Last week, the DC-based Business Group on Health released its latest survey of Big Business’ views about U.S. healthcare: they’re worried about rising costs (as usual) and see a need for systemic reforms. It follow’s Aon’s report the prior week that projected health costs for employers will increase 6.5% to ($13,800 per employee) in 2023–double the rate cost increase they experienced from 2021 to 2022.
Also last week, Amazon announced it’s shuttering Amazon Care, it’s 2019 virtual care solution aimed at large employers: beyond a handful of companies like Hilton and Peloton, it failed to get traction.
And in Jackson Hole, WY at its annual conference, Fed Chair Jerome Powell told the World’s Central bankers that the U.S. inflation target of 2% is still its goal though lowering inflation will “cause pain” on workers: stocks dropped 4% and big employers adjusted ’22-’23 spending plans for bumpy economic recovery.
Quite a week for employers!
Today, every industry has its corporatocracy and its smaller players. ‘Big Business’ is synonymous with Big Tech, Big Oil, Big Banks and so on. The same is true in health care: 5 health insurers control half of the U.S. public and private insurance market. Three large cap companies control the electronic health record market, 3463 (57%) of U.S. hospitals are controlled by multi-hospital systems, PBMs are controlled by 3 players and so on.
For decades, Big Business has enjoyed oversized influence on public policies and special treatment in healthcare. Big Business pays lobbyists and consultants to advance their interests and accountants to minimize the tax consequences of their gains. It’s SOP!
In healthcare, the Big Business playbook is premised on four presumptions:
· Big Business needs a workforce that’s appropriately educated and healthy. Government’s role is to assure both.
· Big Business offers health insurance benefits to their employees and dependents to maintain their workforce and secure a tax deduction for their share of these costs.
· Big Business assumes the financial risk for the care provided for dependents in their plan via self-insurance. In so-doing, they are partially shielded from subsidization of other companies’ health costs.
· Big Business permits use of its employee’ transactional data i.e., disease prevalence, provider utilization, costs, outcomes, satisfaction by actuaries, third party administrators, health insurers, and benefits’ consultants with protections against disclosure and assurance of “value” for de-identified data analysis.
But conditions for Big Business have changed. Gallup polls shows trust in Big Business is low. Its’ workforce is changing: pandemic-induced anxiety, virtual work, and DEI and ESG investments are more important than ever. Transparency about executive compensation, political action committees and contributions, Board compensation and governance policies, supply-chain dependency, banking relationships et al are readily accessible and highly scrutinized.
As a result, the four presumptions of the past are less plausible in the future. The pace of expected changes will be industry specific, with traditional “white collar” industries (education, government, health providers) laggards and young-workforce dependent industries leading. There are 5 trends that will significantly reshape Big Business’ playbook:
· Ownership & Control of Data: Big Businesses will add constraints to monetization of employee health data by vendors, insurers, data sources and third parties. Big Business will direct resources to data science about avoidable/unnecessary health costs, provider competence, efficiency, costs and prices, and re-construct “high performing networks” in collaboration with their workers.
· Whole Person Primary Care (WPPC): Big Business will embrace WPPC as the front door to benefits participation for its plan members and contract for virtual and on-site services that integrate physical and mental health, dental care and nutrition on a shared risk basis. Per employee capitation and risk sharing will be featured in plan designs.
· Carve-Outs and EPO Contracts: Big Business will stratify and segregate high cost, complex services in their plan and contract exclusively with regional/national providers.
· Price Controls: Big Business will encourage cost and price transparency for all provider transactions and incent employees to shop for value. Advocacy efforts will be targeted to price-setting legislation for hospital services and prescription drugs.
· Board Scrutiny: Big Business will educate Board Members to the necessity for and consequence of Big Business activism in healthcare and include “health system” experience in Director recruitment.
Amazon’s pushback from its Amazon Care offering is not an indication that employers are disinterested in healthcare solutions that improve value and lower costs. In fact, they’re more interested than ever. It’s simply a business decision.
The Big Business playbook in healthcare is changing. Stay tuned.
