Study: Chamber of Commerce Association Health Plans Building Political Bridges While Refuting Opposition

A recent ruling[i] by Judge Bates in the District Court of Washington D.C. has endangered the operation of regionally-defined association health plans (AHPs) and other expansions of the AHP market through the Department of Labor’s June 2018 regulation update. The leading force behind these regional AHPs are chambers of commerce. At the time of this report’s writing, chambers are the single most common organization sponsoring new regional AHPs and their health plans illuminate important contrasts between reality of this emerging insurance category and some of the criticisms levied against it.

Report Highlights

  • Out of recently launched AHPs operating under the new regulation, 58 percent are sponsored by a chamber of commerce (whether local, regional, or state chamber)
  • While the new AHP regulation was released during a Republican administration, over 1 in 5 new chamber AHPs includes sponsorship by chambers not associated with conservative politics such as Urban, LBGT, and Hispanic chambers of commerce
  • 56 percent of the new chamber AHPs have their primary sponsorship through a single chamber of commerce
  • For multi-chamber AHPs, the average number of co-sponsoring chambers is 17
  • 18 AHPs sponsored by chambers of commerce and operating under the new regulation can be found in 10 states, with more AHPs still in planning
  • The vast majority of chamber AHPs (94 percent) use third-party insurance companies rather than self-funding their health benefits
  • Chambers vary on the tactics used to ensure plan stability and discourage adverse selection
  • Compared to the overall AHP market, chamber plans were more likely to serve employers between 2 and 50 employees and less likely to extend enrollment to sole proprietors


Introduction: Chambers of Commerce & AHPs

Since the new regulation[ii] took effect that made the formation of association health plans easier, has found 18 of 31 (58 percent) of the new AHPs operating under this rule are sponsored by chambers of commerce. A chamber of commerce is an organization, typically non-profit,[iii] composed of businesses and business people who desire to promote the commercial interests related to their membership. Chambers come in a variety of forms and are organized at the national level (the U.S. Chamber of Commerce) as well as state, regional, and local levels. While at the state or national level, a chamber may lobby for federal legislation or regulation, regional and local chambers are more likely to focus on the issues affecting their individual regions.[iv]

Because the cost of employee healthcare is a major concern for employers, it is unsurprising that chambers of commerce have assumed a major role as both advocate and provider of association health plans. Thomas J. Donohue, President and CEO of the U.S. Chamber of Commerce, has commented, “AHPs are a way for small businesses and self-employed Americans to band together, whether by industry or geography, to enroll in a single group health plan that will cover far more employees than a plan used by an individual small business…Because AHPs will cover so many people, these plans will be governed by rules that apply to large group plans, which are far less prescriptive, allowing coverage to be significantly more affordable.”[v]

Currently, local and regional chambers of commerce account for most (78 percent) chamber AHPs operating under the new regulation. Part of the reason for this may be due to operational considerations. A state-based chamber, particularly in a geographically large state, may need to have coverage from multiple healthcare provider groups since a single healthcare provider group may not have facilities across an entire state. Identifying multiple preferred healthcare provider groups and negotiating with them directly or through an insurer can require more time and slow an AHP’s time to market.

The type of AHP sponsored by a chamber of commerce is regional. In other words, the commonality of interest among the companies belonging to the AHP rests on a shared territory in which the companies have their principal place of business. This means that any type of business within the chamber AHP’s region can join the health plan so long as it abides by membership conditions. Membership conditions normally concern requirements such as:

  • Active membership of the business within the chamber of commerce sponsoring the AHP
  • Having total employees within the range supported by the health plan (e.g. 2 to 50)
  • Satisfying participation requirements regarding the percentage of enrolled employees and how much the company contributes toward the employees’ insurance premiums

This regional commonality is of special interest because critics of association health plans have accused them of carving out preferred groups who have lower medical risk (i.e. lower healthcare utilization trends) and exclude less healthy groups.[vi] However, in the regional model, there is not the ability to select a preferred profession on which to build a health plan (e.g. independent fitness instructors). Instead, as discussed above, a regional AHP must accept employers that satisfy the health plan’s geographic and participation criteria. Businesses that satisfy these criteria cannot be rejected because of large medical claims of their employees.[vii] Additionally, individual employees cannot have their application for insurance rejected due to health factors and their premiums cannot be adjusted based on health factors.

