Sabrina Dunlap 0:00

By the way, under sound effects, it's set under alert sound as funky.

Liz Canada 0:05

That's the podcast. That's healthcare costs. Funky. Am I right? You're listening to New Hampshire has Issues, and I'm your host from The Future Liz Canada. I'm recording this in January, 2026, while this episode was recorded November 4th, 2025. It's been a while. So what we talk about in this episode, one piece in particular, is about the Don't Panic, Enhanced Premium Tax Credits. Don't worry, we're gonna talk about it in the show. But we talk about it with the question of what will Congress do? Will they extend those tax credits? They have until December 31st. Spoiler alert, no, they did not. So you might still see headlines about ACA tax credits and people's premiums going up, the amount of money they have to pay every month to continue their health insurance, because those tax credits expired, which means quite a few people in our country and in our state are going to see the cost of their health care go up even more. And a lot of people are going to stop having health insurance because of that. Lots of links in the show notes about this. I usually ask Molly to listen to an episode before I publish it. A vibe check. She is my spouse. She is my champion. She's typically gonna say, oh, it sounds good, which she does, and that's very lovely. And in this case, I did ask her to listen to it. And a whole lot of other people have listened to this episode in advance. Because even for me, the host who interviewed Brinie and we talked, and I listened to the recording over and over again to like wrap my head around it all, and I wanted to get a vibe check from other folks. And what I learned in that process is that what I wanted to share with you before you listen to the full episode, all of the questions you probably have as you listen, they're probably not going to get answered here because it is so complicated. And that's okay. It would be silly for me to say, well, a 40-minute episode about why health care costs so dang much. If anything, what this episode really highlighted for me is that I want to ask the same simple question to folks in other areas of healthcare. Why does health care cost so dang much? So this episode is from a health insurance perspective. Brinie represents Anthem Blue Cross Blue Shield in New Hampshire. And so I want to take the opportunity to interview other folks from their perspectives, providers, hospitals, to name two. In the episode, I also jokingly, yet not jokingly, say that I should have a segment called What the bleep Is This? Where a listener writes in about something in their health insurance bill or something with their health care and is like, what the bleep is this? Uh, I say it jokingly, but actually, if you have a question, send it in. I don't love doing these long preambles, but this is a very important episode because the cost of health care is on so many people's minds right now. If you would like to support the show, please go to patreon.com/ nh has issues. If you have an idea for an upcoming episode, or if you have something to offer the what the bleep is this segment, send me an email. Newhampshire issueshas @ gmail.com. Thank you for listening. This is the topic of health care costs. So let's start with uh let's start with our taglines. Have you thought about your tagline?

Sabrina Dunlap 3:30

I did, and as a listener of your show, I appreciate like beginning with the tagline and trying to be like snappy and quippy, and I confess I cannot do it. I cannot be witty about it.

Liz Canada 3:43

All right, I'm gonna I'm gonna do mine. Welcome to New Hampshire Has Issues, the podcast that dares to ask, is this episode in network or out of network? That's the best I could do.

Sabrina Dunlap 3:54

It's good because it's simple, it's not like judgmental, and it gets at like one of the foundations, or maybe it is judgmental, I don't know, but it gets at one of the foundations of our whole system of care, managed care, which networks are a very important part. So actually asking if something's in or out of network, you're like, I'm bored already. And skip to the next episode.

Liz Canada 4:13

All right, hit me with your tagline. Let's see what you've got.

Sabrina Dunlap 4:15

I I don't have a tagline. I'm I just don't well no, because I I couldn't come up with anything witty. I actually I really like the in or out of network one, and but I couldn't steal it from you. So podcast that dares ask.

Liz Canada 4:27

Do you have your insurance cards with you? Can you hand me? Did you bring it? Did you take a copy of it? Can you take a picture of it? See that.

Sabrina Dunlap 4:34

Can I take that one? That's good.

Liz Canada 4:35

You can take that one. Yeah, take it. Take it.

Sabrina Dunlap 4:38

Um, although do I want to go there? Insurance cards. We're so highly regulated that there's rules around what has to go on um ID cards, believe it or not.

Liz Canada 4:49

Really?

Sabrina Dunlap 4:50

Yes, it's true.

Liz Canada 4:51

Are there rules about what's on the front of a card versus on the back of a card?

Sabrina Dunlap 4:54

Yeah. Yeah. And it depends on the type. It depends on the type of plan you have. Like I don't have a physical card card anymore.

Liz Canada 5:02

What?

Sabrina Dunlap 5:03

It's digital. So it depends on your plan.

