Employers at the Center of Reform: Inside the 2026 National Alliance Healthcare Policy Summit

On April 7, 2026, the National Alliance of Healthcare Purchaser Coalitions convened its annual Healthcare Policy Summit at Georgetown University McCourt School of Public Policy. This is a full recap of the day's sessions, covering ERISA fiduciary enforcement, PBM transparency reform, hospital pricing, 340B, and what employers are doing differently.

The National Alliance represents employer purchaser coalitions across the country, and the framing they brought to Georgetown positioned the day as a working session for the people who actually pay for care. Employer-sponsored coverage covers roughly 135 million Americans and accounts for somewhere around $850 billion in annual spending, and yet that scale has not historically translated into proportional market leverage.

The keynote speaker, Daniel Aronowitz, Assistant Secretary of Labor and head of the Employee Benefits Security Administration, noted that there are 2.8 million ERISA-covered group health plans covering approximately 135 million Americans, and put it directly:

"Employer sponsored health care isn't just one small part of the American Health System, it is the American Health System."

ERISA as Enforcement Mechanism

Aronowitz's keynote was a clear signal that the Department of Labor intends to treat ERISA fiduciary law as a tool for cost control, not just plan administration. EBSA's role in shaping how employer plans are run has, until recently, been treated as secondary to HHS and CMS in most employer conversations about cost.

"In the healthcare space, unlike the retirement space, ERISA fiduciary duties have largely been undefined, untested and unenforced," Aronowitz said. His argument was that this gap has cost employers and their workers enormously. Plan sponsors have been expected to scrutinize their TPAs, PBMs, brokers, and consultants the way they scrutinize retirement plan administrators, but without a comparable regulatory framework to guide them. EBSA is now moving to close that gap.

The administration's stated agenda runs on four pillars: lowering drug prices, reducing insurance premiums, holding insurance companies accountable, and maximizing price transparency. Aronowitz described the goal as "a health care system where every dollar is traceable, every contract is understandable, and participants in the system, employers and employees alike, get real value for their money."

The PBM Transparency Rule

The most concrete near-term deliverable from EBSA is a proposed PBM disclosure rule. For employers, the significance is in a specific shift: from formulas and percentages to actual dollar amounts.

Aronowitz explained the problem directly. Under the current regime, plan fiduciaries often receive disclosures structured as complicated formulas, percentages of list price, and layered methodologies. "This might sound reasonable on paper," he said, "but it makes it nearly impossible to translate into real money." The proposed rule would require PBMs to disclose manufacturer rebates, spread between the plan-paid price and pharmacy reimbursement, price-protection arrangements, affiliate incentives, and fees not captured elsewhere, all in dollar terms, before contracts are signed, and again in semiannual reports. Audit rights for fiduciaries are included.

The rule is designed to work alongside the Consolidated Appropriations Act of 2026, which requires 100% pass-through of manufacturer rebates. Aronowitz described the combined effect as "a complete transparency framework for prescription drug pricing" for the first time.

Transparency in Coverage: From Data Exhaust to Usable Information

The PBM rule was not the only transparency initiative Aronowitz brought to Georgetown University. He also outlined a proposal to overhaul how negotiated rate data is made available to employers and their employees under the Transparency in Coverage framework.

The problem, as he described it, is that the machine-readable files payers are already required to publish have been technically accessible but challenging to use. "For years, the prices negotiated between insurers and hospitals have been locked away in secret files that are nearly impossible for everyday Americans or even most plan sponsors to use," he said. The proposal would take those existing files and increase their functionality: cleaner data, better labels, clearer network information, and easier ways to compare one plan or provider to another. The goal is to give employers the information they need to negotiate harder, design benefits that reflect their workforce's actual needs, and pursue contracting arrangements that current opacity makes difficult to evaluate.

Aronowitz also addressed the independent dispute resolution process, the system that handles payment disagreements when a patient receives a surprise bill from an out-of-network provider and the plan and provider cannot agree on what the plan should pay. He described the current process as "slow, confusing, and full of back-and-forth that wastes time and money." The aim of the forthcoming rule is to resolve those disputes faster, freeing employers and plans to spend less time on billing paperwork and more on benefit design.

On the regulatory side more broadly, EBSA is updating rules around electronic disclosure for health plans, moving benefits communications to digital channels and reducing the printing and distribution costs that currently run into the billions. Aronowitz framed the through-line across all of these efforts plainly: "None of this work is about adding more red tape. It's about removing barriers so that the market can do what it does best: compete, innovate, and deliver better value." His closing statement on EBSA's mandate was equally direct: "Our mission is simple: use ERISA's full power to demand value and lower costs across the employer-sponsored healthcare system."

