 Good afternoon, everyone. Welcome to our virtual event today. I'm Paula Lance. I'm the James B. Hudak Professor of Health Policy and also Associate Dean for Academic Affairs here at the Ford School of Public Policy at the University of Michigan. And it is my great honor and pleasure to be hosting a conversation today with Congresswoman Lauren Underwood. We are welcoming back to the University of Michigan. Welcome, Representative Underwood. I'm so glad to be with you, Professor Lance. It's so good to meet you. So yeah, we are so delighted you're here. I know you would like to talk about basketball as well as health policy. We're going to focus on health policy today, but feel free. We can talk about any other things on your mind as well. Let me do a little bit of an introduction, and then we can get into our conversation. And we're inviting the audience to submit questions and join us in this conversation as well. Today's event is being made possible in part through the generous support of the Gilbert S. Oman and Martha A. Darland Health Policy Fund. And it's also being co-sponsored by the Program and Practical Policy Engagement here at the Ford School, the School of Nursing, your alma mater, the School of Public Health, and the Alumni Association of the University of Michigan. So again, let me try to do a brief introduction of Representative Underwood. There's a lot to say about her. I will try to be brief, but there's so many great things everyone needs to know about you. First elected in 2018, Congresswoman Lauren Underwood represents Illinois's 14th congressional district. She is the first woman, the first person of color, and the first millennial to serve this district in Congress. She's also the youngest African-American woman to serve in the United States House of Representatives. She brings her education and experience in nursing and public health to Congress. She's a proud 2008 graduate of the University of Michigan School of Nursing, and she also earned two master's degrees in nursing and in public health with the Focus on Health Policy from Johns Hopkins University. Congresswoman Underwood has a rich professional history, including working with a Medicaid plan in Chicago and serving as a senior advisor at the U.S. Department of Health and Human Services where she worked on a number of public health and health care issues, including the implementation of the Affordable Care Act. She also has taught future nurse practitioners at Georgetown University. Currently, Congresswoman Underwood serves on the House Committee of Veterans Affairs, the House Committee on Appropriations. She co-founded and co-chairs the Black Maternal Health Caucus. She also serves on the House Democratic Steering and Policy Committee. I'm not finished. In addition, Representative Underwood is a member of the Future Forum, the Congressional Black Caucus, the LGBT Equally Caucus, and the Gun Violence Prevention Task Force. I could go on the energy, passion, and hard work that she brings to Congress and everything she does as a public service is just really inspiring and impressive. Thank you so much for taking time out of your incredibly busy life and work to be with us here today. Thank you. I'm really glad. I'm so excited to be with you. Even virtually, I could feel the energy, and my heart is just bursting with a go-blue pride. Let's chat. That's great. All right. I have some questions I'm going to ask you, but we've also gotten some audience questions in already and so I'll weave those into our conversations. I'm not sure how many more we'll have time for, but audience members, please, if you want to ask Representative Underwood a question, you can do it through the chat function, or you can also do it via Twitter using the hashtag policy talks, hashtag policy talks. Okay. So without any further ado, let's get started. And I would, for those students in the audience, and I think for a lot of other people too, I would like to start and ask you just a bit about your own career journey and what has motivated you to take the paths and the trails that you've been blazing? You've done clinical work, public health work, government executive branch work, you worked for a Medicaid plan, and now you're an elected member of Congress. Can you just tell us a bit about what has motivated and inspired you along the way? When I was in elementary school, I was diagnosed with a heart condition and it was the care that I received from my cardiologist and team that really got me interested in the career and healthcare. I decided on nursing, and when I got to Michigan, there was a class second semester freshman year at 8 a.m. on a Monday. Oh, politics and nursing and healthcare. And like, it was in the honors programs. There's probably like 10 of us, nobody else was excited about it, especially that early at that time, but I was so pumped. I loved it. And that class changed my life. It really helped me understand the connection between clinical and policy, which is something that I had always been interested in and sort of a, at the time, I would have called it an extracurricular way. I had no idea that this field called health policy existed or that I could pursue that as