January 20, 2026 • 40 mins
What 1,000 facts do we need to know to figure out why health care costs so much?
Liz asks Sabrina (Brinie) Dunlap who should be blamed for the cost of health care. The answer is complicated.
This episode was recorded on November 4, 2025. Pairs well with the Medicaid: It's Health Insurance! episode with Kristine Stoddard.
- Glossary of Health Coverage and Medical Terms (HealthCare.gov)
- Risk Pooling: How Health Insurance in the Individual Market Works (American Academy of Actuaries)
- Ask an Expert: Enhanced Premium Tax Credit (PTC) Expiration (Center on Budget and Policy Priorities)
- 1.4 million fewer people enrolled in ACA plans as premiums spike, tax credits expire (ABC News)
- Higher Premium Payments or Higher Deductibles: The Tradeoffs ACA Enrollees Face (Peterson-KFF Health System Tracker)
- Labor and Delivery Unit Closures in Rural New Hampshire (Urban Institute)
- Critical Condition: How Medicaid Cuts Would Reshape Rural Health Care Landscapes (National Rural Health Association)
- In the News: Labor and delivery units face uncertainty after federal cuts (Monadnock Community Hospital)
NEW: Subscribe to NH Has Issues Substack
NEW: Get your NH Has Issues merch!
New Hampshire Has Issues is generously sponsored by Seacoast Soils, an organic compost and topsoil provider for New Hampshire, Maine, and Northeast Massachusetts. Visit their website at www.seacoastsoil.com!
Podcast theme music by Transistor.fm. Learn how to start a podcast here.
Listen
Watch
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Sabrina Dunlap (00:00):
By the way, under sound effects, it's set
under alert sound as funky.
Liz Canada (00:05):
That's the podcast.
That's healthcare costs.
Funky.
Am I right?
You're listening to NewHampshire has Issues, and I'm
(00:25):
your host from The Future LizCanada.
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 thisepisode, one piece in
particular, is about the Don'tPanic, Enhanced Premium Tax
Credits.
Don't worry, we're gonna talkabout it in the show.
But we talk about it with thequestion of what will Congress
do?
(00:46):
Will they extend those taxcredits?
They have until December 31st.
Spoiler alert, no, they didnot.
So you might still seeheadlines about ACA tax credits
and people's premiums going up,the amount of money they have to
pay every month to continuetheir health insurance, because
those tax credits expired, whichmeans quite a few people in our
(01:08):
country and in our state aregoing to see the cost of their
health care go up even more.
And a lot of people are goingto stop having health insurance
because of that.
Lots of links in the show notesabout this.
I usually ask Molly to listento 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,
(01:30):
and that's very lovely.
And in this case, I did ask herto listen to it.
And a whole lot of other peoplehave listened to this episode
in advance.
Because even for me, the hostwho interviewed Brinie and we
talked, and I listened to therecording over and over again to
like wrap my head around itall, and I wanted to get a vibe
check from other folks.
And what I learned in thatprocess is that what I wanted to
(01:52):
share with you before youlisten to the full episode, all
of the questions you probablyhave as you listen, they're
probably not going to getanswered here because it is so
complicated.
And that's okay.
It would be silly for me tosay, well, a 40-minute episode
about why health care costs sodang much.
If anything, what this episodereally highlighted for me is
(02:13):
that I want to ask the samesimple question to folks in
other areas of healthcare.
Why does health care cost sodang much?
So this episode is from ahealth insurance perspective.
Brinie represents Anthem BlueCross Blue Shield in New
Hampshire.
And so I want to take theopportunity to interview other
folks from their perspectives,providers, hospitals, to name
(02:36):
two.
In the episode, I alsojokingly, yet not jokingly, say
that I should have a segmentcalled What the bleep Is This?
Where a listener writes inabout something in their health
insurance bill or something withtheir health care and is like,
what the bleep is this?
Uh, I say it jokingly, butactually, if you have a
(02:57):
question, send it in.
I don't love doing these longpreambles, but this is a very
important episode because thecost of health care is on so
many people's minds right now.
If you would like to supportthe show, please go to
patreon.com/ nh has issues.
If you have an idea for anupcoming episode, or if you have
something to offer the what thebleep is this segment, send me
(03:18):
an email.
Newhampshire issueshas@gmail.com.
Thank you for listening.
This is the topic ofhealth care costs.
So let's start with uh let'sstart with our taglines.
Have you thought about yourtagline?
Sabrina Dunlap (03:30):
I did, and as a listener of your show, I
appreciate like beginning withthe tagline and trying to be
like snappy and quippy, and Iconfess I cannot do it.
I cannot be witty about it.
Liz Canada (03:43):
All right, I'm gonna I'm gonna do mine.
Welcome to New Hampshire HasIssues, the podcast that dares
to ask, is this episode innetwork or out of network?
That's the best I could do.
Sabrina Dunlap (03:54):
It's good because it's simple, it's not
like judgmental, and it gets atlike one of the foundations, or
maybe it is judgmental, I don'tknow, but it gets at one of the
foundations of our whole systemof care, managed care, which
networks are a very importantpart.
So actually asking ifsomething's in or out of
network, you're like, I'm boredalready.
And skip to the next episode.
Liz Canada (04:13):
All right, hit me with your tagline.
Let's see what you've got.
Sabrina Dunlap (04:15):
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 inor out of network one, and but
I couldn't steal it from you.
So podcast that dares ask.
Liz Canada (04:27):
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 (04:34):
Can I take that one?
That's good.
Liz Canada (04:35):
You can take that one.
Yeah, take it.
Take it.
Sabrina Dunlap (04:38):
Um, although do I want to go there?
Insurance cards.
We're so highly regulated thatthere's rules around what has to
go on um ID cards, believe itor not.
Liz Canada (04:49):
Really?
Sabrina Dunlap (04:50):
Yes, it's true.
Liz Canada (04:51):
Are there rules about what's on the front of a
card versus on the back of acard?
Sabrina Dunlap (04:54):
Yeah.
Yeah.
And it depends on the type.
It depends on the type of planyou have.
Like I don't have a physicalcard card anymore.
Liz Canada (05:02):
What?
Sabrina Dunlap (05:03):
It's digital.
So it depends on your plan.
Liz Canada (05:06):
Yours is digital.
What?
You've got nice healthinsurance.
That's what I'm hearing.
Mine is not digital.
Mine is you get that out ofyour wallet, you find it, and
you turn it in so we can take apicture of it.
Sabrina Dunlap (05:17):
Well, the provider still ask me for a
paper, like a for a physicalcopy so they can take a
photocopy.
And I'm like, I've had the samehealth insurance for six years
and it hasn't changed.
Nothing has changed.
So I feel like maybe they don'tlike the digital answer.
But so do you have a plasticcard or is it like you have to
print it?
Liz Canada (05:34):
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 (05:43):
Okay.
And is the information on ithelpful to you as a consumer?
Liz Canada (05:48):
No.
I don't know a bleep thing thatit says.
I don't understand anythingabout it.
And even when they ask mequestions like who's the policy
holder, I'm like, I'm a person.
I'm holding this card, but Idon't think that's what you're
asking of me.
I think it's Molly is thecorrect answer.
Yeah.
I feel like I'm always failingthe test for my health insurance
check-ins.
Sabrina Dunlap (06:09):
Yeah, that's understandable.
I mean, there's a lot.
There is a lot.
You start to pull a thread.
Policy number.
Liz Canada (06:16):
Group number.
Oh gosh.
Yeah.
Is your that dare to ask, isyour health insurance card
digital plastic for a printout?
Sabrina Dunlap (06:28):
Because I did actually print it for a little
while.
And so I had like a littlefolded paper one in my wallet.
But I was going to asksomething along the lines of
like, how far down like the nerdhealth policy rabbit hole can
you go?
Liz Canada (06:42):
Listener, join us on this journey.
We are going to go into theabyss of health insurance.
I'm excited about this becausewhen I am out in the world and
I'm seeing what's stressingpeople out, the big thing that
people are stressed out aboutthe cost of healthcare.
Healthcare costs are up.
Yeah.
The health insurance issues interms of like being covered or
(07:04):
not covered, what is covered,what isn't.
This used to be, it's nolonger.
All of that is on people'sminds.
So I feel like this is reallyimportant that we're here to
talk about this.
So let me introduce you sincewe've been talking for a little
bit of time, but we can tellpeople who you are.
So welcome to New Hampshire HasIssues.
My guest today is SabrinaDunlap, aka how I refer to her
(07:27):
is Brinie.
So I don't want everybody to beterrified that I'm calling her
by a different name.
She is the senior director ofgovernment relations at Anthem,
Blue Cross, Blue Shield in NewHampshire.
