tested rose between 2023 and 2026, a sign that employers are developing more specific policy views, not simply registering frustration.
Employer policy engagement is also rising. More than half, at 51.3%, said they are now engaged in federal or state healthcare legislative activity, up from 42.5% in 2025. Employers with full pharmacy claims data were significantly more likely to engage than those without (61.3% versus 39.4%).
The survey maps a practical opportunity for brokers. The gap between 7.9 and 11.9 purchasing strategies is not a gap in employer intent. It is a gap in what employers have been given access to.
The broker who negotiates full claims-level data rights into a client's TPA or carrier contract, and who helps that client actually use the data, is the broker whose value cannot be replicated by a competing quote at renewal.
Drug spend now eats close to a third of employer claims, and the employers best equipped to manage that are the ones who can see it. That is the most direct argument for data rights that any broker has had this renewal cycle.