Liz Canada 5:06

Yours is digital. What? You've got nice health insurance. That's what I'm hearing. Mine is not digital. Mine is you get that out of your wallet, you find it, and you turn it in so we can take a picture of it.

Sabrina Dunlap 5:17

Well, the provider still ask me for a paper, like a for a physical copy so they can take a photocopy. And I'm like, I've had the same health insurance for six years and it hasn't changed. Nothing has changed. So I feel like maybe they don't like the digital answer. But so do you have a plastic card or is it like you have to print it?

Liz Canada 5:34

I have a plastic card. Do you want me to find it? I think I have it somewhere, actually. I could hold it up and be like, this is my card. Yes, I have a plastic card.

Sabrina Dunlap 5:43

Okay. And is the information on it helpful to you as a consumer?

Liz Canada 5:48

No. I don't know a bleep thing that it says. I don't understand anything about it. And even when they ask me questions like who's the policy holder, I'm like, I'm a person. I'm holding this card, but I don't think that's what you're asking of me. I think it's Molly is the correct answer. Yeah. I feel like I'm always failing the test for my health insurance check-ins.

Sabrina Dunlap 6:09

Yeah, that's understandable. I mean, there's a lot. There is a lot. You start to pull a thread. Policy number.

Liz Canada 6:16

Group number. Oh gosh. Yeah. Is your that dare to ask, is your health insurance card digital plastic for a printout?

Sabrina Dunlap 6:28

Because I did actually print it for a little while. And so I had like a little folded paper one in my wallet. But I was going to ask something along the lines of like, how far down like the nerd health policy rabbit hole can you go?

Liz Canada 6:42

Listener, join us on this journey. We are going to go into the abyss of health insurance. I'm excited about this because when I am out in the world and I'm seeing what's stressing people out, the big thing that people are stressed out about the cost of healthcare. Healthcare costs are up. Yeah. The health insurance issues in terms of like being covered or not covered, what is covered, what isn't. This used to be, it's no longer. All of that is on people's minds. So I feel like this is really important that we're here to talk about this. So let me introduce you since we've been talking for a little bit of time, but we can tell people who you are. So welcome to New Hampshire Has Issues. My guest today is Sabrina Dunlap, aka how I refer to her is Brinie. So I don't want everybody to be terrified that I'm calling her by a different name. She is the senior director of government relations at Anthem, Blue Cross, Blue Shield in New Hampshire. That's correct. Brinie, welcome to the show.

Sabrina Dunlap 7:41

Thank you for having me. I'm so happy to be here.

Liz Canada 7:43

I'm so happy that you're here because health insurance and health care costs definitely are on a lot of people's minds. Right now it is cold out. It's November. It's like we're in like flu season and people are getting sick. The kids are starting to come home and their noses are running, and it's like, stop, get out of my house. This is where we are. We're in the sickness time. Yes. That's so perfectly timed. Is that how you call it in your home? The sickness. That's how it feels. So, Brinie, I think for our episode today, I have a simple question, and it's really the only question, which I'm hoping you can answer. Why the heck does health care cost so dang much? Why is it so expensive? All right, go. Explain it.

Sabrina Dunlap 8:31

How many episodes do I get?

Liz Canada 8:33

You get as many as you'd like. We'll just keep we'll just keep chick-chatting.

Sabrina Dunlap 8:36

Okay. So um yeah, there's there's a lot to that question. Very important question, not a simple answer. I think anyone who claims to have a simple answer, I'm not sure that I wouldn't not sure I would necessarily believe them. The things I would like to cover, there's like, you know, a little outline. Each thing I'm just I'm speaking about these things pretty generally because this, you know, the ID card is a great example. You start to like peel back the layers, and it's like you could spend hours on each of these topics. And there's so much nuance.

Liz Canada 9:11

An ID card? Why is that so complicated?

Sabrina Dunlap 9:14

Not necessarily the ID card. Right. But like all of these pieces of the puzzle are really complicated. The pieces to the puzzle and then insurance alone. Have you ever looked at the New Hampshire insurance statute? Maybe not.

Liz Canada 9:27

Brinie. I want you to think about that question that you just asked me. What first of all, why would I? Second of all, who does that? You do. And some people do. Yeah. But definitely not me. So

Sabrina Dunlap 9:39

That's fair.

Liz Canada 9:39

That was that was impolite. No, I have not. I have not read this.

Sabrina Dunlap 9:44

How dare you. If you're looking for like dense statutory reading, it is extensive.

Liz Canada 9:51

And when you say statutes, that means our laws, our New Hampshire laws.

Sabrina Dunlap 9:54

Thank you.

Liz Canada 9:55

Go ahead.