Paul
PS: My son, Jordan, is the force that kept my work fact based, documented and current. As a CPA with a Masters in Accounting, he has used his analytic skills to evaluate private equity activity in healthcare, assess the Federal Reserve’s monetary policies that impact healthcare startups and established players and monitor the capital markets for near-term changes and long-term consequences. This is his last week with me: as a professional, he’s one of the best I’ve worked with, and as a son, he’s a source of great pride to his dad. You’re a class act Jordan and a good man!! I will miss you.
Big Business
Amazon retooling healthcare strategy: Amazon revealed plans to shutter Amazon Care in an Aug. 24 letter to Amazon Health Services employees but it is doubtful it will derail Amazon’s healthcare pursuits. The operating entity’s pursuit of large employers did not prove scalable: non-Amazon subsidiary customers did not embrace its virtual-care dependent model.
Amazon built its first foray into telehealth with Amazon Care from the ground up, but the company is now looking for outside expertise to iterate and improve upon its offerings. Amazon reached an agreement to buy virtual and in-person primary care company One Medical for $3.9 billion in a cash transaction announced July 20 and has placed a bid on home health and technology company Signify Health, which was valued at $5 billion in mid-August.
Amazon August 24, 2022 www.amazon.com
Business Group on Health Report: Cost concerns increasing among big employers: Per Business Group on Health’s 2023 Large Employers’ Health Care Strategy and Plan Design Survey based on input from 135 large employers who cover 18 million directly released last Tuesday:
· While the top three conditions fueling health care costs remained the same from last year – they include cardiovascular disease, in addition to cancer and musculoskeletal conditions.
· After experiencing no increase in actual health care cost from 2019 to 2020, employers experienced a significant return to rising costs, with a median 2021 cost increase of 8.2%.
· Despite rising costs, employers expect to cover 82% of the cost of employee coverage in 2022, up from 80% the year before (employer support for family coverage remains at 80% of premium).
· Large employers overwhelmingly (99%) said they were concerned about prescription drug trend. In 2021, prescription drugs accounted for a median of 21% of employers’ health care costs, with more than half of pharmacy spend going to specialty medications.
· While employers will continue to address the affordability of employee premiums and out-of-pocket costs, they remain keenly focused on policy efforts that lower health care and prescription drug costs. Employers are particularly interested in the affordability of maintenance medications, as well as newer gene therapies. In addition, the affordability of mental health services – low- to no-cost virtual health provides affordable access –is of high importance for 24% of employers.
· Virtual health is at a crossroads, warranting further assessment and refinement. While three-quarters of employers (74%) believe that virtual health will significantly impact future health care delivery, 84% said integrating virtual health and in-person care delivery is critical for success. If integration does not occur, it could lead to the duplication of services, unnecessary care, wasteful spending and a fragmented care experience. Further, employers showed interest in virtual primary care. Some 32% will offer these services in 2022, while a total of 69% may do so in 2025.
· Health and well-being strategy continued to play an integral role in workforce strategy, said 65% of employers, an increase from 42% last year.
Business Group on Health August 23, 2022 www.businessgrouphealth.org.
PWC Pulse Survey: business expect to reduce headcount: PWC polled 722 U.S. business executives, including chief financial officers, chief marketing executives, chief information officers, and corporate board directors. Findings:
· Half of respondents said they worked at businesses that would be soon reducing their overall headcount. An additional 19%their companies were considering or developing plans to do so.
· 46% said their companies were nixing or reducing signing bonuses while 44% said they were rescinding offers to job candidates altogether.
PWC Pulse Survey August 18, 2022 www.pwc.com/us/en/library/pulse-survey/managing-business-risks
Study: debt from privately insured patients increased 5X: Almost 58% of patient bad debt in 2021 came from self-pay accounts after insurance, compared with about 11% in 2018, according to a recent study from professional services firm Crowe. Self-pay accounts after insurance include the deductible and amount due after the insurance payment.
The Crowe study found $7,500 to be the threshold at which collections dropped off on self-pay patient accounts. Statement balances greater than $7,500 made up 17.7% of total statements in 2021–triple the proportion in 2018. Balances greater than $14,000 accounted for 16.8% of total statements in 2021, compared with 4.4% in 2018, according to the study.
