New Hampshire Uncharted is a podcast from the New Hampshire Fiscal Policy Institute, produced in partnership with the Marlin Fitzwater Center for Communication at Franklin Pierce University and the Granite State News Collaborative. Let’s dive in.

In today’s episode, we’re tackling an issue that affects every family, every business, and every budget in New Hampshire: the high cost of health care. New Hampshire consistently ranks as one of the most expensive states in the country for health care. Whether it’s monthly premiums, prescription drugs, or other out-of-pocket costs, too many Granite Staters are asking the same questions: why does it cost so much and what can be done about it?

The truth is these steep prices are not inevitable. And this episode will look at what’s driving higher costs here in New Hampshire, what’s working in other states, [00:01:00] and most importantly, what policy solutions could bring relief to families and employers across the state.

Joining me today to break it all down are two of the state’s top experts on health care policy, Deborah Fournier, director of Health Law and Policy at the UNH Institute of Health Policy and Practice and former New Hampshire Medicaid State Director, and Jennifer Frizell who leads the New Hampshire Health Care Cost Initiative, a statewide effort to drive down costs and restore trust in the system. Deborah. Jennifer, welcome to the podcast.

Part of what drives health care pricing and health care costs across the board are the prices themselves – they’ve never been regulated. The trends in hospital consolidation – so the more hospitals are purchased and bought up and become part of a larger corporation the more market share they have and higher the price that they can command.

Utilization always is a factor in price, and aging is always a factor in price, because the aging drives the utilization. But utilization in recent years is just coming back from where it was prior to the COVID-19 pandemic, so it’s recovering [00:03:00] from very low utilization. And then most of what affects utilization or drives utilization is the environment people live in, where they work, where they sleep, where they play, where they worship, where they raise their kids.

We largely don’t address the ultimate drivers of health. Things like, do you have a safe place to live? Do you have affordable housing? Do you have adequate access to a green space? And how much income stability do you have in order to access all of those other things?

We think about 50 states where the laboratories of democracy are at work. What are some policy levers that have worked elsewhere and could work here in New Hampshire?

We have some beginning tools here. We have something that’s called the all-payer claims [00:07:00] database, which is a record of all of the claims that are submitted and paid by state regulated insurance in New Hampshire. We also have a health care commission that was developed a few years ago, whose job it is to look out for the New Hampshire health care consumer and to advise the attorney general about how best to utilize some funds that have been set aside for the benefit of the New Hampshire health care consumer.

Something that is more prevalent in other New England states is something called a cost-growth benchmark, which is basically a way to measure at the statewide level across all different sponsors of entities, whether it’s government or business or any other entity, what is being spent, the dollars that are actually being expended on health care. [00:08:00]

And then they set something that’s like a target. They say, well, we don’t want the rate of growth in those costs to be any faster than a particular index. Like how fast the rate at which the economy grows, or the rate at which inflation grows. So I think New Hampshire is really well positioned to begin to go further down that first bucket of transparency and oversight.

And if we can’t measure it, we can’t improve it, but we don’t even have all of the information right now about what those expenditures are statewide, right? We have bits and pieces, but it’s not all in one place. It hasn’t been analyzed and digested and it’s from there, from a data-driven perspective, a good public conversation should occur about what does New Hampshire want to do. So it has some of those beginning pieces [00:09:00] – an all-payer claims database as part of transparency, and this commission for the protection of New Hampshire health care consumers.

Those are great starting points, and we have done some convenings and gatherings of folks busy and active in the health policy field on the cost-growth benchmark. That idea of being able to know what your state is spending on health care and the rate at which health care costs are growing might be a good starting point, and seem to be a place that most folks were interested in learning more about in terms of what could be done here in New Hampshire.

Jennifer, I’m wondering as you’ve been convening folks and talking to folks through the New Hampshire Health Cost Initiative, what are some of the promising ideas or policy reforms that you’re seeing take shape in New Hampshire right now through your work?

One is investing more in primary care. The second is creating more oversight tools that look out for the transparency and accountability type issues that Deb mentioned. A third is expending more resources on patient navigation and consumer protection. And the fourth is developing a long-term health care vision for New Hampshire that engages and has measurable action items for health care improvements. And to say a little bit more about a couple of those, what we hear a lot from families and patients is that they’re no longer able to get the care that they want in their community – that kind of frontline care that is primary care, mental health care, and maternity care. [00:12:00]

And by giving more resources into those areas of health care, we will be able to address preventative issues at an earlier time as well as support the workforce in those areas. With regard to expanding resources for consumer protection. We know that there are more opportunities for patient voice and for patients to be involved.

And we need resources like patient navigators, consumer advocates, legal services, watchdogs at community-level health care accessing patients to help them understand their rights and options and help them to feel confident in navigating the difficulties that are they’re now facing in health care.