That's correct.
Brinie, welcome to the show.
Sabrina Dunlap (07:41):
Thank you for having me.
I'm so happy to be here.
Liz Canada (07:43):
I'm so happy that you're here because health
insurance and health care costsdefinitely are on a lot of
people's minds.
Right now it is cold out.
It's November.
It's like we're in like fluseason and people are getting
sick.
The kids are starting to comehome and their noses are
running, and it's like, stop,get out of my house.
This is where we are.
(08:04):
We're in the sickness time.
Yes.
That's so perfectly timed.
Is that how you call it in yourhome?
The sickness.
That's how it feels.
So, Brinie, I think for ourepisode today, I have a simple
question, and it's really theonly question, which I'm hoping
you can answer.
Why the heck does health carecost so dang much?
(08:24):
Why is it so expensive?
All right, go.
Explain it.
Sabrina Dunlap (08:31):
How many episodes do I get?
Liz Canada (08:33):
You get as many as you'd like.
We'll just keep we'll just keepchick-chatting.
Sabrina Dunlap (08:36):
Okay.
So um yeah, there's there's alot to that question.
Very important question, not asimple answer.
I think anyone who claims tohave a simple answer, I'm not
sure that I wouldn't not sure Iwould necessarily believe them.
The things I would like tocover, there's like, you know, a
little outline.
Each thing I'm just I'mspeaking about these things
(08:59):
pretty generally because this,you know, the ID card is a great
example.
You start to like peel back thelayers, and it's like you could
spend hours on each of thesetopics.
And there's so much nuance.
Liz Canada (09:11):
An ID card?
Why is that so complicated?
Sabrina Dunlap (09:14):
Not necessarily the ID card.
Right.
But like all of these pieces ofthe puzzle are really
complicated.
The pieces to the puzzle andthen insurance alone.
Have you ever looked at the NewHampshire insurance statute?
Maybe not.
Liz Canada (09:27):
Brinie.
I want you to think about thatquestion 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 (09:39):
That's fair.
Liz Canada (09:39):
That was that was impolite.
No, I have not.
I have not read this.
Sabrina Dunlap (09:44):
How dare you.
If you're looking for likedense statutory reading, it is
extensive.
Liz Canada (09:51):
And when you say statutes, that means our laws,
our New Hampshire laws.
Sabrina Dunlap (09:54):
Thank you.
Liz Canada (09:55):
Go ahead.
Sabrina Dunlap (09:55):
So I was just also going to say that there's
so much nuance generally inhealth care, but also with
health insurance, because again,it comes down to like which
health insurance carrier do youhave a plan through?
And is it employer sponsored?
And is that plan self-insuredor is it fully insured?
Which put a pin in that.
I do want to cover thatdistinction because it's really
(10:20):
and then like you get intobenefit design.
Okay.
That's like a whole thing.
I know.
So you could see how whentrying to talk about these
issues generally, like forexample, at the legislature, I
often I'm like, okay, butthere'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 Ican explain this to you.
Right.
Exactly.
Oh boy.
Sabrina Dunlap (10:45):
Um yeah, I know.
I feel like I'm off to a badstart.
Liz Canada (10:48):
No, you're doing great.
This this is all perfect.
Okay.
So to start off, no, I have notread 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 doingit, Brinie.
It's not happening.
No matter what you say.
I had somebody on earlier, he'she's a marathon runner.
I'm like, not doing thateither.
So the likelihood of me readingthe 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 differentthings I want to touch on that I
hope would be helpful forpeople as we try to like, I
don't know, pull back the layerson on the cost question.
So I'm afraid it might be verydry and boring for you.
But even I'm here for.
(11:40):
Okay.
A little joke here and there.
So even as basic as like whatis 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 itwas not too basic.
Liz Canada (11:55):
Follow-up question.
Why is health insurancedifferent from dental insurance,
different from visioninsurance?
Because I'm pretty sure allthree of those things are my
body.
I know.
Sabrina Dunlap (12:05):
Why?
I need to look into thatbecause I actually I don't know.
Different episode.
I I myself am curious.
I have a lot of I'm very, verynearsighted.
So history of eye issues.
And it is weird that it's likea 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 theanswer 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 thathealth insurance is intended to
protect people from having topay super big medical bills and
also relatedly help makehealth care more affordable.
So the other thing that's superimportant is the idea of risk
pools.
So not gonna go too far downthere, but super important
(12:57):
because the whole like baselineconcept is that many people kind
of come together and yourpremiums, which should we go
into what a premium?
I mean, as I as I touch onthese topics, I'm just gonna
like try to explain briefly whatthey are.
So we're not here for sevenhours.
Premium, that's what you'reit's sort of like a
subscription.
It's like you might pay, let'ssay, like a hundred bucks a
(13:19):
month in premium, and that iswhat you pay into sort of the
bigger pot of money, the riskpool, is then used to pay claims
for people.
So the idea is that when youpool many people together and
you've got a lot of people whoare healthy, some people who
have health issues, you all kindof help cover the costs.
(13:39):
It's sort of like it's kind oflike 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 mosttime in in my life is my fear
pool, where I start talkingabout all my fears and I put it
in my fear pool.
I always struggle with thelanguage that's used because
premiums sounds like, ooh,premium, ooh, fancy.
And that's like it's a it's ait's a fee that you pay.
(14:07):
And that's fine, but that's thecost that it that you put
toward like your contribution.
Yes.
And then lots of people arepart of this risk pool.
Yeah.
Some of those people arehealthy and they're paying into
it.
And so their needs for whenthey get sick might be lower.
And then some folks, my motherused to refer to me as a sickly
(14:30):
child.
People like me, asthma everyyear, could never go
trick-or-treating.
It's a whole Oh no.
Oh.
It's a dramatic telling of mychildhood.
Oh.
You know what?
That was the least of myproblems when you hear about my
childhood, but that's fine.
Folks who need to get healthcare maybe more frequently than
others or different types ofservices, they're also part of
(14:51):
that risk pool.
And so lots of folks sort ofpay into it, and then the claims
are made, and then the moneycomes out of that sort of pool
of money in some way.
That's where it gets a littletricky 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 tolike level set on the whole
getting back to the costquestion.
I think there's this sort ofnotion that health insurance
companies set prices.
Because we we're often, youknow, an easy target for cost.
People are like healthinsurance makes things
expensive.
But that's actually justfactually incorrect.
(15:24):
Health insurance companies, um,we don't set prices.
We actually negotiate, forexample, with like a hospital or
provider, we negotiate so thatour members have more affordable
care.
So we negotiate those rates.
Now, this is where networkscome into play because when we
have a contractual relationship,let's use a hospital, for
example, and they come, theysign the contract with us, they
(15:45):
negotiate their rates with us,they come into our network.
And as part of that, there's awhole host of other things that
come into play as part of theconcept of managed care.
For example, providers arecredentialed with us.
So that means a carrier willask for a little bit of
information about yourbackground, your education to
make sure that sort of, let'ssay, doctor, for example, though
there are many types ofproviders, are who they say they
(16:07):
are.
And so it's for the benefit ofour members that we have these
networks that we maintain.
When you asked if this episodewas in or out of network, it's
actually a very importantquestion because depending on
your type of coverage, like myplan, for example, I have
out-of-network benefits, butthey're just not quite as good.
So if I go to a provider that'sin my health insurance
company's network, more iscovered.
(16:28):
Now, if I go to a providerwho's out of network, I do have
a decent amount of coverage, butit's not as good.
Depending on your plan, youmight not have really have much
of any out-of-network coverage.
So that's where networks becomevery important.
It's for the benefit of ourmembers.
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 partof your who have their little
plastic cards or digital cards.
Like those folks are members.
And so the health insurancecompany is negotiating with
places so that the costs go downfor their members.
(17:04):
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 hitnetworks, 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 thesame 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 riskpools.
I was going to say that peopleat 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 withnumbers.
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 recentlywhere there was like a whole
presentation on actuaries.
Now that might sound not superexciting, 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 theythey have to use data.
So they'll use like claims fromyears past, but then they use
(18:08):
sort of more current data andthen sort of data to project
into the future because thewhole thing is they have to set
rates that make sense so thatthe carrier, the health
insurance carrier, can pay theclaims in the future.
It's really complexmathematical work that they're
doing.
They're really good at it.
But the whole point is likeinsurance companies have to be
able to pay the claims as theycome in.
(18:29):
That is the point.
And so when people think aboutrates, they might say, like, oh,
rates are going up.
But in reality, it's like therates are being set for an
insurance company lookingforward because we have to file
our rates with the insurancedepartment.
So we're highly regulated.
