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

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This is Public Health Review
Morning Edition for Friday,

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February 20th, 2026.
I'm John Sheehan with news from

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the Association of State and
Territorial Health Officials.

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Today, two powerful public
health stories.

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First, we break down the ACA
enhanced premium tax credits

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with Catherine Jones, senior
analyst of government affairs at

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ASTO.
We'll hear what the credits

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were, who they helped, and
what's at stake now that they've

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expired.
Then we shift to public health

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leadership in the next
generation.

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James Bell, the third chief of
staff and director of the

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Michigan Department of Health
and Human Services and a doctor

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of social work, reflects on his
experience in the Delft

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Leadership program and how it
reshaped how he shows up as a

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public health leader.
But let's start with Astos

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Catherine Jones.
This is a bit complicated to

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explain, so please bear with me.
To understand what the enhanced

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premium tax credits are,
enhanced being the keyword here,

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we need to scroll back to the
ACA premium tax credits that

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were part of the original 2014
roll out.

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Basically, the original tax
credits were designed to ensure

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affordable healthcare coverage
in the ACA marketplace based on

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income by subsidizing the
difference between full premium

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set by insurers and an
affordable amount to be paid by

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the enrollee.
So basically, these credits

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significantly expanded coverage
for millions of people, but

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there were still people who were
priced out.

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The enhanced premium tax credits
were enacted in 2021 during the

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pandemic.
These enhanced credits expanded

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the original credits by
increasing financial assistance

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for low and middle income
enrollees.

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So basically people that did not
qualify before now did.

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In 2022, these enhanced credits
were extended to the end of

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2025.
All told, the number of

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enrollees in the ACA marketplace
jumped from about 11,000,000 in

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2022 to about 24 million in
2025.

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OK.
And So what, what is the

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population we're talking about?
Who are the sort of the

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beneficiaries of these enhanced
credits?

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So Americans who would benefit
most by extending the enhanced

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credits are those who simply
can't afford to pay the

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increased insurance premiums.
Some of these groups might

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include middle income families,
older adults who do not yet

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qualify for Medicare, rural
residents, self-employed workers

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or gig workers, and anyone who
lacks employer based healthcare

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coverage.
Yeah.

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And what are the consequences if
these tax credits aren't

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extended?
So to be clear, the enhanced

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premium tax credits expired at
the end of December 2025 and the

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ACA open enrollment period ended
in mid January.

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Premiums have risen sharply for
millions of enrollees, and many

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of them can't afford to pay the
difference.

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It's predicted that millions of
people will drop their

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healthcare coverage all together
for financial reasons in the

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coming months.
A decline in rates of insured

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people would increase
uncompensated care costs for

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hospitals and clinics, and
downstream this could lead to

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hospital closures, especially in
rural areas.

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Yeah, absolutely.
So this is already happening.

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The premiums are already
shooting up.

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People are already grappling
with how to pay for their health

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insurance, and there's a good
likelihood that people will just

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be losing their insurance.
And the consequences of that you

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can sort of spin out as you know
more demands on on healthcare

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services with less money coming
in.

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That's correct, yes.
And can you sort of connect the

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dots for us between those, you
know, very real sort of

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healthcare related issues and
the public health side of it?

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Yeah, that's a great question.
When people lose healthcare

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coverage, they often delay
seeking preventative care.

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They forgo screenings like
cancer and hypertension.

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They skip medications and
basically they rely more on

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emergency rooms.
Stable healthcare coverage

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across the population improves
access to detection and

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management of chronic diseases,
screening services,

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vaccinations, mental health
services, and maternal health

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care, just to name a few.
Higher uninsured rates are

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associated with worse population
health outcomes, higher

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mortality, and increased gaps in
access to healthcare.

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Yeah.
More people uninsured is going

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to put tremendous strain on the
health system.

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And right there, you're already
talking about sort of a public

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health crisis.
That's correct, because without

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health insurance, the level of
population health and access to

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care decreases.
Yeah.

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And there had been talk before
the expiration of these maybe,

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maybe these subsidies being
extended.

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What is the current legislative
outlook regarding these

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subsidies?
Without getting into the weeds,

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in January the House voted to
advance extensions for enhanced

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premium tax credits for three
years.

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The Senate has not yet voted on
this legislation, but last month

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it rejected similar legislation.
Bipartisan discussions are

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continuing, however, the future
of extending the enhanced

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premium tax credits remains very
uncertain.