Higher deductibles, shrinking access networks, facility fees, all more complex layers of health care costs that either cause costs [00:13:00] to drive up for patients and families or cause care to be avoided because they are unable to access that. And by having conversations about some of these key solutions, we continue to feel like we are building more of a network to support the policy changes that are on the horizon.

And you talk about workforce, which I feel like we could have a conversation about workforce and it connects to everything. But I was talking to a friend not too long ago and they need to have a procedure done, and it was an organ of the body that I thought, oh, there’s probably specialists who do that here. And there was no one here in New Hampshire, because that person retired a few months ago, so they had to go down to Boston to be able to have that procedure done. And I thought, wow, that must drive up cost. [00:14:00]

Those fully-funded plans make up about half of the people who are insured, about 400,000 people who are commercially insured in New Hampshire. There’s another 400,000 people who are insured under what are called fully-insured plans. Those plans are regulated at the federal level, and the state has very little jurisdiction over them. There’s about 400,000 people who live in New Hampshire who are in those types of plans. A self-insured plan is essentially when the employer directly provides the health benefits to their employees. They often hire a health insurance entity to be their plan administrator [00:16:00] and to administer those benefits.

I’m wondering on the consumer side again, obviously it sounds like we don’t have the full picture on the measurement side, but what are some of the things that we could do for consumers? Where have you and others seen the most impactful solutions that the state policymakers – if they were listening to this and they wanted to adopt a solution in the next legislative session or they wanted to move through some administrative rules – what are some of the things that folks could do to help have an impact? Whether it’s transparency and oversight, whether it’s cost of service, what are some of the things that folks could do to help support consumers in this process?

People might have insurance questions. They might have access questions. They might not even know what type of health insurance they do have. Do they have Medicaid? If they have Medicaid, is that through a commercial health insurance provider? And what’s the name of that company and how do you get ahold of those folks? And as well as people having access issues with a particular health care entity, they can’t get from point A to point B inside of the health care facility, or they’re confused about why, even though they think they’re insured, they got a massive bill and they thought they were covered for that service but they’re not.

We don’t have any one place where a consumer can go and say, I don’t understand, or I need help managing this massive system. [00:19:00] Or like the example you were saying, my doctor says I need this service and I don’t understand why it’s not here, and what are all the things that I’m going to have to do to get that service? Even though my doctor told me I need it and, and I should really get it.

It’s like the systems don’t talk to each other. So just having one person or one entity to be able to collect information and complaints, to understand what the trends are so that that entity could then turn around to policymakers and say, we received X amount of complaints this year. 20% were about this, 50% were about this, and another 30% were about this.

We are still very much in that space of needing more information and other states have lots of different models for how they do this consumer protection function when it comes [00:20:00] to health care.

They might have private nonprofits outside of government that are there to provide navigation assistance, like help people get through the insurance process or answer their insurance questions. There might be someone like an ombudsman who collects information and says, we have routinely seen these kinds of pain points in the system, and these things need to be addressed. There’s legal assistance in most states. New Hampshire has New Hampshire Legal Assistance and 603 Legal Aid, but those shops aren’t always designed to take on the specificities of health care issues and health care questions.

One example I use and I feel like I’m getting to that age in my life when I get together with friends, [00:21:00] we talk about health care challenges with our parents or our kids or what have you.

But a few years ago when my oldest daughter was in preschool, we had gone to urgent care five times. And one of those visits, I don’t know if it was the fourth or the third visit, but we ended up getting a facility charge and our insurance rejected it, and I called and I went through the process. And again, I run an organization, I oversee health care, so I think I’m pretty knowledgeable on this for the most part, but I just was so taken aback by how difficult it was and how, depending on when I called back, if the customer service person was helpful enough or really wanted to get the solution. But I went through a process of like six weeks where I said why is this happening? And the health care folks at the hospital told me, well Gene, [00:22:00] you signed this document that said you’ll take the responsibility if insurance doesn’t do it.

And I could have just let it go, but I couldn’t of course. And so I ended up calling and if it wasn’t for a claims person who spent an hour with me and found some loophole to charge the claim, I would’ve had to pay that a few hundred dollars charge. And that’s a lot of money.

And so I just wonder—when it comes to a consumer advocate, someone who’s really looking out for people and helping answer their questions—even if you’re knowledgeable, it still feels incredibly difficult to navigate the system. I don’t want to say it’s rigged against you, but it can definitely feel that way. You really have to jump through hoops. And if it’s that hard for someone familiar with this work, imagine how much harder it is for the people most affected. They don’t have the time to sit on the phone, or to spend their lunch break figuring it out. So this really seems like a ripe opportunity for a policy intervention—one that could genuinely help consumers.

I know we’ve already talked a bit about the consumer protection aspect, the oversight board, and the long-term vision. But I’m wondering if you can share a little more. If we go back to the idea of investing in primary care, what are some of the challenges?

