Source

Source: KFF Health Tracking Poll – July 2019

Almost Half of Non-Elderly Families have At Least One Adult with a Pre-Existing Condition

An updated KFF analysis estimates that almost 54 million people – or 27% of all adults under 65 —have pre-existing health conditions that would likely have made them uninsurable in the individual markets that existed in most states before the Affordable Care Act.

The share of adults under 65 with such declinable pre-existing conditions varies significantly across states, from at least a third in West Virginia (37%), Arkansas (34%), Kentucky (34%), and Mississippi (34%) to a little more than one in five in Colorado (22%).

Older working-age Americans (ages 55-64) are the most likely age group to have declinable pre-existing conditions (44%), more than twice the share (18%) among the youngest age group (18-34). Women are more likely than men to have declinable conditions (30% compared to 24%).

Almost half (45%) of non-elderly families include at least one adult with a medical condition who might not be able to buy individual insurance without the ACA’s prohibition of medical underwriting.

The analysis comes as the Fifth Circuit Court of Appeals weighs a decision in the Texas v. Azar case, which seeks to overturn the entire Affordable Care Act, including the provisions that prohibit insurers from denying coverage or charging more to people with pre-existing conditions. The Trump administration has joined the conservative state Attorneys General in arguing that the ACA should be invalidated.

While most people with pre-existing conditions are covered now through employers or public programs such as Medicaid, people may look to the individual market for coverage during periods of transition, such as losing or changing a job, leaving a job due to illness, starting a business, aging off a parent’s policy, retiring before age 65, or losing Medicaid eligibility.

Before the ACA protections took effect in 2014, private insurers in the individual market could use applicants’ health status, history and other risk factors to determine whether and under what terms to issue coverage. Some conditions that could lead to automatic denials of coverage at the time include cancer, diabetes, epilepsy, heart disease, and pregnancy.

Using 2018 data from two large government surveys, the analysis estimates the total number of nonelderly adults in each state with a health condition that could lead to a denial of coverage in the individual insurance market, based on pre-ACA field underwriting guides for brokers and agents. The estimates do not include people with other health conditions that would not necessarily cause a denial, but could lead to higher insurance costs based on underwriting.

Whether and how people with pre-existing conditions could be affected if they seek coverage on the individual market in the future depends on the outcome of the ongoing court challenge, and how federal and state lawmakers respond to the court’s decision.

The impending decision by the Fifth Circuit Court of Appeals in the Texas v. Azar case raises the prospect that insurers will once again be able to return to using people’s health status in determining their eligibility and premiums for health insurance, at least for coverage obtained from the non-group, or individual insurance, market.  In the case, the plaintiff states’ Attorneys General and the Trump Administration are arguing that the Affordable Care Act is unconstitutionally structured and should be invalidated in its entirety.  This would include overturning provisions that guarantee that people with pre-existing health conditions cannot be denied coverage or charged higher premiums due to their health status.

Given the significant barriers to coverage that may reemerge if these provisions in the ACA were to be invalidated, we are updating our prior work looking at the share of nonelderly adults with health conditions that would likely to have caused them to be denied coverage if they applied for non-group health insurance prior to the effective date of the ACA.  And because the financial consequences of these changes would potentially affect the whole family, we extend our analysis to estimate the percent of nonelderly families with at least one adult who has one or more declinable conditions.

Consistent with our previous analysis, we estimate that 27% of nonelderly adults have a declinable health condition, which is about 53.8 million people in 2018.  We further estimate that 45% of nonelderly families have at least one nonelderly adult member with a declinable health condition.  Finally, we update our state-based estimates of the prevalence of declinable pre-existing conditions with the most current data available, showing that the share of non-elderly adults with pre-existing conditions ranges from 22% in Colorado to 37% in West Virginia.

People with pre-existing health conditions were often denied coverage or charged higher premiums for individual market coverage before the ACA took effect in 2014.  While most of people with pre-existing health conditions are covered currently by employer-based coverage or public programs, such as Medicaid, the non-group market is where they may need to look for coverage in times of transition, for example, if they lose a job, change jobs, start a business, divorce, age-off of a parent’s policy, retire before age 65, leave employment due to serious illness, get a job and lose Medicaid, or otherwise lose their eligibility for work-based or public coverage. While we cannot predict how the court would fashion relief if these ACA provisions were overturned, access to individual market insurance for people with pre-existing conditions could be seriously reduced.