Hospital collection rates for self-pay patient accounts Crowe August 13, 2022 www.crowe.com
Insurance
Study: MA premiums unrelated to quality and outcomes: Researchers analyzed the extent to which the quality of care offered by Medicare Advantage plans differ across vs within monthly premium levels. Findings:
Statistically significant but small-to-medium sized (1-3 points of 100) improvements for most clinical and patient experience quality measures is associated with higher premiums. There was a negative association for 1 measure; in contrast, at each premium level, there was substantial variation (≥5 points) in the quality of care among Medicare Advantage plans. “Paying higher premiums is not necessary for higher quality care in Medicare Advantage plans. Greater engagement of enrollees and advocates with quality of care and patient experience information for Medicare Advantage plan selection is recommended.”
Haviland et al Association of Medicare Advantage Premiums with Measures of Quality and Patient Experience JAMA Health Forum. August 26, 2022;3(8): e222826. doi:10.1001/jamahealthforum.2022.2826
KFF: Medicare Advantage to grow to 61% of Medicare by 2032: Since 2006, the role of Medicare Advantage, the private plan alternative to traditional Medicare, has steadily grown. In 2022, 28.4 of 58.6 Medicare eligible seniors are enrolled in a Medicare Advantage plan, accounting for 48% of the eligible Medicare population, and 55% ($427 billion) of total federal Medicare spending (net of premiums). The average Medicare beneficiary in 2022 has access to 39 Medicare Advantage plans, the largest number of options available in more than a decade.
· Enrollment growth: Between 2021 and 2022, total Medicare Advantage enrollment grew by about 2.2 million beneficiaries, or 8% – a slightly slower growth rate than the prior year (10%). The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to 61% by 2032.
· Individual vs. Group Plan: Two-thirds (66%) of Medicare Advantage enrollees, or 18.7 million people, are in plans generally available to all beneficiaries for individual enrollment. That is an increase of 1.3 million enrollees compared to 2021. Individual plans have accounted for approximately the same share of total Medicare Advantage enrollment since 2018. 5.1 million Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union. While this is roughly the same share of enrollment since 2010 (18%), the actual number has increased from 1.8 million in 2010 to 5.1 million in 2022. Group enrollees comprise a disproportionately large share of Medicare Advantage enrollees in six states: Alaska (99%), Michigan (42%), Maryland (36%), West Virginia (35%), New Jersey (35%), and Illinois (30%).
· Special needs plans: 4.6 million Medicare beneficiaries are enrolled in Special Needs Plans (SNPs). SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. The majority of SNP enrollees (89%) are in plans for beneficiaries dually enrolled in both Medicare and Medicaid (D-SNPs). Another 9% of SNP enrollees are in plans for people with severe chronic or disabling conditions (C-SNPs) and 2%are in plans for beneficiaries requiring a nursing home or institutional level of care (I-SNPs). Enrollment in SNPs increased from 3.8 million beneficiaries in 2021 to 4.6 million beneficiaries in 2022 (20% increase), and accounts for about 16% of total Medicare Advantage enrollment in 2022, up from 11% in 2011, with some variation across states. In the District of Columbia and Puerto Rico, SNPs comprise about half of all Medicare Advantage enrollees (47% in DC and 48% in PR). In 11 states, SNP enrollment accounts for about one-fifth of Medicare Advantage enrollment (29% in MS, 27% in NY and in LA, 24% in AR and in FL, 23% in GA, 22% in SC, 21% in CT, and 20% in TN, in AZ, and in HI). More than 95% of C-SNP enrollees (about 380,000 people) are in plans for people with diabetes or cardiovascular conditions in 2022. Enrollment in I-SNPs has been increasing slightly, but is still fewer than 100,000.
· Private insurers: UnitedHealthcare and Humana account for 46% of all Medicare Advantage enrollees nationwide in 2022. In nearly a third of counties (29%; or 945 counties), they account for at least 75% of Medicare Advantage enrollment. (BCBS affiliates (including Anthem BCBS plans) account for 14% of enrollment, and four firms (CVS Health, Kaiser Permanente, Centene, and Cigna) account for 24% of enrollment in 2022.
Medicare Advantage in 2022: Enrollment Update and Key Trends Kaiser Family Foundation Aug 25, 2022 www.kff.org
Study: Insurance coverage in low-income countries: Researchers analyzed levels of health insurance coverage in low- and middle-income countries and how coverage varies by people’s sociodemographic characteristics. Findings:
· 20.3% of populations across the 56 countries in our study had health insurance. Health insurance coverage exceeded 50% in 7 countries and 70% in 3 countries.