So we have to have rates thatmake sense because if you don't
have enough money coming in,then it's harder to how are you
going to pay the claims whenthose medical services are used?
(18:52):
So that's sort of like the mathpiece.
And the risk pool comes intoplay with that because you want
to have a balanced risk pool.
You don't want it going up anddown.
You want, you know, a whole mixof people, different ages.
You know, some people mighthave chronic conditions, some
might be perfectly healthy andnever go to the doctor.
So I don't know exactly there'sprobably a whole episode on
risk pools.
(19:12):
That's kind of the extent of myknowledge.
They're very important.
Liz Canada (19:16):
You're you're talking about how you know
paying the claims and theinsurance company needs to be
able to do that.
So if the health insurancecompany is not dictating the
cost being so high, does thatmean 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 orthrough.
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 topeople 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 usin some way.
So, but who who does who who'sit who did this to us?
Who's making the health carecosts so high?
Sabrina Dunlap (19:58):
It is a fair question.
And I don't actually want toseem like I'm pointing fingers
because I I do believe that allof us in the healthcare space
are sort of like in this soup,this mix together.
And I think everybody can kindof take a little blame and
everybody has a responsibilityto try to make it better.
So some of the players, youhave health insurance, you have
the providers, you havehospitals, some are rural
(20:20):
critical access hospitals, someare massive health systems, you
have um pharma, you have likemedical 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 thembecause they're have you not
heard of PBM?
Yeah, yeah.
Pharmacy benefit manager.
Yeah.
So that's like a whole otherthing.
So the point is there's a lotof players in the health care
space.
I understand insurance is thething you deal with and you
don't necessarily want to bedealing with it.
(20:52):
And so I get why people arelike, oh, it's insurance's fault
because they're going to theirdoctor who they may know very
well and really trust.
And it's like the doctor's notthe problem, it's their
insurance company.
But when you actually look atthe facts and like all the stuff
that goes into costs, I don'tthink there's one person or one
entity to point at.
But it is true that like if youhave a super nice hospital and
(21:15):
a lot of specialties andspecialists, which we do want.
The thing is, those things costmoney.
And so that affects how theynegotiate with the insurance
company.
So there's other things at playthat factor into the cost issue
that's like no one's fault.
They're just facts.
For example, New Hampshire, youmight know, is an aged state.
(21:37):
I believe we're still in thecountry.
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 chronicillnesses associated when people
age.
We're a largely rural state.
And so the way healthcare isdelivered in rural areas is just
different.
In some ways it's morechallenging, in some ways it's
more expensive, in some waysit's less efficient.
But you want those people tohave that care.
But those play into it.
Can I pause you right there?
(22:03):
Because I think that makesheadlines a lot, is that the
cost of delivering health carein rural parts of the state is
just more expensive.
W why?
Is it just because there's justfewer people?
And so it take like what is itabout being in a rural area that
makes it more costly or morechallenging to deliver health
(22:24):
care?
That is a great question.
And I'm gonna like try toanswer it.
You could use like labor anddelivery, for example.
This has been a topic over thelast few years.
Big time.
Yeah.
If you live far from a criticalaccess hospital and there's
just not a big population, andthat hospital needs to have a
labor and delivery unit that canwelcome anyone or an ER or an
(22:45):
emergency department, forexample, and they need they have
that infrastructure which costsmoney and to have doctors and
nurses and other providers onstaff, all of that costs money.
And then if you only have likefive women a year or five people
a year coming in to your ER orfive people giving birth that
year, it's just there's not alot of like money coming in for
those services.
(23:06):
I mean, to think about a unitand like a major city, like a
labor and delivery unit in amajor city.
If they have like, I'm justmaking this up, like 10,000
births a year.
I mean, that helps pay for thatinfrastructure that is
expensive.
So that the cost of the doctorsand the infrastructure and the
like medical devices orwhatever, that cost sort of
stays the same.
But in an urban area, you havea lot more people coming in and
(23:27):
using those.
And in a rural area, you justhave fewer.
And so I think that's part ofit.
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 situationwhere it's because there are
fewer patients, the cost ishigher because there are fewer
people paying for it.
If you build more I know.
Like, how do you get you wantmore 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 tohave 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'sno place to go.
That is true.
Which happens.
That's not even a joke.
Like I make jokes, but that'snot even a joke.
Like people are doing thatbecause it is a far distance to
get to the place they need togo.
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 NewHampshire.
It comes up for our neighboringstates too, of Maine and
Vermont.
But it is a mystery, I think.
Or it's not a mystery, but Idon't think it's clear for folks
of why that's such like abigger issue of rural health
care.
Because it's like I could hearI could hear someone sort of
(24:38):
saying, like, but there's fewerpeople there.
So what's the big deal?
And maybe that is the big deal,is that because there are fewer
people, the services are notused as often or the healthcare
is not used as often.
And then in some cases, theservices go away because they
can't continue to be sustained.
Sabrina Dunlap (24:54):
Yeah.
I'm thinking about likespecialists, for example, like
if you're outside of like amajor metropolitan area that has
like a huge health system andthey have a type of specialist
who might be kind of expensiveto like keep on staff.
But if you have a ton of peopleseeing that specialist, it
makes sense.
But if you're in a rural area,number one, it's hard, probably
more difficult to attract aspecialist there to your
(25:17):
hospital because they just won'tsee as many patients with that
issue.
Liz Canada (25:20):
Yeah, there are fewer people to see.
It's also like to move to arural area as well, is like
there are fewer things perhapscompared to larger urban areas.
Yeah.
Yeah, there's a lot to it, Ithink.
More than it's more expensive.
It's like, but why is it moreexpensive?
I know.
Sabrina Dunlap (25:38):
And I actually don't even know.
It's like I I list it as sortof like a it's a challenge, I
think, for New Hampshire, as itis 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 bigcities.
So maybe I shouldn't put thaton 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 ofthrown out there a lot in news
stories too, of like ruralhealthcare, very expensive, very
hard to access health care inrural parts of the state.
And why?
Who am I supposed to blamebriefly?
Tell me who to blame.
Sabrina Dunlap (26:14):
I know.
I don't I don't want to blameany 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 theproblem.
It's me.
Hi.
All right.
Where were we in our list ofthings here?
I also sort of feel liketalking about the ACA a little
bit because the
Well you didn't call it Obamacare, problem number
one.
I don't know what you'retalking about.
Sabrina Dunlap (26:38):
I was just gonna say that there's this thing in
American health care that isthis is a whole nother episode
too, I think.
But the fact that our healthinsurance 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 historythere.
I I think I I think that is a ahuge issue, if I dare use the
title of the show.
Because I think it it thenresults in people feeling
trapped in in jobs or in placesthat maybe they are not not just
(27:15):
not happy, but like are arejust like really terrible
environments for them, but theycan't lose their health
insurance.
And so they have to hold on foras 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 anoption not tied to your
employer, which it does.
Yeah.
I guess that might be a a placeto just quickly mention the
potential expiration of theenhanced premium tax credits.
Liz Canada (27:43):
Yeah, that might be a place to mention a brief
mention.
Let's just say the phraseagain.
Because if you had given methose four words and said put
them in the correct order, Iwouldn't have been able to do
it.
So I wrote them down formyself.
What are enhanced premium taxcredits?
Sabrina Dunlap (27:58):
And I'm gonna keep this short and basic
because this really is anotherepisode, I think.
But the idea of premium taxcredits was to help people at
certain income levels be able toafford healthcare a little bit
easier through the ACA.
Now, a few years ago, theybumped those up, and that's
those are the ones expiring atthe end of 2025 if Congress
doesn't take action.
(28:19):
And so that is what a lot ofthe 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 makeup to a certain income, you
would have received this taxcredit, which would offset the
costs for your insurancecoverage on the ACA?
Yes.
So tied to income level.
Yeah.
Do we know what the incomelevel is?
Do you know what the incomelevel is?
(28:43):
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 itbecause it is a big issue and
there's lots of people talkingabout it.
Liz Canada (28:56):
Brinie, I I just looked on the internet.
Sabrina Dunlap (28:59):
Uh-huh.
Incomes between 100% and 400% ofthe federal poverty level.
Those are the folks who wouldbe seeing their health insurance
costs go up.
Yeah.
So I I think I would put that under some of the
challenges we have sort of as acountry and as an industry at
the federal and state level,just that there's changes and
(29:22):
there's challenges.
And I wanted to mention that asone at the federal level.
That's a big one.
Yeah.
But it's happening in realtime.
That is true.
And then at the state level,tying us back to cost of care in
New Hampshire, I mentioned, youknow, aging state, rural state.