Sabrina Dunlap 9:55

So I was just also going to say that there's so much nuance generally in health care, but also with health insurance, because again, it comes down to like which health insurance carrier do you have a plan through? And is it employer sponsored? And is that plan self-insured or is it fully insured? Which put a pin in that. I do want to cover that distinction because it's really and then like you get into benefit design. Okay. That's like a whole thing. I know. So you could see how when trying to talk about these issues generally, like for example, at the legislature, I often I'm like, okay, but there's a a thousand different facts that matter. It's very fact-specific.

Liz Canada 10:37

And so I find there's I just need you to remember 1,000 facts. And if you can do that, then I can explain this to you. Right. Exactly. Oh boy.

Sabrina Dunlap 10:45

Um yeah, I know. I feel like I'm off to a bad start.

Liz Canada 10:48

No, you're doing great. This this is all perfect. Okay. So to start off, no, I have not read the laws on this.

Sabrina Dunlap 10:54

Highly regulated, highly regulated entities.

Liz Canada 10:57

I thought you were about to say highly recommended. And I was like, I'm not doing it, Brinie. It's not happening. No matter what you say. I had somebody on earlier, he's he's a marathon runner. I'm like, not doing that either. So the likelihood of me reading the statutes is the same as me running a marathon. Zero percent chance.

Sabrina Dunlap 11:14

Okay. Fair. Zero. Okay, fair.

Liz Canada 11:16

So it's a complicated question.

Sabrina Dunlap 11:19

Well, simple and important question. Complicated, I think. I have like a few different things I want to touch on that I hope would be helpful for people as we try to like, I don't know, pull back the layers on on the cost question. So I'm afraid it might be very dry and boring for you. But even I'm here for. Okay. A little joke here and there. So even as basic as like what is health insurance? Is that too basic? No, no.

Liz Canada 11:49

What is health insurance?

Sabrina Dunlap 11:51

Okay. Thank you. I am delighted that you said it was not too basic.

Liz Canada 11:55

Follow-up question. Why is health insurance different from dental insurance, different from vision insurance? Because I'm pretty sure all three of those things are my body. I know.

Sabrina Dunlap 12:05

Why? I need to look into that because I actually I don't know. Different episode. I I myself am curious. I have a lot of I'm very, very nearsighted. So history of eye issues. And it is weird that it's like a separate, totally separate plan.

Liz Canada 12:17

The eyes are part of my body. Yeah. They are my health.

Sabrina Dunlap 12:20

Yes, this is true. So I don't know the answer. I I probably should know the answer to that one, but I I don't.

Liz Canada 12:25

I'm gonna mark you zero out of one so far. Zero for one.

Sabrina Dunlap 12:30

Okay. Oh God. Okay.

Liz Canada 12:33

So what is health insurance?

Sabrina Dunlap 12:34

Yes, thank you. Okay. So basically the idea is that health insurance is intended to protect people from having to pay super big medical bills and also relatedly help make health care more affordable. So the other thing that's super important is the idea of risk pools. So not gonna go too far down there, but super important because the whole like baseline concept is that many people kind of come together and your premiums, which should we go into what a premium? I mean, as I as I touch on these topics, I'm just gonna like try to explain briefly what they are. So we're not here for seven hours. Premium, that's what you're it's sort of like a subscription. It's like you might pay, let's say, like a hundred bucks a month in premium, and that is what you pay into sort of the bigger pot of money, the risk pool, is then used to pay claims for people. So the idea is that when you pool many people together and you've got a lot of people who are healthy, some people who have health issues, you all kind of help cover the costs. It's sort of like it's kind of like a nice concept when you think about it. A risk pool. But risk pool.

Liz Canada 13:45

It's a nice concept. It sounds fun. Go swim in the risk pool. You'll like it. You know what? The pool that I spend the most time in in my life is my fear pool, where I start talking about all my fears and I put it in my fear pool. I always struggle with the language that's used because premiums sounds like, ooh, premium, ooh, fancy. And that's like it's a it's a it's a fee that you pay. And that's fine, but that's the cost that it that you put toward like your contribution. Yes. And then lots of people are part of this risk pool. Yeah. Some of those people are healthy and they're paying into it. And so their needs for when they get sick might be lower. And then some folks, my mother used to refer to me as a sickly child. People like me, asthma every year, could never go trick-or-treating. It's a whole Oh no. Oh. It's a dramatic telling of my childhood. Oh. You know what? That was the least of my problems when you hear about my childhood, but that's fine. Folks who need to get health care maybe more frequently than others or different types of services, they're also part of that risk pool. And so lots of folks sort of pay into it, and then the claims are made, and then the money comes out of that sort of pool of money in some way. That's where it gets a little tricky for me.