· 71.4% had public health insurance vs. 28.6% with private health insurance.
· Men and older, more educated, and wealthier people were more likely to have health insurance; these sociodemographic gradients in health insurance coverage were strongest in sub-Saharan Africa and followed traditional lines of privilege.
Chen et al Health Insurance Coverage in Low- And Middle-Income Countries Remains Far from The Goal of Universal Coverage Health Affairs August 2022 https://doi.org/10.1377/hlthaff.2021.00951
Cost of Care
Study: chronic disease prevalence linked to financial burden: Researchers analyzed insurance claims data from January 2019 to January 2021 linked to commercial credit data for adults 21 years and older enrolled in a commercial preferred provider organization in Michigan. The study population included 2 854 481 adults (38.4% male, 43.3% female, 12.9% unknown sex, and 5.4% missing sex), 61.4% with no chronic conditions, 17.7% with 1 chronic condition, 14.8% with 2 to 3 chronic conditions, 5.4% with 4 to 6 chronic conditions, and 0.7% with 7 to 13 chronic conditions. Findings:
· Among those with 7-13 chronic conditions, 9.6% had medical debt in collections, 8.3% had nonmedical debt in collections, 16.3% had delinquent debt, 19.3% had a low credit score, and 0.6% had recent bankruptcy.
· Among individuals with 0 vs 7 to 13 chronic conditions, the predicted probabilities of having any medical debt in collections (7.6% vs 32%), any nonmedical debt in collections (7.2% vs 24%), any delinquent debt (14% vs 43%), a low credit score (17% vs 47%) or recent bankruptcy (0.4% vs 1.7%) were all considerably higher for individuals with more chronic conditions and increased with each added chronic condition.
· Among individuals with medical debt in collections, the estimated amount increased with the number of chronic conditions ($784 for individuals with 0 conditions vs $1252 for individuals with 7-13 conditions) In secondary analyses, results showed significant variation in the likelihood and amount of medical debt in collections across specific chronic conditions.
The association between financial health and physical health is bidirectional, and poor financial status is a known risk factor for the development of chronic disease.
Becker et al Association of Chronic Disease with Patient Financial Outcomes Among Commercially Insured Adults JAMA Intern Medicine August 22, 2022. doi:10.1001/jamainternmed.2022.3687
Altarum: July Medicare payments shrink: “In July, Medicare prices fell by nearly a full percentage point, putting overall Medicare services prices below the levels seen back in January 2021. These declining Medicare prices are due to two major factors: very low or no increases in the statutory reimbursement rates for hospital care and physician services in the calendar year 2022 and the re-institution of the mandated sequestration cuts for Medicare provider payments in April and July of this year. The impact of the two sequestration cuts lowered Medicare prices between March and April and then between June and July across all three major settings of care as first a 1% and then a 2% cut were put in place.”. Private Insurance Health Care Price Growth and Major Components, Cumulative since January 2021: All Services +5.4%, Hospital services +7.2%, Physician Services +3.4%, Nursing Home Services +.07
Perspective: Medicare and Private Insurance Health Care Prices Diverge Substantially in 2022 Altarum August 24, 2022https://altarum.org/news/medicare-and-private-insurance-health-care-prices-diverge-substantially- 2022
Study: Per beneficiary MSSP spending higher than Medicare Advantage: In this economic evaluation of 15,763 MA and MSSP beneficiaries between 2014 and 2018, spending was 22% to 26% higher for MSSP beneficiaries than for MA beneficiaries even after controlling for detailed clinical risk factors. This was accounted for by higher outpatient hospital spending for MSSP beneficiaries. Related findings:
· MA beneficiaries, compared with MSSP beneficiaries, were more likely to be older (median [IQR] age, 75.0 [69.9-81.8] years vs 73.1 [68.3-79.8] years), male (5515 [43%] vs 1119 [37%]), and White (9644 [76%] vs 2046 [69%]) and less likely to live in low-income zip codes (2338 [19%] vs 750 [25%]).