“The HIPAA nondiscrimination rules apply to group health plans, including AHPs. Therefore, AHPs, like any other group health plan, cannot discriminate in eligibility, benefits, or premiums against an individual within a group of similarly situated individuals based on a health factor. AHPs, like other group health plans, generally may make distinctions between groups of individuals based on bona fide employment-based classifications consistent with the employer’s usual business practice, provided such distinction is not directed at individual participants or beneficiaries based on a health factor.”[viii]

Expanded nondiscrimination provisions are part of the changes to association health plans enacted by the new Department of Labor regulation mentioned earlier.[ix]


“Go It Alone” or “Strength in Numbers”?

Chambers of commerce have the option to sponsor an association health plan alone or in collaboration with other chambers of commerce. Among the new chamber AHPs, single chamber sponsorship was most common. 56 percent of the new chamber AHPs have their primary sponsorship through a single chamber of commerce (though some single-chamber AHPs have programs that allow other chambers to participate).[x]

44 percent of chamber AHPs have multiple chambers as primary sponsors. On average, these multi-chamber AHPs have 17 co-sponsoring chambers.[xi]  The high end of the range was VASEplus Health Plans with 31 co-sponsoring chambers in the state of Vermont.

Chambers have multiple considerations when deciding whether to collaborate on an AHP. A compelling health insurance product can be a valuable tool for increasing chamber membership.[xii] For chambers that have overlapping regions (e.g. local and regional), there may be a concern that collaborating may reduce the potential for maximum membership growth. However, collaboration among multiple chambers brings with it several advantages. First, and most importantly, multiple chambers sponsoring a single AHP maximizes the size of the AHP. The more members within a single AHP, the more leverage that AHP has in price negotiations with an insurer or healthcare providers. Scale is the foundation of the group health insurance market and a principal value proposition for small businesses and sole proprietors who otherwise would have little bargaining power in health insurance negotiations. The second advantage of maximum AHP size is that it can bring rate stability, particularly for self-funded AHPs. In a very large AHP, there is less disruption if the association loses some member employers during the course of a year because the premiums from the remaining employers can maintain cash flow needed for the operation of the AHP. Additionally, more members in a health plan can improve its prospects for a good balance of healthy enrollees alongside enrollees who use more healthcare.


Building Political Bridges?

While traditionally chambers are associated with Republican leanings,[xiii] chambers of commerce not identified with conservative politics have been observed among the co-sponsors of new chamber AHPs. 4 of 18 (22 percent) of the new chamber AHPs evidenced this attribute.

  • The Southern Arizona Chamber Benefits Plan from the Southern Arizona Chamber of Commerce Association includes the sponsorship of the Tucson Hispanic Chamber of Commerce and the Tucson GLBT Chamber of Commerce[xiv]
  • The Clark County Health Plan Association includes sponsorship from the Urban Chamber of Commerce, The Latin Chamber of Commerce – Las Vegas, and the Las Vegas Asian Chamber of Commerce[xv]
  • The Greater Choice Oklahoma plan from the Greater Oklahoma City Chamber of Commerce includes participation from the Greater Oklahoma City Hispanic Chamber of Commerce[xvi]
  • North Texas Employer Health Plan Cooperative has both the North Texas GLBT Chamber and the Irving Hispanic Chamber among the chamber participants in the AHP[xvii]

For those who are not politically monogamous, this finding is intuitive. American businesses representing diverse interests and backgrounds have a common challenge finding affordable health coverage that can help them retain quality employees. This common challenge appears to be fostering collaboration.


Avoiding Adverse Selection & Instability

Health insurance, like other forms of insurance, seeks broad risk pools (i.e. collections of insurance customers) so that there are enough people with low medical claims to compensate for enrollees who have high medical claims. This principle was behind the Affordable Care Act’s efforts to enroll “young invincibles”[xviii] (i.e. millennials who were more likely to be very healthy and use medical services less) in their health plans. As Kaiser Health’s Julie Rovner explained:

“Well, the Affordable Care Act made individual insurance available to people who were older and sicker, and they jumped at the chance to buy it. The hope was that younger people would buy it because they were required to and their lower expenses would help balance out the risk pool, helping them basically subsidize older, sicker people on the theory that someday they’ll become older, sicker people and young people will subsidize them.”[xix]

Health plans typically seek legal ways to avoid enrolling people who wait until they are sick before they start paying for health insurance. For Affordable Care Act plans, several tactics are used to avoid this scenario, generally referred to as “adverse selection.” These tactics include an annual enrollment period, outside of which enrollment is prohibited without special qualifying life events (e.g. birth of a child). This strategy helped Affordable Care Act plans prevent people from waiting until they were sick and then buying coverage. Another tactic was the implementation of a mandate that fined Americans who did not have health insurance coverage. This penalty was intended not only to discourage people from being uninsured but also move more people into Affordable Care Act insurance coverage.