We have also these other issueswhich you've done episodes on,
like workforce challenges, childcare costs, the housing
(29:45):
challenges in New Hampshire, allthese macroeconomic issues that
are all interconnected andhealthcare 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 smalland because so much of the state
is rural, but also it's anopportunity because we can make
(30:05):
changes in our little state thatactually help people.
And there's a lot of likereally good, smart people
working on health policy issuesthat maybe would be more
difficult or take longer orwhatever in a much bigger state.
So I think the size of ourstate and the landscape are both
sort of, you know, they'rechallenges and opportunities.
Is that too Pollyanna?
Liz Canada (30:24):
A little bit.
A little bit.
But I think that's that's whatyou have to that's what you have
to go with.
I'm not a Pollyanna type, asanyone can tell you really.
But that's yeah.
There's value to the smallstate because you can, I don't
know, try new things, yeah, beinnovative.
Sabrina Dunlap (30:41):
Bringing us back to why is health care expensive
and the role of healthinsurance.
Okay, here we go.
So we're focused onaffordability.
So New Hampshire has weactually have, I think it's 95%
of the state has some form ofinsurance, which is great.
We want that.
But it's like there's somepeople who have health insurance
and healthcare still feelsunaffordable to them.
(31:02):
And that's real.
Yeah.
And so we have to get at thataffordability question, which is
big.
And that's where like all theseother factors come into play, I
think, in New Hampshire aboutthe cost of living generally.
Some of the things thatinsurance does specifically to
try to help with the cost issue.
So we negotiate the contractsand the rates with the
providers.
We have our networks, healthinsurance companies also, one of
(31:24):
our roles is to um help try toprevent fraud, waste, and abuse
in the healthcare space.
Because I don't know if you'veever read about that, but it
does cost this country like inthe many billions.
And it's not all fraud.
Billing in the healthcare spaceis can be very confusing.
And so that's one area, though,where health insurance
(31:44):
companies play an importantrole.
And if you can prevent fraud orcatch fraud, or if you can
prevent sort of like billinganomalies, things that are
adding cost to the system.
I mean, that's a superimportant role.
And that's something thatbasically only health insurance
companies are doing.
And then we also are trying todo more to help our members take
(32:06):
control of their healthcare, sonot just through ID cards, and
understand the cost ofhealthcare.
And I think to the extent wecan try to make people better
informed consumers ofhealthcare, we want to try to do
that.
So, for example, I use myinsurance company's digital app.
That's where my digital cardis.
But it also has like thedigital.
(32:26):
Um, it has everything laid outabout my health insurance in one
place that is superunderstandable.
And there's ways to findproviders.
Um, it actually is veryuser-friendly.
Brainy.
Liz Canada (32:39):
How many of those words would I need to look up?
And this is not a dig on theyour specific your specific
insurance, but like I I don'tthink I'm a smart person, but I
know words and I try to readthings.
Okay.
And there there have been timesin my life where, especially
now that, you know, obviouslyMolly and I are married now, and
I'm the step parent to the twoboys.
(33:00):
And so like I think about allof this in a different way than
I did when I was just living itup solo, right?
Yeah.
And so I've tried to readthrough the different types of
plans and understand what theycover.
And they are kind of hard tounderstand, Breedy.
Does the app make it a littlebit easier than that?
Because I think it is difficultto know what those different
(33:21):
things mean.
Sabrina Dunlap (33:22):
It is.
And one of the things we dostrive 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 veryunderstandable.
Even though I like live andbreathe health insurance, I do
find it very useful.
There's other tools out therethat help people understand the
cost.
(33:42):
So, like if you were lookingfor like an MRI and it was like
not an emergency situation, youcould compare those costs
because they do vary quite a bitdepending on where you get that
service.
So those are like the types ofconsumer-centric ideas to try to
help people take more controlover their health care and um
hopefully control costs to someextent.
We as a carrier are trying todo our best to make things more
(34:06):
understandable for peoplebecause it is complicated.
Liz Canada (34:08):
It is really complicated.
Yeah.
Yeah.
We need a what the hell is thissegment, which is just people
sending in their question oflike, I have this in my alp
insurance.
What the hell is this?
And then we can try to explainit.
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, becausethey are a big cost driver
across the country, not just inNew Hampshire.
And I want to say on thisissue, oh, it's a tough one
because the specialty drug worldis quite amazing.
I mean, some of these drugs arelife-changing and we want them.
(34:46):
Um, GLP ones are amazing intheir ways.
It's the talk of the town, theGLP 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 companywill set the price of the drug.
Oftentimes people think it'sthe insurance company.
It is not, it is the drugcompany.
Specialty drugs are superimportant and we want people to
(35:08):
have access to them, but they docost a lot of money.
So it's just it's like one ofthose hard healthcare
conversations I think we allhave to be having, because I'm
not sure there's like a greatanswer to it, but that is a
driver of costs, specialtydrugs.
Liz Canada (35:22):
The pharmaceutical companies they say this is how
much these drugs cost.
The healthcare providers insome capacity say this is how
much it costs to deliver thehealthcare.
The health insurance companiessay these are these are our
members right here.
I'm gonna negotiate for thesemembers right here to lower the
(35:45):
things that you all have set,you know, make them a little bit
more palatable over here.
And there are other folks whoare in different types of
coverage or lack thereof.
Uh I'm just gonna say it soundslike a big mess, Brini.
It sounds like a big mess.
And I can say that because I'mwearing flannel.
You're wearing professionalclothing, you can't say it, but
I'm gonna say it sounds like amess.
(36:06):
Oh, you know, really, reallycomplicated and challenging.
And hard to say, like, well, ifyou just did this one thing, it
would fix everything.
Like that's not the case.
Because they're all reallyembedded.
Sabrina Dunlap (36:19):
Yeah, I think you've summed it up quite well.
Ugh.
I know.
If I if I could just add alittle personal experience, I
don't want to be an oversharer,but I I share this publicly.
Please.
So I have like a very deeplived experience in the
healthcare space as a caretakeradvocate.
Uh, one of our kids has a rare,severe chronic autoimmune
(36:42):
disease for which there is nocure.
You manage it through varioustreatments, including specialty
drugs.
We spent a lot of time in apediatric hospital.
And as somebody who grew upwith like the privilege of
health, I didn't know what myinsurance did, even as like a
young adult working.
I was like, whatever.
But that changes when you havea family member, or obviously
yourself, who suddenly needslike specialists and you're in
(37:05):
and out of the hospital.
And then I had a differentexperience in the acute
healthcare space, which wasabout six years ago, my husband,
who was healthy and 39, wefound out he had a large brain
tumor.
And it came out of left field.
And that tumor hit 11 out of 12cranial nerves.
It went up his brainstem.
(37:26):
And we, like that, we wereshookath.
I mean, we're not expectingthat.
I was thankfully sort ofexperienced with the chronic
disease management with one ofour kids.
And so I was able to managethrough that probably maybe a
little bit easier than somebodywho like hadn't lived through a
difficult health experience.
But that was difficult andawful in its own way.
(37:46):
But it was like this acute,intense long surgery at a major
hospital with a very difficultrecovery.
Um, thankfully, knock on wood.
He's doing fine.
It was not malignant, it wasjust a big tumor.
And he still actually has apiece 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 justbecause this these experiences
(38:10):
have taught me like veryprofound lessons in perspective.
And I carry those things withme every single day.
So with these lived experiencesI have, like I understand the
importance of specialty drugsbecause one of my kids needs
them basically to survive.
And so I see the cost of them.
I see how they're administered.
(38:31):
I see sort of like the lifecycle of those specialty drugs,
but I also understand howincredibly life-changing they
are.
And and same with like thesurgery, to have like a major
brain surgery and like come outthe other side and be okay, to
have access to that is amazing.
And so I know we talk a lotabout like the mess of the
American healthcare system.
(38:51):
And I think that's real.
I don't want to, I don't wantto diminish um what people live
through every day.
And and I know the fear ofworrying like, is this gonna be
covered?
And like, can I pay for it?
And I wish that people goingthrough healthcare issues did
not have to worry about that.
So, like, that's real.
Everything for me is throughthis lens of like what I've
lived through with my familymembers.
(39:11):
And so I think always about myNorth Star being like what's
best for our members.
How do we increase access andkeep it, make it more
affordable?
I mean, those are the thingsthat drive us every day.
And even if we're we don't haveanswers to everything, and even
if things aren't going tochange overnight, I do believe
that we can make things betterfor people.
(39:32):
And I hold that in my heart.
Liz Canada (39:34):
We have an extremely complicated system in the
United States that is notperfect.
Not perfect.
So probably not changingdramatically overnight.
And so how to make it moreaccessible, affordable, and
understandable for regularpeople.
Brittany, thank you so much fortaking 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 oftime.