Hospital Prices: The Bigger Problem

Hospital prices were the economic core of the day. Bret Jackson, President and CEO of the Economic Alliance for Michigan and moderator of the hospital pricing panel, opened the conversation referring to a graph that has become a recurring reference among employer groups: hospital prices sit at the top of U.S. price inflation, above housing, education, and every other major category.

Jackson brought the data close to home. Labor and delivery in his market ran $6,900 at one hospital and $12,000 to $15,000 at nearby competitors for essentially the same service. A 30-day supply of Humira cost roughly $1,235 at the University of Michigan and $12,000 to $15,000 at more than ten other hospitals in the same geographic area. "That market is not working," he said.

Christine H. Monahan, an assistant professor at Georgetown's Center on Health Insurance Reforms, offered the structural explanation. Employer-sponsored coverage was long considered the gold standard of American health insurance: comprehensive, well-negotiated, and generous. That reputation has eroded as hospital consolidation, both horizontal across regions and vertical into physician practices and outpatient facilities, has shifted bargaining power away from employers. The result is that even large purchasers are increasingly unable to secure rates that reflect actual costs or competition. Hospitals can now charge facility fees on services delivered in settings that bear little resemblance to a hospital, and contract terms can prohibit steering or network tiering in ways that make innovation difficult for plan sponsors.

Site-neutral payment reform addresses this directly. The concept is straightforward: pay roughly the same total amount for a given service regardless of whether it is delivered in a hospital outpatient department or an independent office. Monahan noted that facility fees make sense for true hospital-level care, inpatient admissions, emergencies, trauma. The problem arises when a routine evaluation and management visit or a telehealth consultation carries the same facility overhead charge. She also noted a limitation in the legislative approach: state facility-fee-only laws do not necessarily cap total prices. Hospitals can respond by raising professional fees, which means transparency and facility-fee legislation alone may not move the needle on what employers actually pay.

What Policy Can and Cannot Do

Mark E. Miller, PhD, Executive Vice President of Health Care at Arnold Ventures, offered a candid ranking of which reforms are likely to move market behavior most. Direct rate regulation, for example capping commercial payments at a multiple of Medicare for state employee plans, would have the largest impact. It is also, he said, the hardest thing to achieve politically. Site-neutral and facility-fee reforms are the next tier. Anti-competitive contracting bans, which would prohibit all-or-nothing clauses, anti-steering provisions, and most-favored-nation arrangements, are further down in complexity but still face significant resistance.

Miller's view on the state-federal question was pragmatic: Congress is constrained by concentrated lobbying, and national standards on rate caps or market conduct may not arrive soon. States are moving ahead, and regulatory windows in existing Medicare authority have allowed some site-neutral reforms to advance without statutory changes. Employers watching for progress should probably be watching state capitols as closely as Washington.

Una Lee, a senior staffer on the House Energy and Commerce Committee with over a decade working on cost and market reform, confirmed how slow the legislative timeline tends to be. Hospital price transparency efforts began in earnest in 2018 and did not fully land until 2024 and 2025. Anti-competitive contracting reforms have been discussed since at least 2020. The No Surprises Act was a genuine milestone, but the independent dispute resolution process it created has been slow, expensive, and prone to unintended consequences that regulators have been slow to address.

Employers Who Are Already Moving

James Startare, a senior benefits leader at Aramark, offered the most operationally specific perspective of the day. Aramark has roughly 70,000 covered lives in the U.S. and spends $300 to $400 million annually on health and welfare benefits. Startare has been direct contracting with health systems since 2024 in five geographies, negotiating rates personally despite a background on the consulting and carrier side. The direct contracting strategy involves creating preferred plan tiers branded around the contracted health systems, offering richer benefits to employees who use them, and wrapping a broader secondary network around them for continuity. The access Aramark has from its food service work in hospitals opened doors that most employers do not have, which limits how broadly this specific approach can be replicated. But the model itself, building a tiered structure with genuinely different pricing at each tier, is one more employers are starting to explore.

Startare also uses reference-based pricing, though he was candid about its limitations for a largely lower-wage workforce. The more telling data point was what happens at the facility level: hospitals that publicly resist reference-based pricing accept it 85 to 90 percent of the time when claims actually come in. That gap between institutional rhetoric and actual behavior is notable, and it suggests that the floor for what hospitals will accept is lower than their negotiating posture implies.