Use of Health Status in Underwriting and Rating Before the ACA

Estimates of the Share of Adults with Pre-Existing Conditions

We used data from the National Health Interview Survey (NHIS) to estimate that 27% of nonelderly adults had a declinable health condition in 2018, the same percentage that we found in our earlier analysis for 2015. The NHIS has a number of questions about whether the respondent has ever been diagnosed with a number of the health conditions that would have been declinable in the pre-ACA non-group market. While we cannot duplicate the underwriting processes carried out by insurers, we feel that our approach is reasonable and may be conservative because the NHIS does not contain information about all of the conditions (e.g.,  AIDS/HIV) used by insurers and does not provide information on prescriptions that insurers also used to decline applicants for coverage.

Although each family member would have been separately underwritten in the pre-ACA non-group market, the economic consequences of having a member of the family denied coverage or surcharged due to their health would likely be felt by all members of the family. To look at the number of people that might be affected, we extended our previous methods and estimate that, in 2018, 45% of non-elderly families included a non-elderly adult with a declinable condition. Individuals living in households without a relative are considered to be a family of one person for this analysis.

A larger share of non-elderly adult women (30%) than men (24%) have declinable pre-existing conditions in 2018, unchanged from 2015.  We estimate that 23.7 million men have a pre-existing condition that would have left them uninsurable in the individual market pre-ACA, compared to 30.1 million women. Pregnancy explains part (about 2 million women) but not all of this difference.

The prevalence of declinable conditions also increases with age among non-elderly adults: ranging from 18% of those in the 18-34 age group to 44% for those in the 55-64 age group.

The rates of declinable pre-existing conditions continue to vary from state to state. On the low end, in Colorado, at least 22% of non-elderly adults have conditions that would likely be declinable if they were to seek coverage in the individual market under pre-ACA underwriting practices.  Rates are higher in other states – particularly in the South – such as Arkansas (34%), Kentucky (34%), Mississippi (34%), and West Virginia (37%), where at least a third of the non-elderly population would have declinable conditions.

Discussion

Since the effective date of the ACA market changes in January of 2014, people with pre-existing health conditions have not had to worry about their health conditions affecting their access to health insurance or increasing the premiums that they pay. The legislation assures people access to individual market coverage with comprehensive benefits through a variety of changes in their work and life circumstances.  This could change quite quickly if the ACA market protections for people with pre-existing conditions were invalidated.  While many adults with pre-existing conditions have Medicaid or employer coverage that would still provide protection, over a quarter of nonelderly adults have a health condition that would jeopardize their access to non-group coverage without the ACA market protections, potentially affecting almost one-half of non-elderly families in the country.  For these families, an invalidated ACA could fundamentally affect future access to health care.

Methods

To calculate nationwide prevalence rates of declinable health conditions, we reviewed the survey responses of nonelderly adults for all question items shown in Methods Table 1 using the CDC’s 2018 National Health Interview Survey (NHIS).  Approximately 27% of 18-64 year olds, or 54 million nonelderly adults, reported having at least one of these declinable conditions in response to the 2018 survey.  The CDC’s National Center for Health Statistics (NCHS) relies on the medical condition modules of the annual NHIS for many of its core publications on the topic; therefore, we consider this survey to be the most accurate means to estimate both the nationwide rate and weighted population.

Since the NHIS does not include state identifiers nor sufficient sample size for most state-based estimates, we constructed a regression model for the CDC’s 2018 Behavioral Risk Factor Surveillance System (BRFSS) to estimate the prevalence of any of the declinable conditions shown in Methods Table 1 at the state level.  This model relied on three highly significant predictors: (a) respondent age; (b) self-reported fair or poor health status; (c) self-report of any of the overlapping variables shown in the left-hand column of Methods Table 1.  Across the two data sets, the prevalence rate calculated using the analogous questions (i.e. the left-hand column of Methods Table 1) lined up closely, with 21% of 18-64 year old survey respondents reporting at least one of those declinable conditions in the 2018 NHIS and 23% of 18-64 year olds in the 2018 BRFSS.  Applying this prediction model directly to the 2018 BRFSS microdata yielded a nationwide prevalence of any declinable condition of 29%, a near match to the NHIS nationwide estimate of 27%.

