America's Largest Employers Sound the Alarm: PBGH Survey Lays Bare a Health Care Affordability Crisis

The frustration that has been simmering inside corporate benefits departments for the better part of a decade boiled over this week. On April 15, the Purchaser Business Group on Health (PBGH), a coalition of forty of the country's largest public and private health care purchasers — names that include Walmart, Boeing, Salesforce, the California Public Employees' Retirement System, and Tesla — pulled back the curtain on its 2026 Annual Member Survey. The findings landed with the bluntness that only employers signing checks for $350 billion of annual coverage can deliver. Affordability is not just a concern. It is the concern, the same one PBGH members named last year and the year before that, only louder and angrier this time around. And the survey makes plain that those employers are no longer waiting for traditional carriers and pharmacy benefit managers to fix the problem.

PBGH's coalition covers roughly 21 million workers and family members, which is to say their behavior is a reasonable proxy for what the next two open enrollments will look like across most of corporate America. The numbers in the survey describe a market in motion. Thirty-seven percent of PBGH members are running a medical RFP this year, and another 23% are running a pharmacy RFP. Twenty-seven percent are already working with what PBGH calls a "non-traditional" PBM — a category that ranges from transparent pass-through pharmacy benefit administrators like Capital Rx and Navitus to the new wave of cost-plus models built around the Mark Cuban Cost Plus Drug Company supply chain. Put differently, more than a third of the country's most sophisticated benefits buyers are about to put their incumbent carrier on notice, and almost a quarter are doing the same to their PBM, all in a single calendar year.

The CEO who calls it a wake-up call

Elizabeth Mitchell, PBGH's president and CEO, framed the survey results in language that is unusual for an industry that tends to prefer euphemism. "These priorities coupled with the growing frustrations our members are expressing should be a wake-up call for many health care stakeholders who think the status quo is acceptable and that the days of blank checks will never end," Mitchell said. She paired that warning with a more methodical observation about the actual state of price discovery in 2026: "Getting access to price and quality data to effectively evaluate whether employers and families are paying a fair price for health care services is still too hard, but PBGH and our members are taking action to combat these challenges." The trio of priorities the survey identifies — affordability, data analytics and transparency, and advanced primary care — reads like a strategic roadmap. Mitchell described it as exactly that, calling the results "an affirmation of our strategic roadmap" and signaling more programmatic work on fair pricing, accountability, and what she called fiduciary success for plan sponsors.

Premiums up, again, with no end in sight

The economic backdrop is the part that should worry every CFO and benefits leader who has been promising the C-suite that health cost inflation would moderate this year. Premiums are tracking 6% to 7% higher in 2026 according to the figures cited alongside the PBGH release, with some individual market plans rising more than 20% as the enhanced ACA premium tax credits remain expired and underlying medical and pharmacy trend keeps grinding upward. Mercer's most recent National Survey of Employer-Sponsored Health Plans pegged the average per-employee cost of employer-sponsored health insurance at $17,496 in 2025, a 6% jump that already outran inflation and wage growth, with employers anticipating an additional 6.7% increase in 2026 that will push that number above $18,500 per employee. Pharmacy is the loudest engine inside that machine. Large employers saw prescription drug spending grow an average of 9.4% in the most recent reporting cycle, and PBGH members are anticipating 11% to 12% pharmacy increases as 2025 transitions into 2026. Almost half of large employers — 49%, up from 44% — now cover GLP-1 weight-loss medications, a category that has gone from rounding error to top-five line item in the span of three plan years.

It is against that pricing backdrop that the RFP statistics start to read less like business-as-usual and more like a coordinated revolt. When 37% of the PBGH membership is shopping medical and 23% is shopping pharmacy, with another 27% already running a non-traditional PBM, the share of America's top corporate health spenders who are either actively switching vendors or planning to is the highest it has been in the survey's history. The dam, in other words, is leaking.