Sabrina Dunlap 15:04

It's not that. It's also more than that. Yeah, I know. And just one thing sort of to like level set on the whole getting back to the cost question. I think there's this sort of notion that health insurance companies set prices. Because we we're often, you know, an easy target for cost. People are like health insurance makes things expensive. But that's actually just factually incorrect. Health insurance companies, um, we don't set prices. We actually negotiate, for example, with like a hospital or provider, we negotiate so that our members have more affordable care. So we negotiate those rates. Now, this is where networks come into play because when we have a contractual relationship, let's use a hospital, for example, and they come, they sign the contract with us, they negotiate their rates with us, they come into our network. And as part of that, there's a whole host of other things that come into play as part of the concept of managed care. For example, providers are credentialed with us. So that means a carrier will ask for a little bit of information about your background, your education to make sure that sort of, let's say, doctor, for example, though there are many types of providers, are who they say they are. And so it's for the benefit of our members that we have these networks that we maintain. When you asked if this episode was in or out of network, it's actually a very important question because depending on your type of coverage, like my plan, for example, I have out-of-network benefits, but they're just not quite as good. So if I go to a provider that's in my health insurance company's network, more is covered. Now, if I go to a provider who's out of network, I do have a decent amount of coverage, but it's not as good. Depending on your plan, you might not have really have much of any out-of-network coverage. So that's where networks become very important. It's for the benefit of our members. That's the point of it.

Liz Canada 16:44

And so members, you mean the folks who are covered by your health insurance or part of your who have their little plastic cards or digital cards. Like those folks are members. And so the health insurance company is negotiating with places so that the costs go down for their members. Mm-hmm. Okay. I'm following you so far. Okay. I'm I'm with you. I'm with you.

Sabrina Dunlap 17:08

Okay, good. Okay. So we got that. Now I hit premiums, I hit networks, I hit risk pools. Okay. We're what time is it? We're doing great.

Liz Canada 17:14

We're zipping, we're zipping right along. Okay. Excellent. Why isn't everybody just in the same risk pool, Brinie?

Sabrina Dunlap 17:22

Is this like a philosophical question or like a technical question? Because

Liz Canada 17:26

Aren't we all part of the same risk pool? It's part of the human race.

Sabrina Dunlap 17:30

The world? I think very good question. I'm not an expert on risk pools. I was going to say that people at health insurance companies who crunch the numbers, well, there's more than one type, but do you know what an actuary is? They are very good with numbers.

Liz Canada 17:46

Yeah.

Sabrina Dunlap 17:47

I'm not that great with numbers. I am not an actuary. I went to a conference recently where there was like a whole presentation on actuaries. Now that might sound not super exciting, but it actually was fascinating. So they have to, I can't even, I'm just going to put it into my like non-math terms, but they they have to use data. So they'll use like claims from years past, but then they use sort of more current data and then sort of data to project into the future because the whole thing is they have to set rates that make sense so that the carrier, the health insurance carrier, can pay the claims in the future. It's really complex mathematical work that they're doing. They're really good at it. But the whole point is like insurance companies have to be able to pay the claims as they come in. That is the point. And so when people think about rates, they might say, like, oh, rates are going up. But in reality, it's like the rates are being set for an insurance company looking forward because we have to file our rates with the insurance department. So we're highly regulated. So we have to have rates that make sense because if you don't have enough money coming in, then it's harder to how are you going to pay the claims when those medical services are used? So that's sort of like the math piece. And the risk pool comes into play with that because you want to have a balanced risk pool. You don't want it going up and down. You want, you know, a whole mix of people, different ages. You know, some people might have chronic conditions, some might be perfectly healthy and never go to the doctor. So I don't know exactly there's probably a whole episode on risk pools. That's kind of the extent of my knowledge. They're very important.

Liz Canada 19:16

You're you're talking about how you know paying the claims and the insurance company needs to be able to do that. So if the health insurance company is not dictating the cost being so high, does that mean health care providers are doing who's doing it?

Sabrina Dunlap 19:33

That's a good questions.

Liz Canada 19:34

Who can I point to? I want to yell at somebody. Tell me who to yell at or through.

Sabrina Dunlap 19:38

You can yell at me.

Liz Canada 19:39

Okay.

Sabrina Dunlap 19:40

Yell at me. And and like I'm I'm used to people being annoyed with me, so that's you know, it's fair.

Liz Canada 19:46

Well, we work in the State House, so that happens inevitably. Somebody's gonna be mad at us in some way. So, but who who does who who's it who did this to us? Who's making the health care costs so high?

