1073: Coverage, Consequences, and the Leaders Shaping Public Health’s Future

JOHN SHEEHAN: 

This is Public Health Review Morning Edition for Friday, February 20, 2026. I'm John Sheehan, with news from the Association of State and Territorial Health Officials.

Today, two powerful public health stories. First, we break down the ACA enhanced premium tax credits with Catherine Jones, senior analyst of government affairs at ASTHO. We'll hear what the credits were, who they helped, and what's at stake now that they've expired. Then we shift to public health leadership in the next generation. James Bell, III, chief of staff and director of the Michigan Department of Health and Human Services and a Doctor of Social Work, reflects on his experience in the DELPH leadership program and how it reshaped how he shows up as a public health leader.

But let's start with ASTHO's Catherine Jones.

CATHERINE JONES: 

This is a bit complicated to explain, so please bear with me to understand what the enhanced premium tax credits are. Enhanced being the keyword here, we need to scroll back to the ACA premium tax credits that were part of the original 2014 rollout. Basically, the original tax credits were designed to ensure affordable health care coverage in the ACA marketplace based on income by subsidizing the difference between the full premium set by insurers and an affordable amount to be paid by the enrollee. So basically, these credits significantly expanded coverage for millions of people, but there were still people who were priced out of the enhanced premium tax credits that were enacted in 2021 during the pandemic. These enhanced credits expanded the original credits by increasing financial assistance for low- and middle-income enrollees. So basically, people that did not qualify before now did in 2022. These enhanced credits were extended to the end of 2025. All told, the number of enrollees in the ACA marketplace jumped from about 11 million in 2022 to about 24 million in 2025.

SHEEHAN: 

Okay, and so what is the population we're talking about? Who are the sort of the beneficiaries of these enhanced credits?

JONES: 

So, Americans who would benefit most by extending the enhanced credits are those who simply can't afford to pay the increased insurance premiums. Some of these groups might include middle-income families, older adults who do not yet qualify for Medicare, rural residents, self-employed workers or gig workers, and anyone who lacks employer-based health care coverage.

SHEEHAN: 

Yeah, and what are the consequences if these tax credits aren't extended?

JONES: 

So, to be clear, the enhanced premium tax credits expired at the end of December 2025, and the ACA open enrollment period ended in mid-January. Premiums have risen sharply for millions of enrollees, and many of them can't afford to pay the difference. It's predicted that millions of people will drop their health care coverage altogether for financial reasons in the coming months, a decline in rates of insured people would increase uncompensated care costs for hospitals and clinics, and downstream, this could lead to hospital closures, especially in rural areas.

SHEEHAN: 

Yeah. Absolutely. So, this is already happening. The premiums are already shooting up. People are already grappling with how to pay for their health insurance, and there's a good likelihood that people will just be losing their insurance. And the consequences of that, you can sort of spin out, is, you know, more demands on health care services with less money coming in.

JONES: 

That's correct, yes.

SHEEHAN: 

And can you sort of connect the dots for us between those, you know, very real, sort of health care-related issues and the public health side of it?

JONES: 

Yeah, that's a great question. When people lose health care coverage, they often delay seeking preventative care. They forego screenings like cancer and hypertension, they skip medications, and basically, they rely more on emergency rooms. Stable health care coverage across the population improves access to detection and management of chronic diseases, screening services, vaccinations, mental health services, and maternal health care, just to name a few. Higher uninsured rates are associated with worse population health outcomes, higher mortality, and increased gaps in access to health care.

SHEEHAN: 

Yeah, more people uninsured is going to put tremendous strain on the health system. And right there, you're already talking about sort of a public health crisis.

JONES: 

That's correct, because without health insurance, the level of population health and access to care decreases.