In order to align BRFSS to NHIS overall statistics, we then applied a Generalized Regression Estimator (GREG) to scale down the BRFSS microdata’s prevalence rate and population estimate to the equivalent estimates from NHIS, 27% and 54 million.  Since the regression described in the previous paragraph already predicted the prevalence rate of declinable conditions in BRFSS by using survey variables shared across the two datasets, this secondary calibration solely served to produce a more conservative estimate of declinable conditions by calibrating BRFSS estimates to the NHIS.  After applying this calibration, we calculated state-specific prevalence rates and population estimates off of this post-stratified BRFSS sample.

To calculate nationwide prevalence rates of declinable health conditions at the family-level, we imputed person-level presence of any condition onto the NHIS person file using the main 2018 NHIS sample adult estimate.  This model relied on three highly significant predictors: (a) respondent age; (b) self-reported fair or poor health status; (c) self-report of any health-related activity limitation, disability, hospitalization, or high rate of physician visits.  Since all individuals responding to the NHIS sample adult questionnaire also respond to the NHIS person component of the survey, these factors produced a reasonably predictive estimate, matching 27% of non-elderly adults with pre-existing conditions for all individuals participating in the survey.  Unlike the NHIS sample adult file, the NHIS person file allows for analyses of family-wide characteristics.  This prediction yielded 53% of non-elderly adults having a declinable condition themselves or co-habiting with a non-elderly adult family member with a declinable condition; using the NHIS family weights, this results in 45% of non-elderly families (families having at least one non-elderly adult family member) having one or more adults with a declinable condition.  In total, approximately 54 million non-elderly adults may have a pre-existing condition and almost as many non-elderly adults without pre-existing conditions live with a family member that does.

The programming code, written using the statistical computing package R v.3.6.1, is available upon request for people interested in replicating this approach for their own analysis.

SAN FRANCISCO – KFF is pleased to announce that Kaiser Health News (KHN), its editorially independent health news service, has won a top prize Wednesday in the 13^th annual Barlett & Steele Awards for Investigative Journalism.

KHN Senior Correspondent Christina Jewett discovered that for nearly 20 years, the FDA was striking deals with medical device makers to keep millions of malfunction and injury reports out of the public database known as MAUDE – and instead letting device makers submit reports to a secret database, hidden from public view.

KHN’s “Hidden Harm” investigative series also revealed that the FDA granted special reporting exemptions that were so obscure that safety experts, doctors and even a recent FDA commissioner were not aware they existed.

The hidden database included 500,000 reports of injuries or malfunctions tied to breast implants; 66,000 surgical stapler malfunctions and more than 50,000 incidents tied to the Sprint Fidelis, a device implanted in the chest to shock a patient’s heart back to normal.

Citing KHN’s work, device-safety experts called on the FDA to open up the hidden reports of harm. That triggered FDA Commissioner Dr. Scott Gottlieb to tweet that the reports would be open to the public:  “We’re now prioritizing making ALL of this data available,” Gottlieb wrote. On June 21, the FDA published its entire hidden database online, revealing 5.7 million device-related injuries or malfunctions for the first time.

“We established KHN to do truly important and impactful journalism just like this – getting out the facts, holding government accountable, and most of all helping people,”  said Drew Altman, KFF’s President and CEO and Founding Publisher of KHN.

“It’s so gratifying to publish an investigation that has such rapid impact and will make medical care safer for millions of patients,” said KHN editor-in-chief Elisabeth Rosenthal. “‘Transparency’ is all the rage in health care. But as Christina showed, it often take relentless reporting to expose the truth.”

The KHN series was one of two “Gold” award winners in the Barlett & Steele Awards, administered by the Donald W. Reynolds National Center for Business Journalism at Arizona State University.  Other winners announced Wednesday include The Wall Street Journal, the International Consortium of Investigative Journalists, NBC News, The Associated Press and The Oregonian.

The awards are named for the investigative team of Don Barlett and Jim Steele, whose honors included two Pulitzer prizes.

About The Henry J. Kaiser Family Foundation and Kaiser Health News:

Filling the need for trusted information on national health issues, KFF (the Kaiser Family Foundation) is a nonprofit organization based in San Francisco, California.  KHN is an editorially independent program of KFF and is the nation’s leading and largest health and health policy newsroom, producing stories that run on kffhealthnews.org and are published by hundreds of news organizations across the country.