Sabrina Dunlap 19:58

It is a fair question. And I don't actually want to seem like I'm pointing fingers because I I do believe that all of us in the healthcare space are sort of like in this soup, this mix together. And I think everybody can kind of take a little blame and everybody has a responsibility to try to make it better. So some of the players, you have health insurance, you have the providers, you have hospitals, some are rural critical access hospitals, some are massive health systems, you have um pharma, you have like medical device companies.

Liz Canada 20:28

I didn't even think about pharma, but I'm writing that down.

Sabrina Dunlap 20:30

Yeah. Uh take note. Pharma. Um, I will say PBMs. I I don't want to go into PBMs. I'm just mentioning them because they're have you not heard of PBM? Yeah, yeah. Pharmacy benefit manager. Yeah. So that's like a whole other thing. So the point is there's a lot of players in the health care space. I understand insurance is the thing you deal with and you don't necessarily want to be dealing with it. And so I get why people are like, oh, it's insurance's fault because they're going to their doctor who they may know very well and really trust. And it's like the doctor's not the problem, it's their insurance company. But when you actually look at the facts and like all the stuff that goes into costs, I don't think there's one person or one entity to point at. But it is true that like if you have a super nice hospital and a lot of specialties and specialists, which we do want. The thing is, those things cost money. And so that affects how they negotiate with the insurance company. So there's other things at play that factor into the cost issue that's like no one's fault. They're just facts. For example, New Hampshire, you might know, is an aged state. I believe we're still in the country. And so I mean, yes, of course. Absolutely.

Liz Canada 21:42

I didn't mean to laugh at that.

Sabrina Dunlap 21:43

So we're older. There's a lot of like chronic illnesses associated when people age. We're a largely rural state. And so the way healthcare is delivered in rural areas is just different. In some ways it's more challenging, in some ways it's more expensive, in some ways it's less efficient. But you want those people to have that care. But those play into it.

Liz Canada 22:02

Can I pause you right there? Because I think that makes headlines a lot, is that the cost of delivering health care in rural parts of the state is just more expensive. W why? Is it just because there's just fewer people? And so it take like what is it about being in a rural area that makes it more costly or more challenging to deliver health care?

Sabrina Dunlap 22:24

That is a great question. And I'm gonna like try to answer it. You could use like labor and delivery, for example. This has been a topic over the last few years. Big time. Yeah. If you live far from a critical access hospital and there's just not a big population, and that hospital needs to have a labor and delivery unit that can welcome anyone or an ER or an emergency department, for example, and they need they have that infrastructure which costs money and to have doctors and nurses and other providers on staff, all of that costs money. And then if you only have like five women a year or five people a year coming in to your ER or five people giving birth that year, it's just there's not a lot of like money coming in for those services. I mean, to think about a unit and like a major city, like a labor and delivery unit in a major city. If they have like, I'm just making this up, like 10,000 births a year. I mean, that helps pay for that infrastructure that is expensive. So that the cost of the doctors and the infrastructure and the like medical devices or whatever, that cost sort of stays the same. But in an urban area, you have a lot more people coming in and using those. And in a rural area, you just have fewer. And so I think that's part of it.

Liz Canada 23:32

Is that making sense? Okay. It makes it makes some sense, but it feels a little bit like a chicken in the egg situation where it's because there are fewer patients, the cost is higher because there are fewer people paying for it. If you build more I know. Like, how do you get you want more people there, but that requires some steps to get it.

Sabrina Dunlap 23:52

This is true. And we want our rural areas. Obviously, you want people to have access to this health care.

Liz Canada 23:59

You don't want folks to have to give birth on the side of the road because there's no place to go. That is true. Which happens. That's not even a joke. Like I make jokes, but that's not even a joke. Like people are doing that because it is a far distance to get to the place they need to go.

Sabrina Dunlap 24:14

Now we need to do an episode on rural health care. This question is.

Liz Canada 24:17

I think it is an extremely big issue because it comes up a lot for New Hampshire. It comes up for our neighboring states too, of Maine and Vermont. But it is a mystery, I think. Or it's not a mystery, but I don't think it's clear for folks of why that's such like a bigger issue of rural health care. Because it's like I could hear I could hear someone sort of saying, like, but there's fewer people there. So what's the big deal? And maybe that is the big deal, is that because there are fewer people, the services are not used as often or the healthcare is not used as often. And then in some cases, the services go away because they can't continue to be sustained.