Transparency data turns into a weapon

The second priority PBGH members named — data analytics and transparency — would have been an aspiration as recently as 2024. Hospital price transparency revisions took effect April 1 of this year, requiring full machine-readable files with median, 10th, and 90th percentile negotiated rates and EDI 835 attestations, a regulatory shift that finally gives plan sponsors and their consultants useful comparative pricing instead of the obscured charge-master data hospitals had previously been allowed to publish. Combined with the Transparency in Coverage rules that already require carriers to publish negotiated rates and out-of-network amounts, employers now have the raw material for the kinds of bundled-payment and direct-to-employer contracting strategies PBGH members highlighted in the survey. The PBGH analysis described this as employers "leveraging transparency data insights to inform health care purchasing strategies, including bundled payments, direct-to-employer contracts, and the use of centers of excellence." Translation: the data finally exists, and the buyers are using it.

The PBM piece of the story is moving in parallel. The Consolidated Appropriations Act of 2026, signed into law in February, brought Congress's first comprehensive PBM reform package across the finish line. The legislation prohibits PBMs from earning remuneration linked to drug prices for Medicare Part D, restricts spread pricing in Medicaid, requires contractual transparency, mandates 100% pass-through of rebates in ERISA-regulated plans, and adds an Any Willing Pharmacy provision starting in 2028. PBGH applauded the package without claiming victory. As one of the survey's framing observations put it, "with the passage of the Consolidated Appropriations Act 2026, PBM reform remains a top priority for both policymakers and purchasers in addressing rising pharmacy costs and opaque business practices across the industry." The fact that 27% of the country's largest purchasers have already abandoned traditional PBMs entirely, and that another 23% are putting their pharmacy contracts out to bid, suggests employers are not waiting for the next legislative session to take matters into their own hands.

Three priorities employers are pushing on hardest

The PBGH survey distilled the membership's strategic posture into three areas where action is happening now. The list is short by design — the things every benefits team will hear about in their next consultant briefing.

• Affordability: the dominant concern for the second consecutive year, with double-digit premium increases unchecked and pharmacy trend running near 12%
• Data analytics and transparency: machine-readable files, post-April 1 hospital pricing data, and Transparency in Coverage feeds being turned into bundled-payment and direct-contract strategies
• Advanced primary care: value-based and risk-bearing primary care arrangements seen as the most reliable lever for reducing downstream specialty and hospital spending

A market reordering, not a single story

The PBGH data did not arrive in a vacuum. Within the same week the survey hit, the Texas marketplace shed one of its prominent regional carriers when Baylor Scott & White Health Plan announced on April 15 that it will exit the Texas Medicaid Managed Care Program on August 31 and discontinue Individual Marketplace plans after December 31, ending coverage for roughly 125,000 Medicaid members and 100,000 marketplace enrollees and eliminating 321 health-plan jobs, including 65 in North Texas. The plan had failed to win most of the contracts in the latest state Medicaid procurement cycle and was awarded only a limited award in Lubbock, a market where it does not operate hospitals. Baylor Scott & White hospitals and clinics will continue to accept other carriers' Medicaid and marketplace plans, but the exit underscores how quickly individual and Medicaid markets are reordering after the One Big Beautiful Bill Act and the expiration of enhanced ACA subsidies — the same reordering Elevance Health flagged in pre-window commentary about ACA enrollees shifting toward bronze tier coverage.

The investment picture is moving on a parallel track. Rock Health's Q1 2026 digital health funding overview, released earlier this month and circulating heavily through this week's news cycle, found that startups raised $4 billion across 110 deals, a billion-dollar jump over Q1 2025, with the largest average deal size since Q4 2021 at $36.7 million. Capital is concentrating sharply: 59% of the quarter's dollars went to a small set of mega-deals, including Qualified Health's $125 million round, Garner Health's $118 million Series D, Cognito Therapeutics' $105 million, and Midi Health's $100 million Series D, which crossed the unicorn threshold. Rock Health retired its dedicated AI deal-tracking analysis this quarter on the grounds that AI has become "table stakes" in how digital health companies build and deliver. For employer plan sponsors hunting for cost relief, the Rock Health concentration story matters because it tells them where the next generation of point solutions and tech-enabled networks will come from, and which of those vendors are likely to still be operating in three years.