A recurring theme in Startare's remarks was the CFO relationship. Health and welfare spend sits just behind payroll as the second-largest line item for many large employers. His advice was direct: treat it that way, build the relationship with finance, and stop managing benefits as a human resources function disconnected from the core business.

Questions the Summit Left Open

Rosa Novo from Miami-Dade County Public Schools described a $497 million annual health spend, with 63% going to hospital-based or affiliated facilities. Even with NPI data and transparency tools, she said, hospitals still refuse to share actual cost data or bundle prices in ways that allow meaningful comparison. The panel's response pointed toward facility-only reference-based pricing paired with a branded professional network as a potential path, though it was acknowledged as a partial solution rather than a fix.

The ASC question came up as well. Ambulatory surgery centers could theoretically pull significant outpatient volume away from hospital systems and lower costs, but many ASCs are now owned by those same systems, which dulls the competitive effect. One creative contracting example from Chicago was mentioned, pairing two competing health systems with an independent provider network and requiring inpatient referrals from the independent network to route to the system partners. It is not a scalable template, but it illustrates that systems will work together when the volume case is clear.

The harder version of the question, whether hospital market power should be regulated the way utilities or railroads have been regulated, did not get a fully satisfying answer. State authority over providers is real, and interest in more active financial and ownership oversight is growing. But ERISA's preemption of self-funded employer plan regulation complicates the picture at the state level, and federal legislation on rate caps remains a long-range prospect.

340B: A Program That Has Outgrown Its Purpose

Alexandra Williams, Director of Strategy and Innovation at AbbVie, spent most of her career on the other side of the table from her current employer. She managed 340B programs at large health systems in North Carolina and Ohio, worked at the program's prime vendor, and audited covered entities on HRSA's behalf. Her argument at the Summit was that many 340B hospitals today are using the program in ways that raise costs rather than lower them, particularly for commercially insured patients, and her background gave the critique a credibility that a straight manufacturer representative would not have had.

The 340B statute contains language stating the program is intended to stretch federal resources as far as possible while reaching more vulnerable patients. Williams acknowledged that framing but argued it no longer reflects what the program actually does. When 340B launched in 1992, it was designed to cover approximately 1,000 entities: roughly 850 public health service clinics and around 100 public hospitals. Today, the program covers more than 50,000 hospitals and participating entities. According to IQVIA, 340B purchases reached $147.8 billion at list price in 2024. That figure has grown every year, placing the program second in size only to Medicare Part D and, on its current trajectory, on track to surpass it. "The original program intent was for vulnerable patients," Williams said, "yet everyone in this room is a 340B patient, and this just shows you how off track the program is."

Under 340B, manufacturers sell covered drugs to eligible entities at a ceiling price that averages around 60% of list price and can fall well below that, sometimes to nominal levels. Hospitals then bill payers at list price or close to it, capturing the spread as revenue. Williams was direct about what that structure produces today: "340B covered entities use higher price medications, full stop. That is what we see today. We are also finding that 340B hospitals are opening more clinics and sites in affluent areas because they are targeting patients with full time jobs and insurance." The incentive is clear: a commercially insured patient on a high-cost drug generates a much larger spread than a Medicaid patient on a generic.

The Humira data Williams presented made the dynamic concrete. Humira lost exclusivity in January 2023, and ten biosimilars have since come to market at substantially lower prices. Based on AbbVie's own purchasing data, Williams said that rather than shifting toward those cheaper alternatives, 340B hospitals went the other direction. "When you look at 340B hospitals, and you look at our data since the release of biosimilars, the use of Humira has doubled or tripled in 340B hospitals. Let that soak in for a minute." The reason, she said, is straightforward: hospitals are choosing the more expensive product because of the margin it generates. AbbVie sells Humira to 340B entities at a price that can drop to a penny per unit while list price exceeds $7,000. In Minnesota, one large 340B hospital went from roughly $18 million in Humira purchases in 2022 to $50 million in 2025. "Not only is 340B not meeting its original intent," Williams said, "but it's driving up costs."

Williams was equally direct about where the money flows. "Patients don't get it," she said. "Patients don't benefit from the fact that they are considered a 340B patient." What she described instead is a structure where the spread between acquisition cost and commercial reimbursement is shared among hospitals, for-profit specialty pharmacies, PBM-affiliated entities, and 340B consultants, with little of it reaching the vulnerable populations the program was designed to serve.