And again, when we talk about health care, we’re also talking about the cost of housing. We’re talking about how to get someone to move here—can you even hire a provider if they can’t afford to buy a house in the area? So I’m just wondering: what are some of the challenges you’re hearing about when it comes to investing in primary care and supporting the provider workforce?

Insurance premiums [00:25:00] —whether people are paying them directly or having them paid on their behalf—combined with high copays and deductibles, leave many wondering: what care am I actually paying for? And too often, they’re still not able to access the most basic care in their own community.

And then within that global amount of spending data and analysis, which would show very little, less than 10 cents on the dollar, maybe even some places 5 cents on the dollar is being invested in primary care. And we know that is the entry point for people to establish a medical home –if our system is working in a way that allows prevention and early detection to work.

And if we’re only spending 5 or 10% on primary care, it means we’re spending so much more on chronic care and specialized care and acute care.

And health care isn’t like other products in the sense that you [00:26:00] just shop for it like a car or a washing machine. We have to proactively speak up for the kind of health care system we think should be in every community. And I think one of the things that we’re hearing is people are concerned in New Hampshire that more and more of our communities are losing maternity care.

We’ve had 11 hospitals close their labor and delivery units over the last 20 years. That’s nearly half of our hospitals. And so the issue of primary care, I think shows up as, what kind of care everybody wants to be able to get in their home community, and what are the ways that the economics and the delivery of our system and the incentives for where facilities are closing and consolidation is impacting care.

How is that making that most basic preventative and primary care harder to get and less of our dollars going towards it? And I’d say that’s some of the obstacles that I’ve seen in coming to understand that and how people are experiencing it. And I bet Deb [00:27:00] has a kind of a policy lens on why that’s really challenging as well.

Those kinds of solutions require everyone to be around the table. It’s not just a provider issue, it’s not just an insurance issue.

And it’s not just a health care issue, as Jennifer was saying, it’s a community issue. People need certain types of care available to them wherever they live. Do they live in the North Country? Do they live in Keene? Do they live in Rockingham County? Do they live in [00:28:00] Hillsborough County? Do they live in Manchester?

So how providers are paid and then how insurance companies get paid – in New England we have historically been a great laboratory for how to deliver health care. And some of our southern neighbors have really pursued, Massachusetts and Connecticut have pursued this idea of a cost-gross benchmark, right? Which is the thing where you measure how fast your health care costs are growing and you set a target that says, we don’t want to grow faster than the economy, or we don’t want to grow faster than inflation. And they have done that through statute by saying we are going to do this, and therefore all these different actors have all of these different reporting responsibilities so that we can get all the information [00:31:00] so that we can get the big picture, and then we can make some decisions about what we ought to do about it.

Rhode Island did that through a voluntary process. They got all – they’re a small enough state – they got all of the relevant stakeholders around the table and said, do we have to pass a law? Can we agree? Can you just say that we’re all going to participate in this? And they said, yes, we are. So they built a cost-growth benchmark and they set a target, but they also put in affordability standards into their commercial insurance regulation which essentially acted as a cap on hospital prices so that they couldn’t grow beyond a certain amount.

And so that seems like a very New Hampshire friendly solution. Right? It’s voluntary, and it connects both the overall state performance with the premiums that people are paying in their insurance policies. [00:32:00] And there was just a study that came out, just a few weeks ago that the hospital price reductions that occurred, because of those affordability standards led to really substantial reductions in fully insured premiums like up to a thousand dollars per member.

The shortfall with that is that a state can only regulate those fully-funded plans. Remember, we talked about the 400,000 fully-funded and the 400,000 self-funded, so the state couldn’t regulate those self-funded plans and couldn’t put affordability caps on those insurance products, right? So they could only provide that savings to the people in the fully-insured market, which means, and as a general rule slightly more people are in [00:33:00] self-funded plans than fully-funded plans. So that savings didn’t reach the majority of people covered by commercial insurance in New Hampshire and in Rhode Island. And overall had a very modest impact on premium increases in those markets.

But for employers, that’s really challenging. I’m already taking a snapshot of my next fiscal year budget, and there’s nothing else in the organizational [00:35:00] budget that’s going up 10, 15%. There’s just nothing else that’s like that. And it puts a real growth cap on hiring and being able to do more of that.

And I hear that from other organizations. And again, just eight people. Like an 800 person organization, I would imagine a different scale, but it really is an important conversation as we, again, thinking about how can we measure it, how can we have the right consumer protections to really help drive those costs down.

Deborah. Jennifer, thank you so much for this conversation. There’s so much more I feel like we could get into, but really to be able to start to tackle this, it sounds like, again, where New Hampshire is on the starting end of this and looking forward to checking in the months to come to see where New Hampshire lands.

This podcast is produced by the New Hampshire Fiscal Policy Institute in partnership with the Marlin Fitzwater Center for Communication at Franklin Pierce University and the Granite State News Collaborative. A big thank you to our partners without whom this would not be possible. Thanks for listening, and we’ll see you next time on New Hampshire Uncharted.