The carrier M&A landscape is, by contrast, looking weary. An analysis released April 14 by ACORD, the insurance industry standards body, examining recent insurance carrier and reinsurer mergers and acquisitions concluded that 75% of recent deals featuring reinsurers and multiline insurers as buyers destroyed value for shareholders. The ACORD report, "Carrier Mergers & Acquisitions: Drivers, Implications & Outcomes," lands at a moment when the health insurance side of the industry is testing whether last year's vertical integration playbooks — Highmark closing on Blue Cross Blue Shield of Kansas City on March 31, and the broader stream of carrier-pharmacy-provider tie-ups — actually deliver the synergies their proxy statements promised. The skepticism is not incidental. It is part of the same employer impatience PBGH measured.

Washington listens, sometimes

The political calendar caught up with the affordability theme on April 15 as well. The House Energy and Commerce Subcommittee on Health convened a legislative hearing titled "Healthier America: Legislative Proposals to Improve Public Health" in the Dingell Room of the Rayburn House Office Building, examining a stack of bills that included H.R. 4348 to reauthorize the Kay Hagan Tick Act, H.R. 4541 the EARLY Act Reauthorization, H.R. 3747 on dementia and Alzheimer's provider training, H.R. 8209 the School-Based Health Centers Reauthorization Act of 2026, H.R. 8201 the Expanding Community Access to Health Services Act, and a Digital Health Screeners Act of 2026. None of those bills will move the affordability needle for a Fortune 500 plan sponsor on its own, but the hearing's framing — public health, access, screening, community care — tracks closely with the advanced-primary-care priority PBGH members named in the survey. The American Hospital Association added its own piece to the policy mosaic the day before, on April 14, joining a coalition letter expressing support for the Chronic Care Management Improvement Act of 2026.

The Office of Personnel Management, meanwhile, issued its annual Federal Employees Health Benefits Call Letter for the 2027 plan year on March 31, with the policy reverberating through coverage in this week's window. OPM is asking carriers in the federal program — the largest employer-sponsored insurance program in the country — to "exhaust every cost-containment option before passing increases on to enrollees" and is steering FEHB toward what OPM is now calling "well care," a whole-person health framework with new requirements for behavioral therapy, nutritional counseling, and intensive lifestyle intervention as a precondition for GLP-1 coverage. App-only programs will not satisfy the requirement; human coaching must be part of the package. The federal program is a different beast from a private-employer self-funded plan, but the directional signal — utilization management on GLP-1s, lifestyle medicine, primary-care reorientation — is the same one PBGH members described.

What the survey actually changes

The 2026 PBGH Annual Member Survey will not, by itself, change a single carrier's medical loss ratio or knock a percentage point off any health plan's pharmacy trend. What it does is mark a moment. A coalition that controls $350 billion of annual coverage spending has put the industry on public notice that more than a third of its membership is already shopping medical, almost a quarter is shopping pharmacy, and more than a quarter has already left the traditional PBM market behind. The infrastructure those buyers need — full hospital price transparency files since April 1, Transparency in Coverage feeds since 2022, statutory PBM transparency from the Consolidated Appropriations Act of 2026 — is in place for the first time. The political environment, with both parties dragging affordability into their hearings and HHS leaning on FEHB carriers to cut costs, is in place too. The Q1 earnings season that begins next week will give carriers their chance to respond. UnitedHealth Group reports April 21, Elevance the day after, and Humana, Centene, CVS, and Cigna in the days that follow. PBGH's members, and the brokers and consultants serving everyone behind them, will be watching to see whether the carriers' guidance reflects the affordability message — or whether it sounds, once again, like the days of blank checks have not ended after all.