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 coveringMedicaid.
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 reallyappreciate 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 sheis always willing to just like
talk to me.
She's not coming at me.
She's interested in likeactually talking about the
issue, and a lot of people are.
But Kristine stands out as onewho 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 aprofessional who cares about the
issue and is willing to workwith me.
Don't tell anyone.
Kristine is a wonderful person.
By the way, under sound effects, it's set
under alert sound as funky.
Liz Canada (00:05):
That's the podcast.
That's healthcare costs.
Funky.
Am I right?
You're listening to NewHampshire has Issues, and I'm
(00:25):
your host from The Future LizCanada.
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 thisepisode, one piece in
particular, is about the Don'tPanic, Enhanced Premium Tax
Credits.
Don't worry, we're gonna talkabout it in the show.
But we talk about it with thequestion of what will Congress
do?
(00:46):
Will they extend those taxcredits?
They have until December 31st.
Spoiler alert, no, they didnot.
So you might still seeheadlines about ACA tax credits
and people's premiums going up,the amount of money they have to
pay every month to continuetheir health insurance, because
those tax credits expired, whichmeans quite a few people in our
(01:08):
country and in our state aregoing to see the cost of their
health care go up even more.
And a lot of people are goingto stop having health insurance
because of that.
Lots of links in the show notesabout this.
I usually ask Molly to listento 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,
(01:30):
and that's very lovely.
And in this case, I did ask herto listen to it.
And a whole lot of other peoplehave listened to this episode
in advance.
Because even for me, the hostwho interviewed Brinie and we
talked, and I listened to therecording over and over again to
like wrap my head around itall, and I wanted to get a vibe
check from other folks.
And what I learned in thatprocess is that what I wanted to
(01:52):
share with you before youlisten to the full episode, all
of the questions you probablyhave as you listen, they're
probably not going to getanswered here because it is so
complicated.
And that's okay.
It would be silly for me tosay, well, a 40-minute episode
about why health care costs sodang much.
If anything, what this episodereally highlighted for me is
(02:13):
that I want to ask the samesimple question to folks in
other areas of healthcare.
Why does health care cost sodang much?
So this episode is from ahealth insurance perspective.
Brinie represents Anthem BlueCross Blue Shield in New
Hampshire.
And so I want to take theopportunity to interview other
folks from their perspectives,providers, hospitals, to name
(02:36):
two.
In the episode, I alsojokingly, yet not jokingly, say
that I should have a segmentcalled What the bleep Is This?
Where a listener writes inabout something in their health
insurance bill or something withtheir health care and is like,
what the bleep is this?
Uh, I say it jokingly, butactually, if you have a
(02:57):
question, send it in.
I don't love doing these longpreambles, but this is a very
important episode because thecost of health care is on so
many people's minds right now.
If you would like to supportthe show, please go to
patreon.com/ nh has issues.
If you have an idea for anupcoming episode, or if you have
something to offer the what thebleep is this segment, send me
(03:18):
an email.
Newhampshire issueshas@gmail.com.
Thank you for listening.
This is the topic ofhealth care costs.
So let's start with uh let'sstart with our taglines.
Have you thought about yourtagline?
Sabrina Dunlap (03:30):
I did, and as a listener of your show, I
appreciate like beginning withthe tagline and trying to be
like snappy and quippy, and Iconfess I cannot do it.
I cannot be witty about it.
Liz Canada (03:43):
All right, I'm gonna I'm gonna do mine.
Welcome to New Hampshire HasIssues, the podcast that dares
to ask, is this episode innetwork or out of network?
That's the best I could do.
Sabrina Dunlap (03:54):
It's good because it's simple, it's not
like judgmental, and it gets atlike one of the foundations, or
maybe it is judgmental, I don'tknow, but it gets at one of the
foundations of our whole systemof care, managed care, which
networks are a very importantpart.
So actually asking ifsomething's in or out of
network, you're like, I'm boredalready.
And skip to the next episode.
Liz Canada (04:13):
All right, hit me with your tagline.
Let's see what you've got.
Sabrina Dunlap (04:15):
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 inor out of network one, and but
I couldn't steal it from you.
So podcast that dares ask.
Liz Canada (04:27):
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 (04:34):
Can I take that one?
That's good.
Liz Canada (04:35):
You can take that one.
Yeah, take it.
Take it.
Sabrina Dunlap (04:38):
Um, although do I want to go there?
Insurance cards.
We're so highly regulated thatthere's rules around what has to
go on um ID cards, believe itor not.
Liz Canada (04:49):
Really?
Sabrina Dunlap (04:50):
Yes, it's true.
Liz Canada (04:51):
Are there rules about what's on the front of a
card versus on the back of acard?
Sabrina Dunlap (04:54):
Yeah.
Yeah.
And it depends on the type.
It depends on the type of planyou have.
Like I don't have a physicalcard card anymore.
Liz Canada (05:02):
What?
Sabrina Dunlap (05:03):
It's digital.
So it depends on your plan.
Liz Canada (05:06):
Yours is digital.
What?
You've got nice healthinsurance.
That's what I'm hearing.
Mine is not digital.
Mine is you get that out ofyour wallet, you find it, and
you turn it in so we can take apicture of it.
Sabrina Dunlap (05:17):
Well, the provider still ask me for a
paper, like a for a physicalcopy so they can take a
photocopy.
And I'm like, I've had the samehealth insurance for six years
and it hasn't changed.
Nothing has changed.
So I feel like maybe they don'tlike the digital answer.
But so do you have a plasticcard or is it like you have to
print it?
Liz Canada (05:34):
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 (05:43):
Okay.
And is the information on ithelpful to you as a consumer?
Liz Canada (05:48):
No.
I don't know a bleep thing thatit says.
I don't understand anythingabout it.
And even when they ask mequestions like who's the policy
holder, I'm like, I'm a person.
I'm holding this card, but Idon't think that's what you're
asking of me.
I think it's Molly is thecorrect answer.
Yeah.
I feel like I'm always failingthe test for my health insurance
check-ins.
Sabrina Dunlap (06:09):
Yeah, that's understandable.
I mean, there's a lot.
There is a lot.
You start to pull a thread.
Policy number.
Liz Canada (06:16):
Group number.
Oh gosh.
Yeah.
Is your that dare to ask, isyour health insurance card
digital plastic for a printout?
Sabrina Dunlap (06:28):
Because I did actually print it for a little
while.
And so I had like a littlefolded paper one in my wallet.
But I was going to asksomething along the lines of
like, how far down like the nerdhealth policy rabbit hole can
you go?
Liz Canada (06:42):
Listener, join us on this journey.
We are going to go into theabyss of health insurance.
I'm excited about this becausewhen I am out in the world and
I'm seeing what's stressingpeople out, the big thing that
people are stressed out aboutthe cost of healthcare.
Healthcare costs are up.
Yeah.
The health insurance issues interms of like being covered or
(07:04):
not covered, what is covered,what isn't.
This used to be, it's nolonger.
All of that is on people'sminds.
So I feel like this is reallyimportant that we're here to
talk about this.
So let me introduce you sincewe've been talking for a little
bit of time, but we can tellpeople who you are.
So welcome to New Hampshire HasIssues.
My guest today is SabrinaDunlap, aka how I refer to her
(07:27):
is Brinie.
So I don't want everybody to beterrified that I'm calling her
by a different name.
She is the senior director ofgovernment relations at Anthem,
Blue Cross, Blue Shield in NewHampshire.
That's correct.
Brinie, welcome to the show.
Sabrina Dunlap (07:41):
Thank you for having me.
I'm so happy to be here.
Liz Canada (07:43):
I'm so happy that you're here because health
insurance and health care costsdefinitely are on a lot of
people's minds.
Right now it is cold out.
It's November.
It's like we're in like fluseason and people are getting
sick.
The kids are starting to comehome and their noses are
running, and it's like, stop,get out of my house.
This is where we are.
(08:04):
We're in the sickness time.
Yes.
That's so perfectly timed.
Is that how you call it in yourhome?
The sickness.
That's how it feels.
So, Brinie, I think for ourepisode today, I have a simple
question, and it's really theonly question, which I'm hoping
you can answer.
Why the heck does health carecost so dang much?
(08:24):
Why is it so expensive?
All right, go.
Explain it.
Sabrina Dunlap (08:31):
How many episodes do I get?
Liz Canada (08:33):
You get as many as you'd like.
We'll just keep we'll just keepchick-chatting.
Sabrina Dunlap (08:36):
Okay.
So um yeah, there's there's alot to that question.
Very important question, not asimple answer.
I think anyone who claims tohave a simple answer, I'm not
sure that I wouldn't not sure Iwould necessarily believe them.