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Catherine Jones is senior
analyst of Government affairs at

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ASTO.
Now let's hear from James Bell,

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the third chief of staff and
director of the Michigan

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Department of Health and Human
Services.

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James is also an alumnus of the
first class of the Developing

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Executive Leaders in Public
Health, or Delph, program.

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Death to me is an opportunity
for leaders to really come

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together.
And I say leaders, and it may

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feel premature even people might
not see themselves as leaders,

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but to be recognized nationally
as individuals who are prepared

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for taking on the mantle of very
important and critical public

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health functions as view them as
the future leaders of this work.

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And when you think about the
mission and the vision, I think

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it's to create a network of
leaders who are equipping

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themselves with the leadership
development, with the

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foundational capabilities and
all the other necessities to be

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prepared to navigate a complex
public health future.

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And you went through the
program, correct?

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I did.
I am a member of the inaugural

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cohort and I'm very proud to say
that.

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So even more excited that we're
now 6 cohorts in.

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Yeah, absolutely.
What was your experience like?

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My experience was very
affirming.

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I think for me it introduced the
fact that I am more of a leader

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than I thought I was and it also
gave me the opportunity to

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challenge myself in new ways.
It showed me that leadership is

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not just a series of skill sets
or maybe some banked words to

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use in certain situations, but
it actually gave me a posture in

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a certain way that I show up in
different rooms.

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It gave me the confidence to
speak out a lot more and that

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sometimes I may disagree and
that is OK with what may be the

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status quo or what may be the
popular convention.

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But that is actually what makes
you a leader, to be able to to

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stand behind the things that you
recommend and be prepared to do

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that and justify what the
evidence and the science that

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supports it.
You say it's given you sort of a

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new posture and a new way to
when you walk into certain

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rooms.
Can you kind of?

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Build more on that.
That's really interesting.

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Sure.
I think before Delphi, I've

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found myself to be a little bit
more introverted, at least in

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terms of the way that I show up
in meetings.

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Delft gave me the opportunity to
start thinking about my

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communication skills as a
message, but also as a vehicle

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for change.
And so how do I, as a director

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of a program, come into a space
whole and authentic and

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recognize that there's things
going on in the environment that

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are impacting me, but are also
impacting my staff?

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And so being empathetic and also
being humanistic about the ways

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that we approach public health,
Sure, we can rely on the

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numbers, we can rely on the
statistics, the evidence.

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But what are we doing in the
moment, right now as leaders,

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talking about what might be the
difficult topic?

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So is it, is it sort of
advocating for yourself and your

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team?
Is it sort of is it being

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confident in your approach and
sort of going into a situation

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with with intention?
I believe it to be all of the

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above.
When I think of my public health

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career, sometimes I can find
myself a bit distanced from the

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current situation at hand.
You you make your way through

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various ranks and you find
yourself maybe higher on the

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organizational chart.
You might not be directly

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impacting or as close to a
particular problem as when you

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first started, but I'm often
reminded that the decisions that

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I make impact individuals on a
daily basis.

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And so I'm reminded that there
are communities that are

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counting on me to come into
spaces to say the difficult

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thing.
Especially as a leader of color,

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there's certain lived
experiences that I have that I

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have to reflect on and that I
have to bring into the room

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because if I don't, there's a
potential consequence that those

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things will not be taken into
consideration when we are making

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decisions.
And unfortunately, what we tend

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to see is those outcomes then
create these disparities or

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inequities that further widen
gaps.

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Because I didn't take the
opportunity to speak up.

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And so Delph gave me the
confidence in, again, that

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posture, that backbone of like
there's certain skills or

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opportunities that I have,
especially now that I'm in the

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room that I have a seat at the
table that I have to definitely

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take advantage of.
Wow.

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And you're, it sounds to me like
you're speaking more about that

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you have to think more about
others rather than necessarily

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yourself in in those decision
making processes.

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I'm fortunate that the mentors
around me introduced me to the

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concept of servant leadership
early in my career.

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And so it was always the seed
was always planted that, you

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know, I am making way for those
behind me and those that are

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around me.
And so as a leader, I'm I'm

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typically thinking about my
teams, I'm thinking about the

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people that they're trying to
serve.

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And so how do I remove barriers
so that they can show up as

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their full and authentic self?
Are there other?

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Takeaways or skills?
Or or.

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Procedures or thought processes
that.