· The mean unadjusted per-member per-year spending difference between MSSP and MA disease-specific sub-cohorts was $2159 in diabetes, $4074 in CHF, $2560 in CKD, and $2330 in hypertension. After matching on clinical risk and demographic factors, MSSP spending was higher for patients with diabetes (mean per-member per-year spending difference in 2015: $2454), CHF ($3699), CKD ($2478), and hypertension ($2258).
Parikh et al Evaluation of Spending Differences Between Beneficiaries in Medicare Advantage and the Medicare Shared Savings Program JAMA Network Open August 23, 2022;5(8): e2228529. doi:10.1001/jamanetworkopen.2022.28529
Study: Traveler nursing costs down: The average weekly travel nurse pay in July in the U.S. was $2,997, up 12 percent from $2,681 during the same time in 2021, according to a report from Vivian Health. The report.
Vivian Health www.vivian.com
Skilled Nursing
Regulators probing quality, costs in skilled nursing: The HHS Office of the Inspector General (OIG) last week announced an additional investigation as part of its 2022 Work Plan — specifically focusing its efforts on whether skilled nursing facilities are reporting related-party costs in accordance with federal regulations. The agency will also look into whether Medicare reimbursement is sufficient to cover beneficiary care – particularly if overhead costs have increased while allocations for patient care decreased.
OIG Launches Investigation into Nursing Home Medicare Payments to Related Parties Skilled Nursing News August 23, 2022 skillednursingnews.com/2022/08/oig-launches-investigation-into-nursing-home-medicare-payments-to-related-parties
Mental Health
Mental health issues spiked for children: The COVID-19 pandemic has exacerbated rates of depression, anxiety, and other behavioral health issues among youth. Pre-pandemic, 1 in 5 children experienced a mental health condition every year and 54% of non-institutionalized youth enrolled in Medicaid or CHIP received mental health treatment. Between March 2020 to October 2020, mental health–related emergency department visits increased 24% among youth ages 5 to 11 and 31% among ages 12 to 17, compared with 2019 emergency department visits.
Bolstering the Youth Behavioral Health System: Innovative State Policies to Address Access & Parity HMA www.healthmanagement.com/insights/weekly-roundup/August-24-2022
Big Business
Amazon retooling healthcare strategy: Amazon revealed plans to shutter Amazon Care in an Aug. 24 letter to Amazon Health Services employees but it is doubtful it will derail Amazon’s healthcare pursuits. The operating entity’s pursuit of large employers did not prove scalable: non-Amazon subsidiary customers did not embrace its virtual-care dependent model.
Amazon built its first foray into telehealth with Amazon Care from the ground up, but the company is now looking for outside expertise to iterate and improve upon its offerings. Amazon reached an agreement to buy virtual and in-person primary care company One Medical for $3.9 billion in a cash transaction announced July 20 and has placed a bid on home health and technology company Signify Health, which was valued at $5 billion in mid-August.
Amazon August 24, 2022 www.amazon.com
Business Group on Health Report: Cost concerns increasing among big employers: Per Business Group on Health’s 2023 Large Employers’ Health Care Strategy and Plan Design Survey based on input from 135 large employers who cover 18 million directly released last Tuesday:
· While the top three conditions fueling health care costs remained the same from last year – they include cardiovascular disease, in addition to cancer and musculoskeletal conditions.
· After experiencing no increase in actual health care cost from 2019 to 2020, employers experienced a significant return to rising costs, with a median 2021 cost increase of 8.2%.
· Despite rising costs, employers expect to cover 82% of the cost of employee coverage in 2022, up from 80% the year before (employer support for family coverage remains at 80% of premium).
· Large employers overwhelmingly (99%) said they were concerned about prescription drug trend. In 2021, prescription drugs accounted for a median of 21% of employers’ health care costs, with more than half of pharmacy spend going to specialty medications.
· While employers will continue to address the affordability of employee premiums and out-of-pocket costs, they remain keenly focused on policy efforts that lower health care and prescription drug costs. Employers are particularly interested in the affordability of maintenance medications, as well as newer gene therapies. In addition, the affordability of mental health services – low- to no-cost virtual health provides affordable access –is of high importance for 24% of employers.
· Virtual health is at a crossroads, warranting further assessment and refinement. While three-quarters of employers (74%) believe that virtual health will significantly impact future health care delivery, 84% said integrating virtual health and in-person care delivery is critical for success. If integration does not occur, it could lead to the duplication of services, unnecessary care, wasteful spending and a fragmented care experience. Further, employers showed interest in virtual primary care. Some 32% will offer these services in 2022, while a total of 69% may do so in 2025.