For associations sponsoring AHPs, there are a variety of tactics observed in the effort to avoid adverse selection and promote plan stability. While they are not required to have an annual enrollment period, they can choose to use one as well as tactics such as:

  • Requiring a minimum percentage of eligible employees to participate in the health plan to avoid an employer just enrolling the least healthy workers in the AHP[xx]
  • Requiring a minimum membership time in the association before allowing an employer to participate in the health plan[xxi]
  • Requiring a minimum waiting period before withdrawing from the insurance coverage or not renewing the coverage[xxii]


Health Plan Funding

The new chamber-sponsored AHPs heavily favor the “fully-insured” health plan funding model where the responsibility for paying medical claims is completely transferred to a third-party insurance company in exchange for premium payments. All but one chamber AHP, 94 percent, were fully-insured. In comparison, chamber of commerce AHPs had an even higher preference for fully-insured plans than is the case for the market as a whole (86 percent).[xxiii]

The high reliance on the fully-insured model is of particular interest because many of the criticisms directed at AHPs surrounds the potential to offer self-insured plans. Self-funded plans are at greater risk for insolvency than fully-insured plans because a fully-insured plan is typically backed by an insurance company with greater capital resources to withstand catastrophic medical expenses. However, self-funding’s greater risk should be contextualized within several facts:

  • There are tactics, such as the combination of cash reserves and stop loss insurance, that can greater reduce the risk of insolvency
  • Self-funded plans are widely used in the American health insurance

Reinforcing the latter point above, research from the Kaiser Family Foundation has noted, “Both public and private employers use self funding to provide health benefits…Sixty-one percent of covered workers are in a self-funded health plan. Self-funding is common among larger firms because they can spread the risk of costly claims over a large number of workers and dependents.”[xxiv]

The rationale behind self-funding, inside or outside the association health plan market, is the ability to reduce costs (and, by extension, premiums) compared to fully-insured plans by:

  • Paying less for administration and other operations costs
  • Eliminating profit paid to the insurance company paid for primary coverage[xxv]
  • Eliminating taxation paid on insurance premiums
  • Identifying and challenging overcharges and mischarges within enrollee medical claims

The last of the four bullets deserves special attention. Within a typical fully-insured health plan, the sponsoring organization does not have access to medical claims. Inaccessible claims data prevents the organization sponsoring a health plan from systematically analyzing the data and challenging the errors to reduce the overall expenses that drive premium costs. Errors and overcharges in medical claims have attracted increasing attention in recent years.

“Accounts of medical billing errors vary widely. While the American Medical Association estimated that 7.1 percent of paid claims in 2013 contained an error, a 2014 NerdWallet study found mistakes in 49 percent of Medicare claims. Groups that review bills on patients’ behalf, including Medical Billing Advocates of America and CoPatient, put the error rate closer to 75 or 80 percent.”[xxvi]

For some within healthcare reform, rigorously improving claims accuracy is the next frontier of cost reduction in American healthcare.[xxvii]

While self-insuring has the potential for larger savings than fully-insured plans, it also requires more preparation and expense to launch than is the case for a fully-insured plan. For a properly managed self-funded plan, there is a need for:

  • Cash reserves to address claims that exceed claims during a given month
  • Stop-loss insurance to protect against excessive medical expenses
  • Vendors to address health plan operations work outside the expertise of the association (e.g. claims processing, plan compliance, etc.)
  • Large collection of enrollees so that the loss of a few employers during a given coverage period does not endanger either cash reserves or claims predictability

The absence of the above measures in a self-funded plan can lead to compliance violations, operational problems, and financial insolvency. However, properly implemented, these measures have produced successful self-funded plans across the country.