SHEEHAN: 

Yeah, and there had been talk before the expiration of these, maybe, maybe these subsidies being extended. What is the current legislative outlook regarding these subsidies

JONES: 

Without getting into the weeds, in January, the House voted to advance extensions for enhanced premium tax credits for three years. The Senate has not yet voted on this legislation, but last month, it rejected similar legislation. Bipartisan discussions are continuing. However, the future of extending the enhanced premium tax credits remains very uncertain.

SHEEHAN: 

Catherine Jones is senior analyst of government affairs at ASTHO.

Now let's hear from James Bell, III, chief of staff and director of the Michigan Department of Health and Human Services. James is also an alumnus of the first class of the Developing Executive Leaders in Public Health, or DELPH, program.

JAMES BELL III: 

DELPH, to me, is an opportunity for leaders to really come together, and I say leaders, and it may feel premature, even people might not see themselves as leaders, but to be recognized nationally as individuals who are prepared for taking on the mantle of very important and critical public health functions as view them as the future leaders of this work. And when you think about the mission and the vision, I think it's to create a network of leaders who are equipping themselves with the leadership development, with the foundational capabilities and all the other necessities to be prepared to navigate a complex public health future.

SHEEHAN: 

And you went through the program, correct?

BELL: 

I did. I'm a member of the inaugural cohort, and I'm very proud to say that, so even more excited that we're now six cohorts in.

SHEEHAN: 

Yeah, absolutely. What was your experience like?

BELL: 

My experience was very affirming. I think for me, it introduced the fact that I am more of a leader than I thought I was, and it also gave me the opportunity to challenge myself in new ways. It showed me that leadership is not just a series of skill sets or maybe some banked words to use in certain situations, but it actually gave me a posture in a certain way that I show up in different rooms. It gave me the confidence to speak out a lot more, and that sometimes I may disagree, and that is okay with what may be the status quo or what may be the popular convention, but that is actually what makes you a leader, to be able to stand behind the things that you recommend and be prepared to do that and justify what the evidence and the science that supports it.

SHEEHAN: 

You say it's given you sort of a new posture and a new way, like when you walk into certain rooms. Can you kind of build more on that? That's really interesting.

BELL: 

Sure. I think before DELPH, I found myself to be a little bit more introverted, at least in terms of the way that I show up in meetings. DELPH gave me the opportunity to start thinking about my communication skills as a message, but also as a vehicle for change. And so how do I as a director of a program come into a space whole and authentic and recognize that there's things going on in the environment that are impacting me, but are also impacting my staff, and so being empathetic and also being humanistic about the ways that we approach public health, sure, we can rely on the numbers, we can rely on the statistics, the evidence, but what are we doing in the moment, right now, as leaders talking about what might be the difficult topic,

SHEEHAN: 

So, is it sort of advocating for yourself and your team? Is it sort of, is it being confident in your approach and sort of going into a situation with intention?

BELL: 

I believe it to be all of the above. When I think of my public health career, sometimes I can find myself a bit distanced from the current situation at hand. You make your way through various ranks, and you find yourself maybe higher on an organizational chart. You might not be directly impacting or as close to a particular problem as when you first started, but I'm often reminded that the decisions that I make impact individuals on a daily basis, and so I'm reminded that there are communities that are counting on me to come into spaces to say the difficult thing, especially as a leader of color, there are certain lived experiences that I have that I have to reflect on and that I have to bring into the room, because if I don't, there's a potential consequence that those things will not be taken into consideration in. When we are making decisions, and unfortunately, what we tend to see is those outcomes then create these disparities or inequities that further widen gaps. Because I didn't take the opportunity to speak up, and so DELPH gave me the confidence, and again, that posture, that backbone of like, there's certain skills or opportunities that I have, especially now that I'm in the room, that I have a seat at the table that I have to definitely take advantage of.

SHEEHAN: 

Wow, it sounds to me like you're speaking more about that you have to think more about others, rather than necessarily yourself, in those decision-making processes.