a career path. And so once that was identified for me, I just went forward. I ended up in undergrad and turning for Senator Obama and down at the Centers for Disease Control and Prevention while my classmates were at, you know, Mother Baby or they were texting an ICU. And I was really all in on this policy pathway. And so I was in graduate school when the Affordable Care Act was being negotiated in the Congress and a new graduate when it was signed into law. And so I knew that I wanted to be able to help implement this huge transformative change that was coming to our healthcare system and connecting millions of Americans to coverage. And so I ended up getting a job as a career federal employee actually to implement the Affordable Care Act. But I was working in the immediate office of the secretary at HHS. I had this incredible office with a view of the Capitol and a door and with my name on it. And I was in charge of healthcare policy reform related to Medicare quality and anything the Obama administration was getting sued on that was ACA related. So that was everything. And that's a big portfolio. Lobby Lobby and all the iterations of that. The Supreme Court case around, you know, the individual mandate, all of it. So I spent my 20s doing the ACA and I felt, you know, so mission driven and so excited and honored to be able to do this work. And then had an opportunity to join the Obama administration. I got a call the week that Mr. Duncan had Ebola in Dallas asking, did I want to join the president's team? And I was like, yes. So we did Ebola, we did Zika, the water crisis in Flint, and every other public health emergency and disaster over, you know, a two and a half year span. And I stayed until the last day of the Obama administration. Now during the transition after the 2016 election, the Trump team made it really clear that they wanted to take away healthcare coverage, right? They wanted to dismantle the ACA. And I knew I didn't want to be part of that. And so that's why I left government and returned to Illinois and began working for that Medicaid plan and just happened to go to a town hall that my congressman offered during and it happened to be during the time of Obamacare repeal. And I heard him make a promise about protecting coverage for people like me with preexisting conditions. You know, I'm a nurse. I worked on the ACA. So this was important to me. I believed him and then he broke his word. And that's how I decided to run. So, you know, I thought about it before that. You know, I had thought about service and public service is something that's been really important to me, not that I was going to be running for Congress at 30. Right. And so, you know, sometimes we have these ideas that come into our minds. I'm going to start a business. I'm going to write a book. I'm going to, you know, start an organization and then life happens. This is something that I just could not let go. I felt so betrayed and so upset. Like you cannot be cavalier with people's healthcare. And especially these kinds of protections and it's life and death for so many people. And so I decided to run. I beat six guys in a primary and then ultimately beat him, my congressman, in the 2018 election. And congratulations. Thanks. Might seem like a long time ago that happened. We'll talk about everything that's happened. Yes, ma'am. Since you ran and became a member of Congress. But let's, you know, let's just get into the weeds on health care policy now. So you've been working in support of the Affordable Care Act for a long time. Yes. And since you joined Congress, you introduced legislation both in the previous Congress and recently, you know, HR 369 and the current Congress as a way to strengthen the, the Affordable Care Act. And then also the American Rescue Plan Act just has a lot of things related to, and I'm sure you got your fingers in that, related to the affordable care and then just health, health care more broadly. So let's talk about, what do you want to talk about? But let, you know, let's, let's talk about, you know, your ideas for how to shore up and enhance and strengthen the Affordable Care Act. What are you excited about in the American Rescue Act plan? What else needs to be done? Yes. Okay. So in my community, I represent a rural and suburban community outside of Chicago. I live 45 minutes west of the city. And in our community, it is not uncommon for people to be paying 20 or 25% of their income on premiums, on premiums. And so one refrain that I hear over and over and over is about the high cost of health care. And it's put it out of reach. Now, many people manifest that when they talk about prescription drugs. But as you know, and so many who are watching this talk know that the first health care dollar that most families spend every month is on their premium. And so that is too expensive. It blocks out your opportunity from seeing a provider, from having a procedure, from filling your prescriptions, right? And so if we can solve this premium problem, it helps to solve the out-of-pocket cost problem that we have within our health care system that, you know, millions of families are struggling with. And so the legislation that I wrote