Health Plan Trends

When compared to new AHPs in general, the chamber AHPs share similarities and differences from the new AHP market as a whole. Like the new market in general, chamber AHP benefits are represented as broad and sometimes include explicit statements that the plans are not “skinny”[xxviii] as some critics have alleged they would be. Chamber-sponsored health plans offered more health plan options to their members than the rest of the AHP market, averaging nearly 14 plan options.[xxix] An earlier study of the market inside and outside chambers found the average number of plans to be 11.[xxx]

One of the significant differences between the current crop of chamber AHPs and the rest of the market concerned the size of employers who could participate in the insurance coverage. The chamber plans were more likely to restrict participation to employers of 2 to 50 employees and less likely to support sole proprietors. 72 percent (13 of 18) of chamber-sponsored AHPs limited coverage to employers with 2 to 50 employees compare to 54 percent in the AHP market as a whole.[xxxi] 28 percent (5 of 13) of chamber AHPs were available to sole proprietors compared to 43 percent in the AHP market as a whole.[xxxii]  The Wausau Region Chamber Association Health Plan and VACEplus Health Plans from the Vermont Association of Chamber of Commerce Executives offered membership above 50 employees, though it should be noted that the definition of small group plans in Vermont extends to businesses employing up to 100 workers.

Over half (61 percent) of the chamber AHPs use UnitedHealthcare (or subsidiaries of UnitedHealthcare) to deliver their insurance benefits. UnitedHealthcare often claims savings for AHPs in the range of 5 percent to 15 percent. The Georgia Chamber of Commerce’s SMART Health Plan, which is self-funded, claims savings up to 40 percent[xxxiii] depending on the company’s former coverage and the dimensions on which a premium is based. In Affordable Care Act plans, premiums are normally based on an applicant’s age, the region in which he or she lives, tobacco use, and income (via lower-income subsidies). In association health plans, premiums can be determined by additional factors, though there is flexibility of which additional factors are employed. These additional factors include occupation, industry, and sex. However, health factors such as pre-existing conditions, medical history, or genetic information cannot be used to adjust association health plan premiums. Since association health plans do not have income-based premium subsidies, there is little prospect that these offerings will capture significant numbers of subsidized consumers off of Affordable Care Act exchanges. Subsidized enrollees are the heart of Affordable Care Act exchange enrollment, with 87 percent of enrollees receiving an advanced premium tax credit.[xxxiv] The average premium for these subsidized consumers on was $87 for the 2019 plan year.[xxxv]



The court ruling by Judge Bates invalidating the operation of expanded association health plans like the ones sponsored by chambers of commerce is expected to be vigorously appealed by the current administration given the strategic benefits these health plans represent for a small business market that has struggled with medical insurance affordability. Prior to the new regulation for association health plans, small businesses could pay more for the same benefits because they lacked the leverage of scale in negotiations and small business health plans were legally allowed to devote a higher portion of premiums for administration and profit than was the case for large company health plans.[xxxvi] Commenting on this situation, the U.S. Chamber of Commerce has lamented, “Previously, the unequal treatment of large and small companies left smaller employers with a stark choice: either pay for high-priced comprehensive plans or offer no health coverage at all. Is it any wonder that the number of small businesses offering coverage has fallen in recent years?”[xxxvii] Scott Waller, president and owner of XETX Business Solutions, shared similar sentiments. “Large enterprises have had a huge advantage over small businesses and that they were able to offer benefit packages that a small business simply could not offer.”[xxxviii]

Through the new Department of Labor regulation, the same large company insurance model that already covers roughly 95 million Americans was made available to small businesses through associations. This change has been a matter of market access. The definition and rules related to large company health insurance have not changed. Instead, the playing field between small companies and large companies was leveled with respect to health insurance costs. The preservation of this leveling is likely dependent on a successful appeal of Judge Bates ruling unless Congress decides to act. With the ACA markets also endangered by a recent court ruling,[xxxix] it is a possible scenario that both the ACA and AHP markets will be impaired leaving chaos in markets for private insurance. It is conceivable that a bipartisan bill could be sponsored between the two major parties in Congress that implements a nominal individual mandate fine (and thus maintaining the ACA’s constitutionality as a tax instrument) in exchange for a formalization of the new AHPs rules within law rather than regulation.