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Were implanted because of the
Delft program.

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Yeah, The other thing I want to
talk about is networking in that

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relationship building.
I had a very specific idea of

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what networking looked like.
It was fast-paced.

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It was you pull out your
business card, you tell people

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who you are, what you do and
what you can offer them.

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But it was never rooted in this
idea of relationship building.

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Delft introduced me to a series
of other colleagues who are now

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friends that I can call on in,
in those difficult situations as

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public health leaders that we
only we would understand because

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there's certain things that
happen in public health that you

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wouldn't believe actually
happened on a daily basis.

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And so being able to have
colleagues who are experiencing

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similar things and to be able to
come together as thought

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partners to create strategies
like, you know, how, how would

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you respond to this?
And being able to say, Hey, you

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know what, I just need to take a
break.

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You know what I do too.
And so being able to have that

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camaraderie in that networking
that is it's less pressure and

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more authentic, I think that
we're able to, one, create

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better solutions, but also is
more sustainable.

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It's not transactional in the
way that, hey, I'm going to do

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this for you, You're going to do
this for me.

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It's something that's long term.
And ideally, it's

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transformational because I know
now that I have partners that

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are in local health departments.
I have partners that are in

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philanthropy.
I have partners that are at the

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federal level.
And so we're still having these

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conversations.
We have these different vantage

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points.
It's really exciting to see like

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how we all approach it together.
Are there?

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Are there things that you want
to make sure that you impart?

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To the new cohort.
Yeah, I would say trust the

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process.
I know in the beginning it can

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feel really intimidating.
You're around other people or

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for me, I, I felt almost
insecure in the beginning, like,

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Oh my God, these people and
their credentials and the things

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they're doing, the programs that
they're leading.

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Remind yourself that you're also
in that conversation and you're

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also a part of this now
wonderful community of, of

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public health leaders.
You have a responsibility

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because you have a seat at set
table.

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But also know that this
opportunity opens the doors for

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so many others.
And so as you go about their

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Delft experience, know that
there are people who are looking

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at you within your own
institution who want to do

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something similar.
And so please be a resource to

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them.
Tell them about what Delft has

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done for you.
Tell them about the people that

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you've been connected to and the
types of conversations that

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you're having so that we
continue this wonderful program.

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Getting back to that idea of the
career of service.

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I think of it as, you know,
informal mentoring.

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I mean, you, you never know
who's paying attention to you.

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I've had some really great
conversations with staff that I

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didn't even know one worked in
the organization.

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We're large here in Michigan.
And so when someone says, oh, I

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saw this press release and I saw
that you were a part of this

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program, could you tell me more
about it?

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Could you help me with my
application?

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You know, you become just a
walking resource for others.

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And so while you're enjoying the
experience right now, know that

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there are other people who are
looking up to you who are want

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to be a part of Delft in the
future, who just want to learn

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from your experiences and make
sure that you're you're

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returning that to people.
James Bell, the third, is chief

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of staff and director of the
Michigan Department of Health

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and Human Services and an alum
of the first class of the

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Developing Executive Leaders in
Public Health, or Delft program.

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Earlier we heard from Catherine
Jones, senior analyst of

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government affairs at ASTO.
ASTO welcomes new member Renard

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Washington, acting commissioner
of health for the New Jersey

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00:14:38,160 --> 00:14:40,880
Department of Health.
Prior to this role, Doctor

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Washington served as public
health director for Mecklenburg

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County, North Carolina.
He also has experience serving

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as a health research scientist
for the US Department of Health

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00:14:49,280 --> 00:14:52,520
and Human Services Agency for
Healthcare Research and Quality

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and as an adjunct professor at
American University and Temple

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University.
Go Owls.

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High blood pressure is driving
heart disease, maternal health

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00:15:02,400 --> 00:15:05,320
risks, and long term illness,
but public health teams are

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responding with smarter, more
connected solutions.

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00:15:08,600 --> 00:15:11,840
ASTO explores how communities
are using at home blood pressure

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monitoring, team based care and
culturally responsive programs

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to improve control rates.
Plus, see how states are

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tackling hypertension during
pregnancy to protect both

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00:15:21,920 --> 00:15:25,720
mothers and babies with better
screening, home monitoring and

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postpartum follow up.
Find more the link in the show

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notes.
This.

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Has been Public Health review
Morning Edition.

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I'm John Sheehan for the
Association of State and

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Territorial Health Officials.