is called the Health Care Affordable Act. And what it does is it extends premium tax credits to more people and it expands the size of the tax credits, which ends up lowering costs by hundreds or thousands of dollars per month in my community's example. But, you know, or it could be per year for millions of people. And therefore, it also reduces the number of uninsured Americans, right? Because we're expanding the eligibility for these premium tax credits. The legislation says that no American would pay more than 8.5% of their income on premiums. That's for a silver level plan on the marketplace. This is good coverage. This is not those predictable plans that folks don't want. This is, you know, comprehensive, great coverage. And so imagine being a consumer where you're used to paying a quarter of your income, you get that down to less than 10%. That's offering up, like, significant freedom in that family's budget. So as an example, in my district, a 60-year-old couple making $80,000 a year would save $1,000 a month. Wow. Legislation. And so these are real savings that people need right now. So this is all, we wrote the legislation before the pandemic. We passed it out of the house last Congress before the pandemic. Well, we passed during the pandemic. But, you know, anyways, during this most recent COVID relief package, we got a two-year version of this bill signed into law in the American Rescue Plan. And so what this also means is that if you are uninsured for any part, for any part of 2021, you don't pay any premiums. This is important for folks who, let's say you were working in January and February, your income was too high to qualify for Medicaid. Well, now you have a robust option to have health care coverage for you and your family, right? It makes a big difference. And I'm continuing to work to permanently extend this policy to lower health care costs for individuals and families. The last part that I want people to know is we're in the middle of open enrollment right now, right? There's a special enrollment period. It's open until May 15th. So this means that if you have unaffordable care or coverage, you know, and you just want to see what your options are, this 8.5 percent threshold applies for you in the marketplace. You can go on healthcare.gov and check it all out and enroll. Awesome. That's great. Congratulations on that. So what else, you do want to talk a little bit about what else is in the American Rescue Plan that you're excited about? And again, you know, what's your role? I'm one of the people who's been, you know, worried for years about how on Medicaid, postpartum women lose their coverage at six weeks. So there's that option for states to extend that. And there's other things. So what are you excited about? Okay. So since you bring up postpartum Medicaid, let's just jump in. So I co-founded and co-chair of the Black Maternal Health Caucus, which we are committed to ending our nation's maternal mortality crisis. Why is that? Because in our nation, Black women are three to four times more likely to die from a pregnancy-related complication than white women or birthing people. We should use a gender neutral term, birthing people. And so in my state of Illinois, Black birthing people are six times more likely to die, right? So this is very much a place-based disparity, but nationwide, right, it has caused the United States to leave the industrialized world and maternal mortality. And we see that across education and income groups, too. This is not... I think it's a good control for insurance standards, whether or not you've got prenatal care, right, the disparity persists. You could be Beyonce, you could be Serena Williams, you could be Alice Felix, the great track star, right? Or you could be the girl in the hood around the corner, right? Like it impacts all of us. And I use this word, us, very intentionally. And so, you know, and it's a disparity that's been around my entire lifetime. I'm 34 years old. We've not seen any national initiatives to solve this problem. Those surgeon generals report like nothing. And so when I got to Congress, I knew we wanted to work on it. The single most important intervention, policy-wise, that you could pass to save mom's lives in this country is extending Medicaid coverage. So under statute for those states that did not expand Medicaid under the ACA, coverage cuts off 60 days postpartum. So if you look at the map at the states that didn't expand Medicaid, it's a lot of the south. And then if you look at the map around maternal mortality and these disparities, what do you see? A lot of the south are leading in very, very, very high death rates. And so what we did in the American Rescue Plan led by Congresswoman Robin Kelly is that we have an option to expand postpartum Medicaid coverage from 60 days to one full year. Now, this is really important for two reasons. One, Medicaid pays for 66% of all deliveries to African-American birthing people in this country. Huge payer. But then secondly, secondly, Medicaid also is just like, it's a state-based program, right? So it gives you flexibilities to do this work, but they need an incentive. The politics around Medicaid expansion have