UPDATED: The Senate Appropriations Committee approved the FY 2020 State & Foreign Operations (SFOPs) appropriations bill (and accompanying report) on September 26, 2018 (a draft version of the bill and report were released on September 18, 2019). The SFOPs bill includes funding for U.S. global health programs at the State Department and the U.S. Agency for International Development (USAID).[i] Funding for these programs, through the Global Health Programs (GHP) account, which represents the bulk of global health assistance, totaled $9.1 billion, an increase of $279 million above the FY 2019 enacted level, $2.8 billion above the President’s FY 2020 request, and $181 million below the House FY 2020 level.

Key highlights are as follows (see table for additional detail):

• Funding for most global health programs at State and USAID increased compared to the FY19 enacted level, with the exception of bilateral HIV funding at the State Department, which declined slightly, and neglected tropical diseases (NTDs) programs, which remained flat. In all cases, funding was above the President’s FY 2020 request, which had proposed significant cuts; funding levels varied compared to the House FY20 appropriations bill.
• Bilateral HIV funding through the President’s Emergency Plan for AIDS Relief (PEPFAR) is $4,650 million in the Senate FY20 bill, $50 million below the FY19 enacted and FY20 House levels ($4,700 million), but $1,300 million above the FY20 Request ($3,350 million).
• The bill includes $1,560 million as the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), an increase of $210 million above the FY19 enacted level ($1,350 million), $602 million above the FY20 Request ($958 million), and matching the FY20 House level.
  • The report accompanying the bill states that the committee “anticipates that the United States will pledge not less than [$1.56 billion] for each of the three fiscal years pertaining to the Global Fund’s Sixth Replenishment . . . [and] does not support the administration’s proposal to amend the longstanding matching rates for U.S. contributions to the Global Fund and expects the United States to continue to match other donor contributions at a rate of $1 for every $2 received from other donors.
• Funding for tuberculosis (TB) totals $310 million, $8 million above the FY19 enacted level, $49 million above the FY20 Request ($261 million), and matching the FY20 House level.
• Funding for malaria totals $789 million, $34 million above the FY19 enacted and FY20 House levels ($755 million), and $115 million above the FY20 Request ($674 million).
• The bill includes $847 million for maternal and child health (MCH), an increase of $12 million above the FY19 enacted level ($835 million), $227 million above the FY20 Request ($629 million), and $3 million below the FY20 House level ($850 million). Specific areas under MCH include:
  • Gavi, the Vaccine Alliance funding totals $290 million, matching the FY19 enacted and FY20 House levels, and $40 million above the FY20 Request ($250 million).
  • Polio funding through the GHP account totals $61 million, $2 million above the FY19 enacted and FY20 House level ($59 million).[ii] The President’s FY 2020 Request did not specify funding for polio.
  • The bill includes $137.5 million for the U.S. contribution to the United Nations Children’s Fund (UNICEF) provided through the International Organizations and Programs (IO&P) account, matching the FY19 enacted level and $10 million below the House FY20 level ($147.5 million). While the FY20 Request did not specify a funding amount for UNICEF and proposed to eliminate the IO&P account, it is possible that organizations such as UNICEF could receive funding through other accounts.
• Funding for nutrition totals $150 million, $5 million above the FY19 enacted and FY20 House level ($145 million), and $71.5 million above the FY20 Request ($78.5 million).
• Bilateral family planning and reproductive health (FP/RH) funding totals $633 million ($582 million through the GHP account and $51 million through the ESF account), $58 million above the FY19 enacted level, and $374 million above the FY20 Request ($259 million), but $117 million below the FY20 House level ($750 million).[ii]
• Funding for the United Nations Population Fund (UNFPA) totals $32.5 million, matching the FY19 enacted level, but $23 million below the FY20 House level ($55 million); the FY20 Request proposed eliminating funding for UNFPA.
• Funding for the vulnerable children program totals $26 million, $2 million above the FY19 enacted and FY20 House level ($24 million); the FY20 Request proposed eliminating funding for this program.
• Funding for neglected tropical diseases (NTDs) totals $102.5 million, matching the FY19 enacted and FY20 House level, and $27.5 million above the FY20 Request ($75 million).
• Funding for global health security totals $100 million in the bill. While this is a decrease compared to the FY19 enacted level ($138 million), $38 million of the FY19 amount was provided through a one-time transfer of unspent emergency Ebola funding. The Senate FY20 amount is an increase compared to the FY20 Request ($90 million) and matches the FY20 House level.