On the manufacturer side, she described a specific operational problem: "All of those billions of dollars that we, in the collective, manufacturers that are in this room, are paying in 340B discounts, we don't have any visibility into who those discounts are being used on, and are those patients truly eligible to receive that discount." Without claims-level data, manufacturers cannot verify eligibility, employers cannot see how much of the program's cost is landing on their plans, and policymakers are working from aggregate numbers that obscure what is actually happening at the patient level.

Health economist Sayeh Nikpay, who has spent over a decade studying 340B's history, added important context. She recently interviewed congressional staffers who drafted the original 340B legislation in the early 1990s and found that the oft-cited language about stretching scarce federal resources was written specifically about small, grant-funded public health clinics, not large hospital systems with multi-billion-dollar revenues and outpatient facilities in affluent suburbs. The program's scope has expanded dramatically since then, and the original framing no longer maps onto most of the entities now using it.

Nikpay also brought data from Minnesota, where a state transparency law now requires hospitals to report 340B revenues and acquisition costs. In the most recent reporting year, covered entities there billed roughly $3 billion to insurers and patients against $1.5 billion in acquisition costs, leaving approximately $1.34 billion in margin after fees. About 90% of that came from hospitals, and nearly half came from commercially insured patients. As Nikpay put it to the self-insured employers in the room: "That's a lot of money that's coming from the lives that you cover."

She pushed back on the framing, common in policy circles, that 340B is essentially a victimless transfer from manufacturers to hospitals doing good work in the community. "People who work for the city of Miami who have to get a second job, why should they have to contribute to the 340B margin?" The answer, she argued, is that they shouldn't, and that the scale of commercial cross-subsidization built into the program today was never part of the original design.

Nikpay also raised two less-discussed channels through which 340B affects employer plans. The first involves the interaction between 340B discounts and PBM rebates. When a manufacturer can see that a drug it expected to pay a rebate on is actually subject to a 340B discount, it has little reason to pay both. For a drug like Humira, already being sold to a covered entity for a penny, paying out a PBM rebate on top of that makes little financial sense. The practical consequence for employers: at the end of a plan year, rebates they expected to receive may not materialize, or come in lower than projected, because of this overlap between 340B pricing and commercial rebate arrangements. Nikpay was direct about the implication: "I would argue that that's something everyone here should be concerned about."

The second channel is harder to quantify but raises a fundamental question about how 340B affects list prices across the system. In many states, more than 80% of hospitals participate in 340B. Nikpay argued it is reasonable to ask whether that level of penetration nudges list prices upward over time, and whether that in turn affects what employees pay through deductibles and coinsurance. She acknowledged the causal question is difficult to answer rigorously, but said the scale of the program's spread gives it face validity as a concern. As vice chair of Minnesota's Prescription Drug Affordability Board, she hears directly from consumers on employer-sponsored coverage who cannot afford their medications. "We have deductibles," she said, "and the deductibles make people share in that cost. But when that cost is higher than it should be, it has real implications for patients."

Williams and Nikpay converged on the same reform requirement: claims-level transparency. Williams described a proposed rebate-based model that would require covered entities to submit claims data to manufacturers in order to receive their 340B discount, calling it "the transparency that we desperately need in the program." Nikpay, cautious about burdening small safety-net clinics with new administrative requirements, suggested that carving those providers out from broader reform could allow the program to be restructured without undermining the safety-net services it was originally designed to protect.

340B directly impacts employer plans across the country. It is a direct driver of what commercially insured patients pay, through deductibles and coinsurance calculated off inflated list prices, with a significant share of those inflated charges flowing through the 340B spread.

Where Things Are Heading

The Summit did not resolve the tension at its center, which is that employers bear the largest share of U.S. healthcare costs but have historically had the least leverage over how those costs are set. What it did show is that the combination of ERISA enforcement, transparency reform, state-level policy experimentation, and employer-led contracting innovation is more coordinated than it has been in recent years.

The PBM transparency rule, if finalized in a form that genuinely enables fiduciary comparison, would close one long-standing gap. Site-neutral payment reforms, if extended beyond Medicare into commercial coverage in a durable way, would close another. Claims-level transparency in 340B, if it ever arrives, would close a third. Direct rate regulation remains the policy option with the most leverage and the longest political runway.

Startare's closing framing landed as well as anything said all day: "It's our job, our job being employers, to fix it, and we need to."