really changed in the last 10 years since we've had the Affordable Care Act, so much so that this policy passes a standalone bill out of the house unanimously, unanimously. So that means even the most conservative Freedom Caucus member was supportive of this idea of saving mom's lives. And so that's why I think it's really important and powerful that in a pandemic where we've seen COVID-19 exacerbate, exacerbate existing maternal health disparities, that we can take this action to expand coverage, particularly given that in those, the extended postpartum period we're seeing between a quarter and a third of maternal death. So it's not just in the labor and delivery and immediate postpartum period. We're seeing some a year out. Right. Great. Well, congratulations on that too. That's very exciting. What else in the American Rescue Plan do you think people should know about as it relates to healthcare policies? So there's a lot of talk about vaccines and the hundreds of millions of dollars coming to every state and community, which is I think very, very, very important. Our economy is not going to improve until we can crush this virus. The vaccine is critical to that effort. And I hope that wherever people are, they're starting to see more vaccine become available to them. And I hope that you're making a plan to get vaccinated as soon as that vaccine appointment is available to you because vaccines are safe and they work. I'm getting my second shot next week. Excellent. There's also a lot of resources to support state and local health departments. This is so important. A lot of people pre-COVID had no idea if they had a health department or what that health department does. One of the biggest advances during this pandemic, I think, is the public's understanding of what public health is. I mean, when you're a health department director is on the news every day and you know that person's name, the appreciation for having that backstop in each of our communities is huge. I represent a community, again, like an hour outside of Chicago that doesn't have a hospital. They are lacking behind in many health care resources locally, but they have a health department. The folks in that community now know who their health department director is. This is an opportunity to engage and lift up what I consider critical infrastructure in our health care system. These local health departments and rural communities and underserved communities, and they're getting a lot of resources and support in the rescue plan. Last thing I want to touch on is COBRA. In the American Rescue Plan, we are covering COBRA 100 percent for folks who have lost their jobs. What we are doing is saying that in a pandemic, we do not want Americans to be uninsured. We are taking many different creative approaches to ensure that Americans can get connected to coverage. I think that this is so important. We talk a lot about, especially in the health care circles, universal coverage, single payer, Medicare for all. Save the ACA. What do you want to do? I think that this is an affirmative statement on the coverage piece that says everyone should have it. Let's break down the barriers that would prevent you from getting the care that you might need. Great. Thank you for all that. I know there's more to talk about with the American Rescue Act related to health and health care. Let's talk more about the Affordable Care Act. Looking forward, what do you think also needs to be done legislatively to enhance it, strengthen it? What's on your list? What are you working on? What we're trying to make this premium tax credit legislation permanent? More than two years. Yes. That is on my list. I'm working with a colleague, Angie Craig from Minnesota. She has a piece to fix the risk adjustment programs, right? Reinsurance and make sure that we have a robust marketplace underpinning the ACA, which is something that normal people don't, and when I say normal, I mean like my constituents don't ask about, but it's important to having a functional system, and I think that that will be included. We are talking about opportunities to finish our work to lower prescription drug prices, to allow Medicare to negotiate prescription drug prices on behalf of all Americans and passing the lower drug costs now act. I think that that'll be part of the conversation. And then I think that a public option is long overdue. A public option is something that in my purple swing district, people are like, yeah, it is not controversial. It is not an applause line. It is not a cause for debate or navel gazing or contemplation. People are like, yes, next. And I think, and this is across the ideological spectrum. It's not perceived of as socialism. No. People are like, yes, we need to have options. Yes, it needs to be cheaper. Will it help my family save money? Yes, let's move on. And so had COVID not happened in 2020, we would have passed a public option out of the house. I am very confident of that. And so when you listen to the senators, they are, I think, much more hesitant to be as forthcoming and definitive as I am about this right now. But I think that at least from everything that I've heard throughout the community, I