The things I would like tocover, there's like, you know, a
little outline.
Each thing I'm just I'mspeaking about these things
(08:59):
pretty generally because this,you know, the ID card is a great
example.
You start to like peel back thelayers, and it's like you could
spend hours on each of thesetopics.
And there's so much nuance.
Liz Canada (09:11):
An ID card?
Why is that so complicated?
Sabrina Dunlap (09:14):
Not necessarily the ID card.
Right.
But like all of these pieces ofthe puzzle are really
complicated.
The pieces to the puzzle andthen insurance alone.
Have you ever looked at the NewHampshire insurance statute?
Maybe not.
Liz Canada (09:27):
Brinie.
I want you to think about thatquestion 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 (09:39):
That's fair.
Liz Canada (09:39):
That was that was impolite.
No, I have not.
I have not read this.
Sabrina Dunlap (09:44):
How dare you.
If you're looking for likedense statutory reading, it is
extensive.
Liz Canada (09:51):
And when you say statutes, that means our laws,
our New Hampshire laws.
Sabrina Dunlap (09:54):
Thank you.
Liz Canada (09:55):
Go ahead.
Sabrina Dunlap (09:55):
So I was just also going to say that there's
so much nuance generally inhealth care, but also with
health insurance, because again,it comes down to like which
health insurance carrier do youhave a plan through?
And is it employer sponsored?
And is that plan self-insuredor is it fully insured?
Which put a pin in that.
I do want to cover thatdistinction because it's really
(10:20):
and then like you get intobenefit design.
Okay.
That's like a whole thing.
I know.
So you could see how whentrying to talk about these
issues generally, like forexample, at the legislature, I
often I'm like, okay, butthere'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 Ican explain this to you.
Right.
Exactly.
Oh boy.
Sabrina Dunlap (10:45):
Um yeah, I know.
I feel like I'm off to a badstart.
Liz Canada (10:48):
No, you're doing great.
This this is all perfect.
Okay.
So to start off, no, I have notread 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 doingit, Brinie.
It's not happening.
No matter what you say.
I had somebody on earlier, he'she's a marathon runner.
I'm like, not doing thateither.
So the likelihood of me readingthe 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 differentthings I want to touch on that I
hope would be helpful forpeople as we try to like, I
don't know, pull back the layerson on the cost question.
So I'm afraid it might be verydry and boring for you.
But even I'm here for.
(11:40):
Okay.
A little joke here and there.
So even as basic as like whatis 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 itwas not too basic.
Liz Canada (11:55):
Follow-up question.
Why is health insurancedifferent from dental insurance,
different from visioninsurance?
Because I'm pretty sure allthree of those things are my
body.
I know.
Sabrina Dunlap (12:05):
Why?
I need to look into thatbecause I actually I don't know.
Different episode.
I I myself am curious.
I have a lot of I'm very, verynearsighted.
So history of eye issues.
And it is weird that it's likea 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 theanswer 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 thathealth insurance is intended to
protect people from having topay super big medical bills and
also relatedly help makehealth care more affordable.
So the other thing that's superimportant is the idea of risk
pools.
So not gonna go too far downthere, but super important
(12:57):
because the whole like baselineconcept is that many people kind
of come together and yourpremiums, which should we go
into what a premium?
I mean, as I as I touch onthese topics, I'm just gonna
like try to explain briefly whatthey are.
So we're not here for sevenhours.
Premium, that's what you'reit's sort of like a
subscription.
It's like you might pay, let'ssay, like a hundred bucks a
(13:19):
month in premium, and that iswhat you pay into sort of the
bigger pot of money, the riskpool, is then used to pay claims
for people.
So the idea is that when youpool many people together and
you've got a lot of people whoare healthy, some people who
have health issues, you all kindof help cover the costs.
(13:39):
It's sort of like it's kind oflike 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 mosttime in in my life is my fear
pool, where I start talkingabout all my fears and I put it
in my fear pool.
I always struggle with thelanguage that's used because
premiums sounds like, ooh,premium, ooh, fancy.
And that's like it's a it's ait's a fee that you pay.
(14:07):
And that's fine, but that's thecost that it that you put
toward like your contribution.
Yes.
And then lots of people arepart of this risk pool.
Yeah.
Some of those people arehealthy and they're paying into
it.
And so their needs for whenthey get sick might be lower.
And then some folks, my motherused to refer to me as a sickly
(14:30):
child.
People like me, asthma everyyear, could never go
trick-or-treating.
It's a whole Oh no.
Oh.
It's a dramatic telling of mychildhood.
Oh.
You know what?
That was the least of myproblems when you hear about my
childhood, but that's fine.
Folks who need to get healthcare maybe more frequently than
others or different types ofservices, they're also part of
(14:51):
that risk pool.
And so lots of folks sort ofpay into it, and then the claims
are made, and then the moneycomes out of that sort of pool
of money in some way.
That's where it gets a littletricky 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 tolike level set on the whole
getting back to the costquestion.
I think there's this sort ofnotion that health insurance
companies set prices.
Because we we're often, youknow, an easy target for cost.
People are like healthinsurance makes things
expensive.
But that's actually justfactually incorrect.
(15:24):
Health insurance companies, um,we don't set prices.
We actually negotiate, forexample, with like a hospital or
provider, we negotiate so thatour members have more affordable
care.
So we negotiate those rates.
Now, this is where networkscome into play because when we
have a contractual relationship,let's use a hospital, for
example, and they come, theysign the contract with us, they
(15:45):
negotiate their rates with us,they come into our network.
And as part of that, there's awhole host of other things that
come into play as part of theconcept of managed care.
For example, providers arecredentialed with us.
So that means a carrier willask for a little bit of
information about yourbackground, your education to
make sure that sort of, let'ssay, doctor, for example, though
there are many types ofproviders, are who they say they
(16:07):
are.
And so it's for the benefit ofour members that we have these
networks that we maintain.
When you asked if this episodewas in or out of network, it's
actually a very importantquestion because depending on
your type of coverage, like myplan, for example, I have
out-of-network benefits, butthey're just not quite as good.
So if I go to a provider that'sin my health insurance
company's network, more iscovered.
(16:28):
Now, if I go to a providerwho's out of network, I do have
a decent amount of coverage, butit's not as good.
Depending on your plan, youmight not have really have much
of any out-of-network coverage.
So that's where networks becomevery important.
It's for the benefit of ourmembers.
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 partof your who have their little
plastic cards or digital cards.
Like those folks are members.
And so the health insurancecompany is negotiating with
places so that the costs go downfor their members.
(17:04):
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 hitnetworks, 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 thesame 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 riskpools.
I was going to say that peopleat 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 withnumbers.
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 recentlywhere there was like a whole
presentation on actuaries.
Now that might sound not superexciting, 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 theythey have to use data.
So they'll use like claims fromyears past, but then they use
(18:08):
sort of more current data andthen sort of data to project
into the future because thewhole thing is they have to set
rates that make sense so thatthe carrier, the health
insurance carrier, can pay theclaims in the future.
It's really complexmathematical work that they're
doing.
They're really good at it.
But the whole point is likeinsurance companies have to be
able to pay the claims as theycome in.
(18:29):
That is the point.
And so when people think aboutrates, they might say, like, oh,
rates are going up.
But in reality, it's like therates are being set for an
insurance company lookingforward because we have to file
our rates with the insurancedepartment.
So we're highly regulated.
So we have to have rates thatmake sense because if you don't
have enough money coming in,then it's harder to how are you
going to pay the claims whenthose medical services are used?
(18:52):
So that's sort of like the mathpiece.
And the risk pool comes intoplay with that because you want
to have a balanced risk pool.
You don't want it going up anddown.
You want, you know, a whole mixof people, different ages.
You know, some people mighthave chronic conditions, some
might be perfectly healthy andnever go to the doctor.
So I don't know exactly there'sprobably a whole episode on
risk pools.
(19:12):
That's kind of the extent of myknowledge.
They're very important.
Liz Canada (19:16):
You're you're talking about how you know
paying the claims and theinsurance company needs to be
able to do that.
So if the health insurancecompany is not dictating the
cost being so high, does thatmean 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 orthrough.
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 topeople 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 usin some way.
So, but who who does who who'sit who did this to us?
Who's making the health carecosts so high?
Sabrina Dunlap (19:58):
It is a fair question.
And I don't actually want toseem like I'm pointing fingers
because I I do believe that allof us in the healthcare space
are sort of like in this soup,this mix together.
And I think everybody can kindof take a little blame and
everybody has a responsibilityto try to make it better.
So some of the players, youhave health insurance, you have
the providers, you havehospitals, some are rural
(20:20):
critical access hospitals, someare massive health systems, you
have um pharma, you have likemedical 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 thembecause they're have you not
heard of PBM?