Resources:

• FY2020 State and Foreign Operations Appropriations Bill – Draft Bill
• FY2020 State and Foreign Operations Appropriations Bill – Draft Report

The table (.xls) below compares global health funding in the FY 2020 Senate SFOPs appropriations bill to the FY 2019 enacted funding amounts as outlined in the “Consolidated Appropriations Act, 2019” (P.L. 116-6; KFF summary here), the President’s FY 2020 request (KFF summary here), and the House FY 2020 SFOPs bill (KFF summary here).

[i] Total funding for global health is not currently available as some funding provided through USAID and DoD is not yet available.

[ii] The House FY20 SFOPs bill proposes to move the Economic Support Fund (ESF) from “Bilateral Economic Assistance” to “Security Assistance” and “redirects development, and most democracy and governance, funding that is long-term in nature to the Development Assistance or Democracy Fund accounts.” If the House FY20 bill is approved by Congress, it is possible that global health funding previously provided under the ESF account may be provided under the Development Assistance (DA) account.

The debate among Democratic presidential candidates about how to reform the health care system largely boils down to whether to build on the Affordable Care Act and create an option for people to enroll in Medicare or create a Medicare for all plan that covers everyone.

On the other side of the partisan divide, President Trump has repeatedly promised a health care plan, but not yet delivered one. The president has vowed to repeal the ACA if he is re-elected and Republicans gain control the House in addition to the Senate. More immediately, the Trump administration is arguing in court that the ACA should be overturned, including its pre-existing condition protections, premium subsidies to make coverage more affordable, Medicaid expansion, and a host of other provisions.

In this September 2019 post for The JAMA forum, Larry Levitt provides insight on what “Trumpcare” might look like based on clues in the president’s previous actions and statements, and those of his administration. He observes that the debate among Democrats on health care has obscured the big differences between all Democrats and President Trump.

Other contributions to The JAMA Forum are also available.

Average Annual Deductibles Now at $1,655, Double the Average of a Decade Ago

San Francisco. – Annual family premiums for employer-sponsored health insurance rose 5% to average $20,576 this year, according to the 2019 benchmark KFF Employer Health Benefits Survey released today. Workers’ wages rose 3.4% and inflation rose 2% over the same period.

On average, workers this year are contributing $6,015 toward the cost of family coverage, with employers paying the rest.

Despite the nation’s strong economy and low unemployment, what employers and workers pay toward premiums continues to rise more quickly than workers’ wages and inflation over time. Since 2009, average family premiums have increased 54% and workers’ contribution have increased 71%, several times more quickly than wages (26%) and inflation (20%).

Currently 82% of covered workers have a deductible in their plan, similar to last year and up from 63% a decade ago. The average single deductible now stands at $1,655 for workers who have one, similar to last year’s $1,573 average but up sharply from the $826 average of a decade ago.  These two trends result in a 162% total increase in the burden of deductibles across all covered workers over the past decade.

More than a quarter (28%) of all covered workers, including nearly half (45%) of those at small employers with fewer than 200 employees, are now in plans with a deductible of at least $2,000, almost four times the share who faced such deductibles in 2009. One in eight (13%) now face deductibles of at least $3,000.

“The single biggest issue in health care for most Americans is that their health costs are growing much faster than their wages are,” KFF President and CEO Drew Altman said. “Costs are prohibitive when workers making $25,000 a year have to shell out $7,000 a year just for their share of family premiums.”

About 153 million Americans rely on employer-sponsored coverage, and the 21st annual survey of more than 2,000 small and large employers provides a detailed picture of the trends affecting it. In addition to the full report and summary of findings released today, the journal Health Affairs is publishing an article online with select findings. The article, “Health Benefits in 2019: Premiums Inch Higher, Employers Respond to Federal Policy,” will also appear in its October issue.

KFF is also releasing an updated interactive graphic that charts the survey’s premium trends by firm size, industry, and other firm characteristics, and a separate report highlighting the views and experiences of large employers based on focus-group discussions done in partnership with the Peterson Center on Healthcare.