mean, people are ready. And they're like, it is not even a hard choice. Yeah. So that I'm going to turn to an audience question now, because it's related. And it's actually an audience question from Dr. Gil Oman and Martha Darling, who are have funded our series of policy talks on health policy at the Ford School. So thank you so much for your generosity. Yes. We're so appreciative of them. So they do want to know if you think there will be sufficient support in the Senate for enhancements to the Affordable Care Act. And they also want to know what strategies are being used by members of the House. And they want to know in particular, are you working with the Michigan class of 2018 delegation on some of this work? Yes. Okay. So I think that the Senate is just a tough nut to crack for a couple reasons. One, they haven't been legislating for a long time, right? And in the previous leadership iteration, their focus was moving judicial nominations. It was not having hearings. It was not writing legislation. And so so much of the recent legislative work has been happening on our side of the Capitol, on the House side. And so I feel like a lot of them are just getting their feet wet and getting their bearings once again around not only what's being proposed, but also where the community is on these policies. And so a lot of the hedging and the, I think the timidness that we're seeing from at least the Democratic senators is cautioned because maybe their orientation is grounded in several years back. And I'm not trying to be shady. I'm just trying to be real and say, if you feel strongly about these issues, call your senators and let them know because they have not been doing this the same way we have been in the House. But I hope that on these healthcare issues, particularly in the pandemic, particularly with the level of inequity that we have seen on display, that it is so clear that we need to take decisive bold action right now. And that folks are willing to not only take the hard votes, but also spend the money that will be necessary to correct these changes. Now, with respect to my friends in the Michigan delegation, I work very closely with them on appropriations. We have Brenda Lawrence, who serves on the Labor HHS subcommittee on appropriations, which is like the primo spot of his work. But then also, I have my freshman, we're not freshmen anymore, my classmates, Alyssa Slotkin and Haley Stevens, who have just been real joys to work with. Alyssa and I actually sat next to each other on our Homeland Security Committee in the last Congress. And I found a way to do healthcare work on Homeland, and she was a great partner of mine. And so I really enjoyed our work together. Now, Alyssa is on Veterans Affairs, so I think we're going to get in some good trouble together once again. Excellent. That's great. Thanks. So I have another audience question relating to the Affordable Care Act. And this viewer wants to know what you think of the ACA's provisions regarding nonprofit hospitals and community benefit. Do you think that these provisions need to be strengthened? There is a perception that a lot of hospitals are taking advantage of what they claim as community benefit to maintain that nonprofit's status. So again, what are your thoughts about the community benefit? Yeah, there's always some bad actors and some folks that make it difficult to continue to support the tax structure that we have in place. I'll say it like that. However, we are in an environment where there is such extreme consolidation within our healthcare system. We have a lot of folks coming in, not necessarily in the hospital space, but in the ambulatory space with the influx of private equity. And our healthcare system is shifting right underneath our feet. And my fear is that it will just continue to hurt underserved communities. And so often it is, well, our academic healthcare systems, but also those like quite frankly struggling hospitals that are serving are most vulnerable. And I do not want to take action at trying to solve one problem and then completely, completely eliminating the opportunities for healthcare for our rural and underserved communities. I mean, it is so hard to solve this problem. And I'm not going to say that the student's question isn't valid. It completely is. But right now, we are in a very, I would consider, fragile place. When you look at the ballot sheets and just how these institutions are actually doing in some of these communities, I mean, they need help. And so I think that we are in a political place of wanting to help those institutions versus having some real tough accountability on the bad actors. Great. Thanks for that take on that important question. All right. Let's talk about Medicare for all. Okay. So you're on record as not supporting Medicare for all bills, but that's, I mean, people use that phrase to talk about lots of different things, including I think sometimes a public option. So anyway, what kind of discussions are you having with your colleagues and constituents who are staunch supporters of some kind of Medicare for all approach? And what are your thoughts? So fundamentally, these are conversations that are based on a