Alongside increasing insurance options for small businesses, the new chamber AHPs also provide important refutation of some of the criticisms association health plans have received. As an organization with a regionally-based scope of membership, it is difficult to argue that they are purposely carving out healthier groups from the population from other health insurance markets. Their exclusion from premium subsidies also distinguishes the market of AHPs from the core audience of the exchange market. Additionally, critics concerns over self-funding overblown inasmuch as self-funding is not prevalent among AHPs and we do not have evidence at this time of self-funding best practices (adequate cash reserves, stop loss coverage, etc.) being widely ignored.



Kev Coleman is a widely recognized authority on American health insurance markets and is also the President of Press inquiries regarding this report can be directed to Mr. Coleman at Data from the report may be cited with proper attribution. © Kevin Coleman.



This study examined association health plans that:

  • Are sponsored by a chamber of commerce
  • Are active and enrolling members
  • Operate under the new June 2018 Department of Labor regulation related to association health plans

Chamber health plans that did not satisfy the above criteria, for example the MEWA offered by the Greater Akron Chamber of Commerce, were not included within the analysis. Additionally, AHPs were excluded where the primary sponsors were not chambers of commerce even if the association was open to chambers participating (e.g. Transcend AHP in Michigan whose primary sponsors are the MichBusiness professional association and the Michigan Chamber of Commerce).

Analysis was dependent on public data provided through chamber websites, plan documentations, press releases, and news stories.



[i] Kevin Truong. “Federal judge stymies Trump Administration’s association health plan expansion efforts.” MedCityNews. (March 31, 2019).

[ii] Department of Labor. “Definition of “Employer” Under Section 3(5) of ERISA-Association Health Plans.” Federal Register. (June 21, 2018).

[iii] “Chambers of commerce in the US operate almost exclusively as non-profit entities known as 501(c)(6) corporations. Unlike charities, these 501(c)(6) non-profits have the authority under state and federal tax rules to represent their members in public policy debates.” “Chambers of commerce.” Association of Chamber of Commerce Executives. (November 2, 2009).

[iv] See Will Kenton. “Chamber of Commerce.” Investopedia. (March 25, 2018).

[v] Thomas J. Donohue. “A Health Care Victory for Small Businesses.” U.S. Chamber of Commerce. (June 25, 2018).

[vi] “Any premium advantage touted by AHPs is more likely due either to the teaser rates described above, enrolling members with lower health risk than in the ACA-regulated market, or to the AHP’s ability to bypass the rating and risk pooling rules set up under the ACA.” Kevin Lucia and Sabrina Corlette. “It’s All About the Rating: Touted “Benefits” of Association Health Plans Ignore Key Facts.” Center of Health Insurance Reforms. February 4, 2019.

[vii] See in particular Example 1 within the nondiscrimination guidance. Department of Labor. “Definition of “Employer” Under Section 3(5) of ERISA-Association Health Plans.” Federal Register. (June 21, 2018).

[viii] Department of Labor. “Definition of “Employer” Under Section 3(5) of ERISA-Association Health Plans.” Federal Register. (June 21, 2018).

[ix] “Existing Association Health Plan (AHP) Law vs. New Final Rule.” National Association of Health Underwriters.

[x] For example, the AHP sponsored by the Greater Akron Chamber of Commerce is open to members of other chambers of commerce that belong to the Greater Akron Chamber Alliance.

[xi] The average before rounding was 16.625.

[xii] See commentary on how the loss of health plans for a regional chamber of commerce and the Council of Smaller Enterprises (COSE) had led to membership decline. Jay Miller. “Health insurance offering boosts Greater Cleveland Partnership’s membership” Crain’s Cleveland Business. (January 13, 2019).

[xiii] “The business associations grouping includes small business, pro-business and international trade associations, as well as chambers of commerce. Business associations have historically leaned Republican, giving at least 70 percent of their contributions to the GOP since 2004. The 2016 cycle, however, marked a new high for the partisan giving of these interests. Of their contributions to candidates and party committees, 92 percent went to Republicans; that was up from 83 percent in the 2014 cycle, as well as from the previous peak of 87 percent from 1998-2002.” Nav Sultan. The Center for Responsive Politics. (April 2017). “Business Associations.”

[xiv] Robert Medler. “Southern Arizona chambers come together to address healthcare challenge.” Inside Tucson Business. (March 1, 2019).