As the debate over Medicare-for-all in the Democratic presidential primary puts the spotlight on the role of employer-sponsored health benefits, the survey finds that workers at firms with many low-wage employees face some of the biggest challenges affording employer coverage for their families. Among firms offering coverage, employers with many lower-wage workers (earning $25,000 or less a year) offer health benefits to a smaller share of their workforce and require workers to pay a higher share of premiums than other employers. Specifically:

• Among firms that offer health benefits, two-thirds (66%) of workers at lower-wage firms are eligible for health benefits, significantly less than the share (81%) eligible at other firms.
• Family premiums at firms with many lower-wage workers average $17,633, 15% less than the average at other firms. At the same time, workers covered by lower-wage firms have an annual family contribution of $7,047. Workers at other firms contribute an average of $5,968 annually.
• One result is that fewer workers at lower-wage firms take up their employer’s health benefits when offered. The net effect is that one in three (33%) workers at lower-wage firms offering health benefits are covered by their employer’s health benefits, well below the 63% share at other offering firms.

“Employer-sponsored coverage doesn’t come cheap for employers or workers, and many who work at low-wage firms or small business likely find it too costly to cover their families,” said Gary Claxton, a KFF senior vice president and director of the Health Care Marketplace Project, and the lead author of the study and Health Affairs article.

Few Firms See Impact from Individual Mandate Repeal

The survey also gauges employers’ experiences and views related to several provisions of the Affordable Care Act (ACA).

In 2017, Congress eliminated the ACA’s tax penalty for people who do not have health insurance effective for this tax year, raising questions about whether it would lead workers to drop their coverage. The survey finds 9% of offering firms with at least 50 workers say the elimination of the individual mandate penalty led to fewer workers and dependents enrolling this year.

The ACA also included a tax on high-cost health plans, sometimes called the “Cadillac tax,” that was originally set to take effect in 2018, though Congress delayed the tax until 2022, and the House recently voted to repeal it all together. The survey finds only 16% of offering employers with at least 50 workers say they expect the tax to take effect in 2022. One-third of those firms say the upcoming tax was either “very” or “somewhat” important in making their health benefit decisions for the current year.

Other survey findings include:

• Offer rate holds steady. The survey finds 57% of employers offer health benefits, the same as last year and similar to a decade ago (59%). The larger an employer is, the more likely it is to offer health benefits, with about half (47%) of the smallest firms (3-9 workers) and nearly all (99%) large firms (200 or more workers) offering coverage. Small employers who don’t offer health benefits most often cite cost as the primary reason.
• Provider networks. The vast majority (83%) of offering employers say they are satisfied with the choice of providers available through their insurance plans. Few (5%) say they offer a plan with a narrow provider network, which can help the plan negotiate lower payment rates but also reduces enrollee choices.
• Spousal coverage. While most large employers offering health benefits cover spouses, 11% do not allow spouses to enroll if they have coverage from another source. Among those that do allow such enrollment, 10% require spouses to pay more through a larger premium contribution or higher cost sharing.
• Response to the opioid epidemic. Many large employers (at least 200 workers) report taking specific steps over the past five years in response to the nation’s opioid crisis. These include creating or revising an employee assistance program (40%); providing health information to workers (38%); limiting or otherwise modifying coverage for prescription opioids (24%); and asking their insurer or pharmacy benefit manager to increase monitoring of opioid use (21%).
• Dental and vision coverage. Among offering firms, 60% (including 92% of large firms) also offer separate dental insurance, while 46% (including 83% of large firms) also offer separate vision insurance. Employers sometimes contribute toward the cost of these benefits, but employees sometimes are required to pay the full cost themselves.

Methodology

KFF conducted the annual employer survey between January and July of 2019. It included 2,012 randomly selected, non-federal public and private firms with three or more employees that responded to the full survey. An additional 2,383 firms responded to a single question about offering coverage. For more information on the survey methodology, see the Survey Design and Methods Section.

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California.

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

This report combines data from the 2019 Employer Health Benefits Survey with findings from focus groups conducted with human resources managers to provide an overview of the current strategies firms are employing in their network decision-making. The analysis outlines the various approaches employers have taken to control costs and improve quality of care, and offers a deeper understanding of the resulting successes, barriers, and trade-offs.

The report can be found on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.