basic conviction that we are the wealthiest nation in the world. And we need to have access to quality healthcare and that it shouldn't be a privilege of just a few. It should be the right of everybody. And, you know, the idea of healthcare as a human right has been foundational to my nursing practice, right? I learned that on North Engels at the School of Nursing, right? That was like baked in. And so I think that there's a lot of people who frame this conversation in terms of a binary approach, right? Medicare for all or the ACA. To me, that is a completely false choice. Ultimately, I think we need to be enacting policies like my bill that we discussed in the near term to ensure that everybody in every county in this country has affordable options, right? And we need to make sure that every in every state that has to date refused to expand Medicaid finally does it. And we need to advance other policies that will fill in these coverage gaps. And for me, I am working so urgently to solve that problem. And that's to fill the goal of universal coverage. But I also want to make sure that we remember that, you know, coverage alone does not guarantee access to high quality care, right? Those are two very different things. And that is that is so important as I do my work around ending disparities. I told you about this county that I represent Kendall County that doesn't have a hospital, right? And so we need to be taking these actions to make sure that people actually have, right? Places to go, providers to see. And so this means making robust investments in our health care workforce, including mental and behavioral health, right? We absolutely introduce legislation to expand our nursing workforce, which is projected to have significant workforce shortages in the upcoming decade. And I think that we have to center equity in all of these efforts, right? So as we advance policies to crush the coronavirus and then enact longer term reforms, we need to be thinking about clinical factors, but also non clinical factors that are a case social determinants of health that cause people of color in particular to suffer, you know, disproportionately from adverse health outcomes. So we're talking maternal mortality, but also chronic conditions, we're talking about COVID, we're talking about the whole tent of adverse health outcomes. And we need to be really intentional to, you know, take action to eliminate these disparities. And so that's the work that I'm doing. And I think that, you know, who pays for it is an important piece of the conversation. But just solving or consolidating the payer does not, does not, does not solve our access to care problem and our quality of care problem. And so, you know, I'm doing that work. Great. Thank you. So I did, you were just mentioning nursing and some of the issues. So let's, let's talk about what are the, you know, what do you see as the major issues and priority policy discussions in regard to nursing at the moment? There's, there's workforce issues, as you mentioned, there's scope of practice and debates and turf wars, policy issues regarding telehealth, you know, that, you know, as we hopefully are getting our way out of the pandemic. So from your perspective, what are the, what are the key policy issues? Yep. So even before the pandemic, right, our country faced a large and growing shortage of nurses, we have this aging population that's going to need higher levels of care, as well as, you know, increasing chronic conditions across the lifespan and nurses at all preparation levels, right? BSN advanced practice nurses will be needed in greater numbers than ever for many more years to come. And so layered on top of these trends are then the workforce strains that we've seen related to the pandemic, right, which has really pushed our healthcare systems and pushed the workforce to their limits. Broadly, nurses should be able to practice to the full extent of their education and training. And my work in Congress is firmly rooted in that framework. And so earlier this year, I reintroduced my bicameral future advancement of academic nursing act, which would make a historic $1 billion investment in schools of nursing to recruit and retain nursing students and faculty to strengthen nursing education today and ensure a robust workforce, right, that pipeline for the future. But then we also have legislation to grow and diversify the perinatal workforce. We have, you know, I'm trying to increase funding for the title eight nursing workforce development programs, which is the primary way that the federal government invests in nursing education, right? Medical education has GME and, you know, this intersection with Medicare, but nursing is a much smaller program. And the resources have been much more limited. And so that's been a big priority of mine as a new member of the appropriations committee. Now, you mentioned telehealth. I'll just say this. I am not the biggest telehealth advocate. I find that my colleagues sometimes would rather invest in telehealth than invest in improving the workforce. And, you know, telehealth is not this band aid that will solve all of our problems. And it's not even an evidence based tool for