BELL: 

I'm fortunate that the mentors around me introduced me to the concept of servant leadership early in my career. And so, it was always, the seed was always planted that, you know, I am making way for those behind me and those that are around me. And so as a leader, I'm typically thinking about my teams. I'm thinking about the people that they're trying to serve. And so how do I remove barriers so that they can show up as their full and authentic self?

SHEEHAN: 

Are there other takeaways, skills, procedures, or thought processes that were implanted because of the DELPH program?

BELL: 

Yeah. The other thing I want to talk about is networking in relationship-building. I had a very specific idea of what networking looked like. It was fast-paced. It was you pull out your business card. You tell people who you are, what you do, and what you can offer them, but it was never rooted in this idea of relationship building. DELPH introduced me to a series of other colleagues who are now friends that I can call on in those difficult situations, as public health leaders that we only we would understand, because there's certain things that happen in public health that you wouldn't believe actually happened on a daily basis. And so being able to have colleagues who are experiencing similar things, and to be able to come together as thought partners to create strategies like, you know, how would you respond to this? And being able to say, hey, you know what? I just need to take a break. You know what I do, too. And so being able to have that camaraderie and that networking that is less pressure and more authentic, I think that we're able to, one, create better solutions, but also is more sustainable, is not transactional in the way that, hey, I'm going to do this for you, you're going to do this for me. It's something that's long-term, and ideally, it's transformational, because I know now that I have partners that are in local health departments, I have partners that are in philanthropy, I have partners that are at the federal level, and so we're still having these conversations. We have these different vantage points. It's really exciting to see, like how we all approach it together.

SHEEHAN: 

Are there, are there things that you want to make sure that you impart to the new cohort?

BELL: 

Yeah, I would say trust the process. I know in the beginning it can feel really intimidating you're around other people, or for me, I felt almost insecure in the beginning, like, Oh, my God, these people and their credentials and the things they're doing, the programs that they're leading, remind yourself that you're also in that conversation, and you're also a part of this now wonderful community of public health leaders, you have a responsibility because you have a seat at set table. But also know that this opportunity opens the doors for so many others, and so as you go about your Delft experience, know that there are people who are looking at you within your own institution who want to do something similar, and so please be a resource to them. Tell them about what Delf has done for you. Tell them about the people that you've been connected to and the types of conversations that you're having, so that we continue this wonderful program.

SHEEHAN: 

Getting back to that idea of the career of service.

BELL: 

I think of it as, you know, informal mentoring. I mean, you never know who's paying attention to you. I've had some really great conversations with staff that I didn't even know. One worked in the organization we're large here in Michigan. And so when someone says, Oh, I saw this press release, and I saw that you were a part of this program, could you tell me more about it? Could you help me with my application? You become just a walking resource for others. And so while you're enjoying the experience right now, know that there are other people who are looking up to you, who want to be a part of DELPH in the future, who just want to learn from your experiences and make sure that you're returning that to people.

SHEEHAN: 

James Bell, III, is chief of staff and director of the Michigan Department of Health and Human Services and an alum of the first class of the Developing Executive Leaders in Public Health, or DELPH, program.

Earlier, we heard from Catherine Jones, senior analyst of government affairs at ASTHO.

ASTHO welcomes new member, Raynard Washington, acting commissioner of health for the New Jersey Department of Health. Prior to this role, Dr. Washington served as public health director for Mecklenburg County, North Carolina. He also has experience serving as a health research scientist for the U.S. Department of Health and Human Services' Agency for Healthcare Research and Quality, and as an adjunct professor at American University and Temple University: Go Owls.

High blood pressure is driving heart disease, maternal health risks, and long-term illness, but public health teams are responding with smarter, more connected solutions. ASTHO explores how communities are using at-home blood pressure monitoring, team-based care, and culturally responsive programs to improve control rates, plus see how states are tackling hypertension during pregnancy to protect both mothers and babies with better screening, home monitoring, and postpartum follow-up. Find more at the link in the show notes.

This has been Public Health Review Morning Edition. I'm John Sheehan for the Association of State and Territorial Health Officials.