Yeah, yeah.
Pharmacy benefit manager.
Yeah.
So that's like a whole otherthing.
So the point is there's a lotof players in the health care
space.
I understand insurance is thething you deal with and you
don't necessarily want to bedealing with it.
(20:52):
And so I get why people arelike, oh, it's insurance's fault
because they're going to theirdoctor who they may know very
well and really trust.
And it's like the doctor's notthe problem, it's their
insurance company.
But when you actually look atthe facts and like all the stuff
that goes into costs, I don'tthink there's one person or one
entity to point at.
But it is true that like if youhave a super nice hospital and
(21:15):
a lot of specialties andspecialists, which we do want.
The thing is, those things costmoney.
And so that affects how theynegotiate with the insurance
company.
So there's other things at playthat factor into the cost issue
that's like no one's fault.
They're just facts.
For example, New Hampshire, youmight know, is an aged state.
(21:37):
I believe we're still in thecountry.
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 chronicillnesses associated when people
age.
We're a largely rural state.
And so the way healthcare isdelivered in rural areas is just
different.
In some ways it's morechallenging, in some ways it's
more expensive, in some waysit's less efficient.
But you want those people tohave that care.
But those play into it.
Can I pause you right there?
(22:03):
Because I think that makesheadlines a lot, is that the
cost of delivering health carein rural parts of the state is
just more expensive.
W why?
Is it just because there's justfewer people?
And so it take like what is itabout being in a rural area that
makes it more costly or morechallenging to deliver health
(22:24):
care?
That is a great question.
And I'm gonna like try toanswer it.
You could use like labor anddelivery, for example.
This has been a topic over thelast few years.
Big time.
Yeah.
If you live far from a criticalaccess hospital and there's
just not a big population, andthat hospital needs to have a
labor and delivery unit that canwelcome anyone or an ER or an
(22:45):
emergency department, forexample, and they need they have
that infrastructure which costsmoney and to have doctors and
nurses and other providers onstaff, all of that costs money.
And then if you only have likefive women a year or five people
a year coming in to your ER orfive people giving birth that
year, it's just there's not alot of like money coming in for
those services.
(23:06):
I mean, to think about a unitand like a major city, like a
labor and delivery unit in amajor city.
If they have like, I'm justmaking this up, like 10,000
births a year.
I mean, that helps pay for thatinfrastructure that is
expensive.
So that the cost of the doctorsand the infrastructure and the
like medical devices orwhatever, that cost sort of
stays the same.
But in an urban area, you havea lot more people coming in and
(23:27):
using those.
And in a rural area, you justhave fewer.
And so I think that's part ofit.
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 situationwhere it's because there are
fewer patients, the cost ishigher because there are fewer
people paying for it.
If you build more I know.
Like, how do you get you wantmore 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 tohave 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'sno place to go.
That is true.
Which happens.
That's not even a joke.
Like I make jokes, but that'snot even a joke.
Like people are doing thatbecause it is a far distance to
get to the place they need togo.
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 NewHampshire.
It comes up for our neighboringstates too, of Maine and
Vermont.
But it is a mystery, I think.
Or it's not a mystery, but Idon't think it's clear for folks
of why that's such like abigger issue of rural health
care.
Because it's like I could hearI could hear someone sort of
(24:38):
saying, like, but there's fewerpeople there.
So what's the big deal?
And maybe that is the big deal,is that because there are fewer
people, the services are notused as often or the healthcare
is not used as often.
And then in some cases, theservices go away because they
can't continue to be sustained.
Sabrina Dunlap (24:54):
Yeah.
I'm thinking about likespecialists, for example, like
if you're outside of like amajor metropolitan area that has
like a huge health system andthey have a type of specialist
who might be kind of expensiveto like keep on staff.
But if you have a ton of peopleseeing that specialist, it
makes sense.
But if you're in a rural area,number one, it's hard, probably
more difficult to attract aspecialist there to your
(25:17):
hospital because they just won'tsee as many patients with that
issue.
Liz Canada (25:20):
Yeah, there are fewer people to see.
It's also like to move to arural area as well, is like
there are fewer things perhapscompared to larger urban areas.
Yeah.
Yeah, there's a lot to it, Ithink.
More than it's more expensive.
It's like, but why is it moreexpensive?
I know.
Sabrina Dunlap (25:38):
And I actually don't even know.
It's like I I list it as sortof like a it's a challenge, I
think, for New Hampshire, as itis 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 bigcities.
So maybe I shouldn't put thaton 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 ofthrown out there a lot in news
stories too, of like ruralhealthcare, very expensive, very
hard to access health care inrural parts of the state.
And why?
Who am I supposed to blamebriefly?
Tell me who to blame.
Sabrina Dunlap (26:14):
I know.
I don't I don't want to blameany 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 theproblem.
It's me.
Hi.
All right.
Where were we in our list ofthings here?
I also sort of feel liketalking about the ACA a little
bit because the
Well you didn't call it Obamacare, problem number
one.
I don't know what you'retalking about.
Sabrina Dunlap (26:38):
I was just gonna say that there's this thing in
American health care that isthis is a whole nother episode
too, I think.
But the fact that our healthinsurance 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 historythere.
I I think I I think that is a ahuge issue, if I dare use the
title of the show.
Because I think it it thenresults in people feeling
trapped in in jobs or in placesthat maybe they are not not just
(27:15):
not happy, but like are arejust like really terrible
environments for them, but theycan't lose their health
insurance.
And so they have to hold on foras 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 anoption not tied to your
employer, which it does.
Yeah.
I guess that might be a a placeto just quickly mention the
potential expiration of theenhanced premium tax credits.
Liz Canada (27:43):
Yeah, that might be a place to mention a brief
mention.
Let's just say the phraseagain.
Because if you had given methose four words and said put
them in the correct order, Iwouldn't have been able to do
it.
So I wrote them down formyself.
What are enhanced premium taxcredits?
Sabrina Dunlap (27:58):
And I'm gonna keep this short and basic
because this really is anotherepisode, I think.
But the idea of premium taxcredits was to help people at
certain income levels be able toafford healthcare a little bit
easier through the ACA.
Now, a few years ago, theybumped those up, and that's
those are the ones expiring atthe end of 2025 if Congress
doesn't take action.
(28:19):
And so that is what a lot ofthe 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 makeup to a certain income, you
would have received this taxcredit, which would offset the
costs for your insurancecoverage on the ACA?
Yes.
So tied to income level.
Yeah.
Do we know what the incomelevel is?
Do you know what the incomelevel is?
(28:43):
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 itbecause it is a big issue and
there's lots of people talkingabout it.
Liz Canada (28:56):
Brinie, I I just looked on the internet.
Sabrina Dunlap (28:59):
Uh-huh.
Incomes between 100% and 400% ofthe federal poverty level.
Those are the folks who wouldbe seeing their health insurance
costs go up.
Yeah.
So I I think I would put that under some of the
challenges we have sort of as acountry and as an industry at
the federal and state level,just that there's changes and
(29:22):
there's challenges.
And I wanted to mention that asone at the federal level.
That's a big one.
Yeah.
But it's happening in realtime.
That is true.
And then at the state level,tying us back to cost of care in
New Hampshire, I mentioned, youknow, aging state, rural state.
We have also these other issueswhich you've done episodes on,
like workforce challenges, childcare costs, the housing
(29:45):
challenges in New Hampshire, allthese macroeconomic issues that
are all interconnected andhealthcare 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 smalland because so much of the state
is rural, but also it's anopportunity because we can make
(30:05):
changes in our little state thatactually help people.
And there's a lot of likereally good, smart people
working on health policy issuesthat maybe would be more
difficult or take longer orwhatever in a much bigger state.
So I think the size of ourstate and the landscape are both
sort of, you know, they'rechallenges and opportunities.
Is that too Pollyanna?
Liz Canada (30:24):
A little bit.
A little bit.
But I think that's that's whatyou have to that's what you have
to go with.
I'm not a Pollyanna type, asanyone can tell you really.
But that's yeah.
There's value to the smallstate because you can, I don't
know, try new things, yeah, beinnovative.
Sabrina Dunlap (30:41):
Bringing us back to why is health care expensive
and the role of healthinsurance.
Okay, here we go.
So we're focused onaffordability.
So New Hampshire has weactually have, I think it's 95%
of the state has some form ofinsurance, which is great.
We want that.
But it's like there's somepeople who have health insurance
and healthcare still feelsunaffordable to them.
(31:02):
And that's real.
Yeah.
And so we have to get at thataffordability question, which is
big.