Sabrina Dunlap 24:54

Yeah. I'm thinking about like specialists, for example, like if you're outside of like a major metropolitan area that has like a huge health system and they have a type of specialist who might be kind of expensive to like keep on staff. But if you have a ton of people seeing that specialist, it makes sense. But if you're in a rural area, number one, it's hard, probably more difficult to attract a specialist there to your hospital because they just won't see as many patients with that issue.

Liz Canada 25:20

Yeah, there are fewer people to see. It's also like to move to a rural area as well, is like there are fewer things perhaps compared to larger urban areas. Yeah. Yeah, there's a lot to it, I think. More than it's more expensive. It's like, but why is it more expensive? I know.

Sabrina Dunlap 25:38

And I actually don't even know. It's like I I list it as sort of like a it's a challenge, I think, for New Hampshire, as it is for some of our neighboring states, as you said.

Liz Canada 25:46

Yeah.

Sabrina Dunlap 25:47

Um, but there's also challenges with like major health systems, you know, in big cities. So maybe I shouldn't put that on the the cost drivers that were rural.

Liz Canada 25:56

It's more of like a But no, I think it I think you're right. And I think it it is sort of thrown out there a lot in news stories too, of like rural healthcare, very expensive, very hard to access health care in rural parts of the state. And why? Who am I supposed to blame briefly? Tell me who to blame.

Sabrina Dunlap 26:14

I know. I don't I don't want to blame any I'm used to being blamed, I will say. So I I don't want to blame it.

Liz Canada 26:19

I see that you're trying to take the blame on a lot of these things. And it's like I don't know. Maybe maybe I could be the problem. It's me. Hi. All right. Where were we in our list of things here?

Sabrina Dunlap 26:28

I also sort of feel like talking about the ACA a little bit because the

Liz Canada 26:33

Well you didn't call it Obamacare, problem number one. I don't know what you're talking about.

Sabrina Dunlap 26:38

I was just gonna say that there's this thing in American health care that is this is a whole nother episode too, I think. But the fact that our health insurance is tied to our employer.

Liz Canada 26:46

And so I think Oh my god, Brinie, that that is the crux of my issue of all of this.

Sabrina Dunlap 26:52

Yeah, I know. There's history there.

Liz Canada 26:55

Yeah, it's called America. American history is the history there. I I think I I think that is a a huge issue, if I dare use the title of the show. Because I think it it then results in people feeling trapped in in jobs or in places that maybe they are not not just not happy, but like are are just like really terrible environments for them, but they can't lose their health insurance. And so they have to hold on for as long as they can because they need that health insurance. Yikes.

Sabrina Dunlap 27:27

Part of the issue with the ACA was to try to sort of like give people an option not tied to your employer, which it does. Yeah. I guess that might be a a place to just quickly mention the potential expiration of the enhanced premium tax credits.

Liz Canada 27:43

Yeah, that might be a place to mention a brief mention. Let's just say the phrase again. Because if you had given me those four words and said put them in the correct order, I wouldn't have been able to do it. So I wrote them down for myself. What are enhanced premium tax credits?

Sabrina Dunlap 27:58

And I'm gonna keep this short and basic because this really is another episode, I think. But the idea of premium tax credits was to help people at certain income levels be able to afford healthcare a little bit easier through the ACA. Now, a few years ago, they bumped those up, and that's those are the ones expiring at the end of 2025 if Congress doesn't take action. And so that is what a lot of the discussion is about right now.

Liz Canada 28:22

Um, so is it specifically for folks with specific incomes? Like so is it that if you make up to a certain income, you would have received this tax credit, which would offset the costs for your insurance coverage on the ACA? Yes. So tied to income level. Yeah. Do we know what the income level is? Do you know what the income level is? I

Sabrina Dunlap 28:44

I have not

Liz Canada 28:47

Where's that actuary they're just making

Sabrina Dunlap 28:48

this is like a whole nother category. So I just wanted to mention it because it is a big issue and there's lots of people talking about it.

Liz Canada 28:56

Brinie, I I just looked on the internet.

Sabrina Dunlap 28:59

Uh-huh.

Liz Canada 29:00

Liz Canada 29:00

Incomes between 100% and 400% of the federal poverty level. Those are the folks who would be seeing their health insurance costs go up. Yeah.

Sabrina Dunlap 29:10

So I I think I would put that under some of the challenges we have sort of as a country and as an industry at the federal and state level, just that there's changes and there's challenges. And I wanted to mention that as one at the federal level.

Liz Canada 29:25

That's a big one.