[xv] https://clarkcountyhealthplanassociation.com2019UHC18373-CCHPA-SGWO-AHP-Product-Portfolio-Brochure_R5_FINAL.pdf



[xviii] Radio transcript from “All Things Considered.” “The ‘Young Invincibles’: A Huge Hurdle For Obamacare.” National Public Radio. (August 21, 2016).

[xix] Radio transcript from “All Things Considered.” “The ‘Young Invincibles’: A Huge Hurdle For Obamacare.” National Public Radio. (August 21, 2016).

[xx] For example, see the State Chamber of Oklahoma’s association health plan Oklahoma Chamber Blue. “The percentage of enrollment of Eligible Employees which may be required to be maintained is 75%. The minimum contribution amount which is required from the Employer Member is 50% of the premium for Employee Only Coverage.”

[xxi] For example, see the One Southern Indiana association health plan. “Employers must be a member of the 1si chamber of commerce for one year before they are eligible for all plan options. If an employer has not been a member of 1si for 12 months or greater, they will only be eligible for PPO plans with a $5000 deductible or more.”

[xxii] For example, see the Georgia Chamber of Commerce’s SMART Health Plan. “During the policy period, you may only elect to withdraw from the Georgia Chamber SMART Plan at the end of a calendar month by giving written notice at least 60 days prior to that date. At renewal time, you must give written notice at least 30 days in advance.” http://www.gachamber.comGA_Chamber_SMART_Benefit_Plan_FAQ.pdf

[xxiii] Kev Coleman. “First Phase of New Association Health Plans Reveal Promising Trends.” (January 30, 2019). /reports/new-ahp-study/

[xxiv] Gary Claxton et al. Section 10: Plan Funding. “2018 Employer Health Benefits Survey.” Kaiser Family Foundation. (October 3, 2018).

[xxv] It should be noted that there is still some profit paid to third parties such as stop loss providers and vendors performing operational work on behalf of the AHP.

[xxvi] Kelli B. Grant. “It’s Time to Get a Second Opinion Before Paying That Medical Bill.” NBC News. (March 27, 2016).

[xxvii] Organizations such as Pratter.US ( are representative of this belief.

[xxviii] Several plans offered through UnitedHealthcare take pains to refute explicitly the charge of offering narrow benefits. “Is this a “skinny” plan? NO, these are NOT “skinny” plans. These are UnitedHealthCare’s® most popular plans that are offered today to large employers nationwide.” See also

[xxix] 4 chambers did not have public information on the number of plan options they offered to members. Employer characteristics (e.g. size, length of association membership) could reduce the number of options available to an employer within an association.

[xxx] Kev Coleman. “First Phase of New Association Health Plans Reveal Promising Trends.” (January 30, 2019). /reports/new-ahp-study/

[xxxi] Ibid

[xxxii] Ibid

[xxxiii] “”It’s more affordable,” she said. “It can be up to 40 percent less expensive, and the way it’s more affordable is we’re underwriting it — with the ACA, there’s no medical underwriting.” James Swift. “Chamber offering small business health care plan.” The Daily Tribune News. (November 19, 2018).,20573

[xxxiv] “Health Insurance Exchanges 2019 Open Enrollment Report.” Centers for Medicare & Medicaid Services. (March 25, 2019).

[xxxv] “Health Insurance Exchanges 2019 Open Enrollment Report.” Centers for Medicare & Medicaid Services. (March 25, 2019).

[xxxvi] The Medical Loss Ratio (MLR) for small group business plans is 80 percent, which means 20 percent of premiums can be spent on administrative overhead, profit, and marketing. Large group health plans, in comparison, have an 85 percent MLR, which leaves only 15 percent to administrative overhead, profit, and marketing. The Center for Insurance Policy and Research. “Medical Loss Ratio.” National Association of Insurance Commissioners. (September 20, 2018).

[xxxvii] Thomas J. Donohue. “A Health Care Victory for Small Businesses.” U.S. Chamber of Commerce. (June 25, 2018).

[xxxviii] Stefante Randall. “Nacogdoches County Chamber of Commerce offers health plans for small businesses.” KTRE. (November 29, 2018).

[xxxix] Amy Goldstein. “Federal judge in Texas rules entire Obama health-care law is unconstitutional.” Washington Post. (December 14, 2018).