every problem that we're trying to solve, right? And so let's make sure that we are being rooted in the data, right? Data driven, evidence based policymaking, as we're making our investments. And so, you know, not to ran on anybody's parade here, but let's keep this in context. Great. Thanks. Thanks for that. I have a question from the audience related to nursing. And this person put in the chat proud as a nurse that a nurse is leading healthcare policy. How can nursing students mobilize to provide support and policy reform efforts? Yes. So this has been like a real change that I've seen over the last, well, since I've been a nurse, is this open conversation around how nurses can be change agents in the policy space, right? So often when you talk to nurses, you'll hear, oh, that's above my pay grade, or my husband makes those decisions for our family. And like, we cannot afford to sit out. There is this natural tension, I think, between someone's personal political leanings, and then which individual policymaker or candidate or which party even is pursuing an agenda that advances your profession, right? So who's working to advance nursing workforce issues, but then also who's helping patients in a values alignment with where our profession is as nurses? And so sometimes people are like unsure because they identify as conservative Republicans, and yet they can't find a conservative Republican to support. And that's hard. And I think that it's okay to be an advocate as a nurse and be willing to talk to everybody in order to advance your policy goals. That does not mean that you have to become a Democrat. It doesn't mean that you have to abandon your principles if you are not aligned with one political party in order to participate in our political process. And I think that that conversation is increasingly being taught in schools of nursing. The idea of the need for advocacy and engagement is being taught as part of our professional responsibility, which I think is very positive. And I would just invite people to get involved locally. Every community has a health department. We already covered that. Well, guess what? Every community has a supervising party over that health department. We all, as nurses, as engaged healthcare professionals, should be sitting on that oversight body. So whether that means running for county board or getting an appointment to your board of health, we have an expertise that it is our responsibility to offer to our community. Doesn't mean you have to quit your job and run for Congress for a year, right? It means just being available for some meetings in the evening and making sure that that, you know, critical infrastructure in your community is sound and robust. And that's where I encourage people to start. That's great. I'll say I'm not a nurse, but one thing I've done is join the boards of community health centers in D.C. when I live there now on the board of, probably on the board of Packard Health here. And I think, and we have some nurses on the board and that perspective is really important. And it's also a great way to learn more about health policy. You can't sit on the board of a nonprofit related to health and not better understand and be working on health policy. All right. Well, that's, I want to shift a little and talk about those social determinants of health. You know, as you, as you well know, health and health care are not the same thing. And so health and health care policy are not, not the same thing. I'm actually teaching a course this semester that's on social policy approaches to health inequities in the United States. And in this course, no, I'd love to have you come and go teach it. But we're talking about education and income security and housing affordability and neighborhood investment and food security and structural racism and all the upstream, all the way upstream things that, that matter for health. What do you think that local state and federal government should be doing regarding the social determinants of health? How can we, you know, move the needle more and move away from this, you know, conflation of health and health care with the thought like every, every health problem we have in the US has only a health care solution. I mean, that's important. Obviously, health care is important. But how, again, how can we focus more policy attention to the social determinants of health? Such a great question. So the Robert Wood Johnson Foundation has found that social determinants can drive as much as 80% of health outcomes. And I've been really focused on addressing these social determinants through my work on maternal mortality. So we introduced a bill, it's called the Black Maternal Health Mommy Bus Act introduced in 2020 with then Senator Kamala Harris. But now we're with Senator Cory Booker, who's been a fabulous partner. And we have over 120 House and Senate co sponsors, which is incredible. This is a suite of legislation. The Mommy Bus is a package of 12 bills to comprehensively address every driver of our maternal mortality and the health disparities that we see in maternal health in this country. Now, one of the bills in the Mommy Bus is literally called the Social Determinants