Sabrina Dunlap 29:26

Yeah. But it's happening in real time. That is true. And then at the state level, tying us back to cost of care in New Hampshire, I mentioned, you know, aging state, rural state. We have also these other issues which you've done episodes on, like workforce challenges, child care costs, the housing challenges in New Hampshire, all these macroeconomic issues that are all interconnected and healthcare is one of them. They're all tied together. They're all related. And I think in New Hampshire, we have things that make it challenging because we're small and because so much of the state is rural, but also it's an opportunity because we can make changes in our little state that actually help people. And there's a lot of like really good, smart people working on health policy issues that maybe would be more difficult or take longer or whatever in a much bigger state. So I think the size of our state and the landscape are both sort of, you know, they're challenges and opportunities. Is that too Pollyanna?

Liz Canada 30:24

A little bit. A little bit. But I think that's that's what you have to that's what you have to go with. I'm not a Pollyanna type, as anyone can tell you really. But that's yeah. There's value to the small state because you can, I don't know, try new things, yeah, be innovative.

Sabrina Dunlap 30:41

Bringing us back to why is health care expensive and the role of health insurance. Okay, here we go. So we're focused on affordability. So New Hampshire has we actually have, I think it's 95% of the state has some form of insurance, which is great. We want that. But it's like there's some people who have health insurance and healthcare still feels unaffordable to them. And that's real. Yeah. And so we have to get at that affordability question, which is big. And that's where like all these other factors come into play, I think, in New Hampshire about the cost of living generally. Some of the things that insurance does specifically to try to help with the cost issue. So we negotiate the contracts and the rates with the providers. We have our networks, health insurance companies also, one of our roles is to um help try to prevent fraud, waste, and abuse in the healthcare space. Because I don't know if you've ever read about that, but it does cost this country like in the many billions. And it's not all fraud. Billing in the healthcare space is can be very confusing. And so that's one area, though, where health insurance companies play an important role. And if you can prevent fraud or catch fraud, or if you can prevent sort of like billing anomalies, things that are adding cost to the system. I mean, that's a super important role. And that's something that basically only health insurance companies are doing. And then we also are trying to do more to help our members take control of their healthcare, so not just through ID cards, and understand the cost of healthcare. And I think to the extent we can try to make people better informed consumers of healthcare, we want to try to do that. So, for example, I use my insurance company's digital app. That's where my digital card is. But it also has like the digital. Um, it has everything laid out about my health insurance in one place that is super understandable. And there's ways to find providers. Um, it actually is very user-friendly. Brainy.

Liz Canada 32:39

How many of those words would I need to look up? And this is not a dig on the your specific your specific insurance, but like I I don't think I'm a smart person, but I know words and I try to read things. Okay. And there there have been times in my life where, especially now that, you know, obviously Molly and I are married now, and I'm the step parent to the two boys. And so like I think about all of this in a different way than I did when I was just living it up solo, right? Yeah. And so I've tried to read through the different types of plans and understand what they cover. And they are kind of hard to understand, Breedy. Does the app make it a little bit easier than that? Because I think it is difficult to know what those different things mean.

Sabrina Dunlap 33:22

It is. And one of the things we do strive to do is simplify and make things more user-friendly. I will say the app that I use, which is an anthem app, I think is very useful. And it does make things very understandable. Even though I like live and breathe health insurance, I do find it very useful. There's other tools out there that help people understand the cost. So, like if you were looking for like an MRI and it was like not an emergency situation, you could compare those costs because they do vary quite a bit depending on where you get that service. So those are like the types of consumer-centric ideas to try to help people take more control over their health care and um hopefully control costs to some extent. We as a carrier are trying to do our best to make things more understandable for people because it is complicated.

Liz Canada 34:08

It is really complicated. Yeah. Yeah. We need a what the hell is this segment, which is just people sending in their question of like, I have this in my alp insurance. What the hell is this? And then we can try to explain it. I think that's a great idea. Yeah.

Sabrina Dunlap 34:25

I wanted to just mention one other driver of costs. Specialty drugs. I just have to mention, because they are a big cost driver across the country, not just in New Hampshire. And I want to say on this issue, oh, it's a tough one because the specialty drug world is quite amazing. I mean, some of these drugs are life-changing and we want them. Um, GLP ones are amazing in their ways. It's the talk of the town, the GLP ones. It is the talk of the town. But there is a cost to them. Now, when you ask about costs, in this case, typically, I mean, the far pharmaceutical company will set the price of the drug. Oftentimes people think it's the insurance company. It is not, it is the drug company. Specialty drugs are super important and we want people to have access to them, but they do cost a lot of money. So it's just it's like one of those hard healthcare conversations I think we all have to be having, because I'm not sure there's like a great answer to it, but that is a driver of costs, specialty drugs.