· Health and well-being strategy continued to play an integral role in workforce strategy, said 65% of employers, an increase from 42% last year.
Business Group on Health August 23, 2022 www.businessgrouphealth.org.
PWC Pulse Survey: business expect to reduce headcount: PWC polled 722 U.S. business executives, including chief financial officers, chief marketing executives, chief information officers, and corporate board directors. Findings:
· Half of respondents said they worked at businesses that would be soon reducing their overall headcount. An additional 19%their companies were considering or developing plans to do so.
· 46% said their companies were nixing or reducing signing bonuses while 44% said they were rescinding offers to job candidates altogether.
PWC Pulse Survey August 18, 2022 www.pwc.com/us/en/library/pulse-survey/managing-business-risks
Study: debt from privately insured patients increased 5X: Almost 58% of patient bad debt in 2021 came from self-pay accounts after insurance, compared with about 11% in 2018, according to a recent study from professional services firm Crowe. Self-pay accounts after insurance include the deductible and amount due after the insurance payment.
The Crowe study found $7,500 to be the threshold at which collections dropped off on self-pay patient accounts. Statement balances greater than $7,500 made up 17.7% of total statements in 2021–triple the proportion in 2018. Balances greater than $14,000 accounted for 16.8% of total statements in 2021, compared with 4.4% in 2018, according to the study.
Hospital collection rates for self-pay patient accounts Crowe August 13, 2022 www.crowe.com
Quality of Care
Study: Religiosity/Spirituality contribute to heart care improvement for African Americans: This cross‐sectional study using Jackson Heart Study (JHS) data examined relationships between religiosity (religious attendance, private prayer, religious coping) and spirituality (theistic, nontheistic, total) with LS7 individual components (e.g., physical activity, diet, smoking, blood pressure) and composite score among African Americans. Finding:
Higher levels of religiosity/spirituality were associated with intermediate/ideal cardiovascular health across multiple LS7 indicators. Reinforcement of religiosity/spirituality in lifestyle interventions may decrease overall cardiovascular disease risk among African Americans.
Brewer et al Religiosity/Spirituality and Cardiovascular Health: The American Heart Association Life’s Simple 7 in African Americans of the Jackson Heart Study 24 Aug 2022 https://doi.org/10.1161/JAHA.121.024974Journal of the American Heart Association. 2022;0:e024974
Campaign 2022, Politics
Pew: Abortion key issue in 2022 elections: Per a new Pew Research poll conducted August 1-14, 2022:
· In August, 56% of voters said abortion was key to their vote — up from 43% in March. That puts it ahead of energy policies, immigration and foreign policy, though still well below the 77% of voters who see the economy as a top priority followed by Gun policy (62%), violent crime (60%) energy policy (53%) and foreign policy (42%).
Abortion Rises in Importance as a Voting Issue, Driven by Democrats August 23, 2022 www.pewresearch.org/politics/2022/08/23/abortion-rises-in-importance-as-a-voting-issue-driven-by-democrats
Pew: political systems drive coronavirus responses; U.S. most divided: Per a recent Pew Research Center Global Attitudes Survey in 19 countries:
· A median of 68% think their country has done a good job dealing with the coronavirus outbreak, with majorities saying this in every country surveyed except Japan.
· Most (61%) believe the pandemic has created greater divisions in their societies and exposed weaknesses in their political systems vs. 81% in the U.S.
· 52% (median) think their country’s response to the pandemic has been hampered by political system vs. 66% in the U.S.
· 68% (median) think their country has done a good job overall handling the coronavirus vs. 58% in the U.S.
· In the U.S., South Korea, Canada, Italy, Israel, Spain, the Netherlands and Germany, those who place themselves on the left are more likely to call vaccination very important for being a good citizen than those on the right; however, the opposite is true in Hungary, Poland, France and Greece. In the U.S., again, the differences between people on either side of the ideological spectrum is greater than in any other country surveyed (46%).
Partisanship Colors Views of COVID-19 Handling Across Advanced Economies Pew Research August 11, 2022 www.pewresearch.org/global/2022