And that's where like all theseother factors come into play, I
think, in New Hampshire aboutthe cost of living generally.
Some of the things thatinsurance does specifically to
try to help with the cost issue.
So we negotiate the contractsand the rates with the
providers.
We have our networks, healthinsurance companies also, one of
(31:24):
our roles is to um help try toprevent fraud, waste, and abuse
in the healthcare space.
Because I don't know if you'veever read about that, but it
does cost this country like inthe many billions.
And it's not all fraud.
Billing in the healthcare spaceis can be very confusing.
And so that's one area, though,where health insurance
(31:44):
companies play an importantrole.
And if you can prevent fraud orcatch fraud, or if you can
prevent sort of like billinganomalies, things that are
adding cost to the system.
I mean, that's a superimportant role.
And that's something thatbasically only health insurance
companies are doing.
And then we also are trying todo more to help our members take
(32:06):
control of their healthcare, sonot just through ID cards, and
understand the cost ofhealthcare.
And I think to the extent wecan try to make people better
informed consumers ofhealthcare, we want to try to do
that.
So, for example, I use myinsurance company's digital app.
That's where my digital cardis.
But it also has like thedigital.
(32:26):
Um, it has everything laid outabout my health insurance in one
place that is superunderstandable.
And there's ways to findproviders.
Um, it actually is veryuser-friendly.
Brainy.
Liz Canada (32:39):
How many of those words would I need to look up?
And this is not a dig on theyour specific your specific
insurance, but like I I don'tthink I'm a smart person, but I
know words and I try to readthings.
Okay.
And there there have been timesin my life where, especially
now that, you know, obviouslyMolly and I are married now, and
I'm the step parent to the twoboys.
(33:00):
And so like I think about allof this in a different way than
I did when I was just living itup solo, right?
Yeah.
And so I've tried to readthrough the different types of
plans and understand what theycover.
And they are kind of hard tounderstand, Breedy.
Does the app make it a littlebit easier than that?
Because I think it is difficultto know what those different
(33:21):
things mean.
Sabrina Dunlap (33:22):
It is.
And one of the things we dostrive 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 veryunderstandable.
Even though I like live andbreathe health insurance, I do
find it very useful.
There's other tools out therethat help people understand the
cost.
(33:42):
So, like if you were lookingfor like an MRI and it was like
not an emergency situation, youcould compare those costs
because they do vary quite a bitdepending on where you get that
service.
So those are like the types ofconsumer-centric ideas to try to
help people take more controlover their health care and um
hopefully control costs to someextent.
We as a carrier are trying todo our best to make things more
(34:06):
understandable for peoplebecause it is complicated.
Liz Canada (34:08):
It is really complicated.
Yeah.
Yeah.
We need a what the hell is thissegment, which is just people
sending in their question oflike, I have this in my alp
insurance.
What the hell is this?
And then we can try to explainit.
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, becausethey are a big cost driver
across the country, not just inNew Hampshire.
And I want to say on thisissue, oh, it's a tough one
because the specialty drug worldis quite amazing.
I mean, some of these drugs arelife-changing and we want them.
(34:46):
Um, GLP ones are amazing intheir ways.
It's the talk of the town, theGLP 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 companywill set the price of the drug.
Oftentimes people think it'sthe insurance company.
It is not, it is the drugcompany.
Specialty drugs are superimportant and we want people to
(35:08):
have access to them, but they docost a lot of money.
So it's just it's like one ofthose hard healthcare
conversations I think we allhave to be having, because I'm
not sure there's like a greatanswer to it, but that is a
driver of costs, specialtydrugs.
Liz Canada (35:22):
The pharmaceutical companies they say this is how
much these drugs cost.
The healthcare providers insome capacity say this is how
much it costs to deliver thehealthcare.
The health insurance companiessay these are these are our
members right here.
I'm gonna negotiate for thesemembers right here to lower the
(35:45):
things that you all have set,you know, make them a little bit
more palatable over here.
And there are other folks whoare in different types of
coverage or lack thereof.
Uh I'm just gonna say it soundslike a big mess, Brini.
It sounds like a big mess.
And I can say that because I'mwearing flannel.
You're wearing professionalclothing, you can't say it, but
I'm gonna say it sounds like amess.
(36:06):
Oh, you know, really, reallycomplicated and challenging.
And hard to say, like, well, ifyou just did this one thing, it
would fix everything.
Like that's not the case.
Because they're all reallyembedded.
Sabrina Dunlap (36:19):
Yeah, I think you've summed it up quite well.
Ugh.
I know.
If I if I could just add alittle personal experience, I
don't want to be an oversharer,but I I share this publicly.
Please.
So I have like a very deeplived experience in the
healthcare space as a caretakeradvocate.
Uh, one of our kids has a rare,severe chronic autoimmune
(36:42):
disease for which there is nocure.
You manage it through varioustreatments, including specialty
drugs.
We spent a lot of time in apediatric hospital.
And as somebody who grew upwith like the privilege of
health, I didn't know what myinsurance did, even as like a
young adult working.
I was like, whatever.
But that changes when you havea family member, or obviously
yourself, who suddenly needslike specialists and you're in
(37:05):
and out of the hospital.
And then I had a differentexperience in the acute
healthcare space, which wasabout six years ago, my husband,
who was healthy and 39, wefound out he had a large brain
tumor.
And it came out of left field.
And that tumor hit 11 out of 12cranial nerves.
It went up his brainstem.
(37:26):
And we, like that, we wereshookath.
I mean, we're not expectingthat.
I was thankfully sort ofexperienced with the chronic
disease management with one ofour kids.
And so I was able to managethrough that probably maybe a
little bit easier than somebodywho like hadn't lived through a
difficult health experience.
But that was difficult andawful in its own way.
(37:46):
But it was like this acute,intense long surgery at a major
hospital with a very difficultrecovery.
Um, thankfully, knock on wood.
He's doing fine.
It was not malignant, it wasjust a big tumor.
And he still actually has apiece 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 justbecause this these experiences
(38:10):
have taught me like veryprofound lessons in perspective.
And I carry those things withme every single day.
So with these lived experiencesI have, like I understand the
importance of specialty drugsbecause one of my kids needs
them basically to survive.
And so I see the cost of them.
I see how they're administered.
(38:31):
I see sort of like the lifecycle of those specialty drugs,
but I also understand howincredibly life-changing they
are.
And and same with like thesurgery, to have like a major
brain surgery and like come outthe other side and be okay, to
have access to that is amazing.
And so I know we talk a lotabout like the mess of the
American healthcare system.
(38:51):
And I think that's real.
I don't want to, I don't wantto diminish um what people live
through every day.
And and I know the fear ofworrying like, is this gonna be
covered?
And like, can I pay for it?
And I wish that people goingthrough healthcare issues did
not have to worry about that.
So, like, that's real.
Everything for me is throughthis lens of like what I've
lived through with my familymembers.
(39:11):
And so I think always about myNorth Star being like what's
best for our members.
How do we increase access andkeep it, make it more
affordable?
I mean, those are the thingsthat drive us every day.
And even if we're we don't haveanswers to everything, and even
if things aren't going tochange overnight, I do believe
that we can make things betterfor people.
(39:32):
And I hold that in my heart.
Liz Canada (39:34):
We have an extremely complicated system in the
United States that is notperfect.
Not perfect.
So probably not changingdramatically overnight.
And so how to make it moreaccessible, affordable, and
understandable for regularpeople.
Brittany, thank you so much fortaking 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 oftime.
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 coveringMedicaid.
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 reallyappreciate 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 sheis always willing to just like
talk to me.
She's not coming at me.
She's interested in likeactually talking about the
issue, and a lot of people are.
But Kristine stands out as onewho 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 aprofessional who cares about the
issue and is willing to workwith me.
Don't tell anyone.
Kristine is a wonderful person.
Popular Podcasts
Joy 101 with Hoda Kotb
Joy is essential. And it's also elusive. You can't order it, borrow it, or simply hope it into life. But now, there's a new and exciting way to start your journey toward a more joyful existence: The Joy 101 Podcast with Hoda! Best known for her Emmy-winning work and co-anchoring Today, Hoda Kotb infuses her authenticity, curiosity, and warmth into conversations with the world’s most fascinating people. Entertainment legends, sport icons, wellness experts, and everyday folks will share how they find, allow, and experience joy. Hoda will offer her own tips and takes on seeking a more balanced, harmonious life. If you're craving inspiration, support, and useful tools to maximize your joy, tune in to these candid, uplifting, and moving on-air chats. Joy after a breakup, joy as an empty-nester, joy after loss, joy as a caretaker — Hoda's new podcast will speak to you. Joy 101 with Hoda Kotb, an iHeartPodcast.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com