Liz Canada 35:22

The pharmaceutical companies they say this is how much these drugs cost. The healthcare providers in some capacity say this is how much it costs to deliver the healthcare. The health insurance companies say these are these are our members right here. I'm gonna negotiate for these members right here to lower the things that you all have set, you know, make them a little bit more palatable over here. And there are other folks who are in different types of coverage or lack thereof. Uh I'm just gonna say it sounds like a big mess, Brini. It sounds like a big mess. And I can say that because I'm wearing flannel. You're wearing professional clothing, you can't say it, but I'm gonna say it sounds like a mess. Oh, you know, really, really complicated and challenging. And hard to say, like, well, if you just did this one thing, it would fix everything. Like that's not the case. Because they're all really embedded.

Sabrina Dunlap 36:19

Yeah, I think you've summed it up quite well. Ugh. I know. If I if I could just add a little personal experience, I don't want to be an oversharer, but I I share this publicly. Please. So I have like a very deep lived experience in the healthcare space as a caretaker advocate. Uh, one of our kids has a rare, severe chronic autoimmune disease for which there is no cure. You manage it through various treatments, including specialty drugs. We spent a lot of time in a pediatric hospital. And as somebody who grew up with like the privilege of health, I didn't know what my insurance did, even as like a young adult working. I was like, whatever. But that changes when you have a family member, or obviously yourself, who suddenly needs like specialists and you're in and out of the hospital. And then I had a different experience in the acute healthcare space, which was about six years ago, my husband, who was healthy and 39, we found out he had a large brain tumor. And it came out of left field. And that tumor hit 11 out of 12 cranial nerves. It went up his brainstem. And we, like that, we were shookath. I mean, we're not expecting that. I was thankfully sort of experienced with the chronic disease management with one of our kids. And so I was able to manage through that probably maybe a little bit easier than somebody who like hadn't lived through a difficult health experience. But that was difficult and awful in its own way. But it was like this acute, intense long surgery at a major hospital with a very difficult recovery. Um, thankfully, knock on wood. He's doing fine. It was not malignant, it was just a big tumor. And he still actually has a piece of it that they couldn't get to. So he has a MRI once a year. But he's doing great. But so I had that experience. And so I share that just because this these experiences have taught me like very profound lessons in perspective. And I carry those things with me every single day. So with these lived experiences I have, like I understand the importance of specialty drugs because one of my kids needs them basically to survive. And so I see the cost of them. I see how they're administered. I see sort of like the life cycle of those specialty drugs, but I also understand how incredibly life-changing they are. And and same with like the surgery, to have like a major brain surgery and like come out the other side and be okay, to have access to that is amazing. And so I know we talk a lot about like the mess of the American healthcare system. And I think that's real. I don't want to, I don't want to diminish um what people live through every day. And and I know the fear of worrying like, is this gonna be covered? And like, can I pay for it? And I wish that people going through healthcare issues did not have to worry about that. So, like, that's real. Everything for me is through this lens of like what I've lived through with my family members. And so I think always about my North Star being like what's best for our members. How do we increase access and keep it, make it more affordable? I mean, those are the things that drive us every day. And even if we're we don't have answers to everything, and even if things aren't going to change overnight, I do believe that we can make things better for people. And I hold that in my heart.

Liz Canada 39:34

We have an extremely complicated system in the United States that is not perfect. Not perfect. So probably not changing dramatically overnight. And so how to make it more accessible, affordable, and understandable for regular people. Brittany, thank you so much for taking so much time to talk with me.

Sabrina Dunlap 39:53

I'm sorry it took so much time. I was trying to be succinct. Oh my gosh, it took a lot of time.

Liz Canada 39:57

It's very complicated. It's a topic people care about. Out and there's a lot of laps.

Sabrina Dunlap 40:07

That might be one of my favorites, actually. Kristine Stoddard. Shout out to Kristine covering Medicaid.

Liz Canada 40:12

Shout out to Kristine.

Sabrina Dunlap 40:13

Off the record here. I adore Kristine. And one of the things I really appreciate about her

Liz Canada 40:17

is I love that that's off the record. That she's wonderful. Off the record.

Sabrina Dunlap 40:22

You can include that. I was just gonna say that she is always willing to just like talk to me. She's not coming at me. She's interested in like actually talking about the issue, and a lot of people are. But Kristine stands out as one who I really appreciate, and she's so smart.

Liz Canada 40:36

And so what part of this needs to be off the record? Don't tell her. But I think she's a professional who cares about the issue and is willing to work with me. Don't tell anyone. Kristine is a wonderful person.