of Moms Act. And so it includes funding for safe quality housing for pregnant people. It extends the WIC eligibility periods, ensuring that new moms can have access to nutritious foods for themselves and their infants. And it addresses other social determinants like transportation and childcare. Right. And so as we've been engaging the stakeholder community, we've actually been approached by companies like Uber and Lyft who want to be involved and who want to help solve this problem. Right. And so I think that this is something that as we talk about, you know, solutions that make sense to communities, solutions that industry supports. This is something that has that kind of broad cross the board. Another one of the bills in the Mommy Bus is the Protecting Moms and Babies Against Climate Change Act that I introduced with Ed Markey from Massachusetts. So last summer, JAMA put out this article, saying that air pollution and extreme heat are driving adverse pregnancy outcomes and that the risks were disproportionately high for birthing people of color, particularly for black moms. And so we introduced this legislation, the Protecting Moms and Babies Against Climate Change Act, to address these environmental risks through investing in community-based organizations and local initiatives to reduce exposure to climate change related risks and ensure people, you know, the birthing people and their babies have the support and social services that they need. So that means everything from like, if you need an air conditioner, we'll get you an air conditioner, right, to making sure that like the community health workers and the doulas have the support and the recognition within the healthcare system to flag, right, if every, if they're seeing certain trends that maybe are not popping yet at the healthcare system level. And so I think that we have to always be remembering these clinical and the non-clinical drivers of outcomes. Now let's talk a little bit about state and local. State and local elected officials are really well positioned to advance these innovative solutions to address social determinants of health because they have the flexibility to do it in a really place-based way, right. And Congress sometimes will talk about things called demonstration projects, right, so just like show that it works. Well, the state and local elected officials have the opportunity to just do that the first time, right, because they can see a problem, they can try to solve it and, you know, ideate to evaluate in such a shorter time period because they're right there. And we've seen so many exciting ideas through our work with the Black Maternal Health Caucus and, you know, the Ohio legislature where they have incredible leaders advancing solutions. The New Jersey, the first lady of the state of New Jersey, is such an advocate and such a champion that she's really been driving change in her state. And then here in Illinois, we have great partners in the Black Legislative Caucus, right. So there's opportunities for folks to jump in and be impactful without waiting for Congress to act. So let's go. Okay, let's do it. Yeah, that's great. I'm really, I didn't know about the Mommy bus suite of bills. I'm really excited about that. It is so exciting. That is amazing. That is great. So follow up question from a student on this topic. So Medicaid is a complex program with lots of rules. However, there's a lot of flexibility within Medicaid, including through waivers and other sorts of structures. What do you see as the strengths, but also the challenges within Medicaid to better address the social determinants of health and help move towards a health equity? Yeah. So we've seen some states, you know, have really innovative leadership through their waivers to try to address issues like substance use disorders and maternal health. You know, my state has applied for Medicaid waiver to extend that postpartum Medicaid coverage from the one year. And the pregnancy pathway for Medicaid eligibility, it does expire after that 60 days, right? So this is why we're embracing that. And so we've seen more and more states take that on, which I think is good. And there's a robust, you know, evidence in the biomedical literature to support this type of an innovate in an intervention. But the previous administration, the Trump administration never approved Illinois waiver. So we've been working with the other members of the Illinois delegation to ensure the Biden administration, right, gets on it and swiftly approves these waivers. And we're not the only state that's sort of been waiting in limbo. And so I think that, you know, that's one of the downside of these flexibilities is that, you know, it requires both action at the state level and at the executive branch level. And if there's any kind of disruption, everything gets put on hold. The other thing is that, you know, we've seen in these Southern Republican-led states that rejected the Medicaid expansion, you know, they are continuously dug in. And we've seen, right, like over the last 10 years, there's been so many articles showing the consequences being deaths, right? Excess deaths, because states will not expand Medicaid. We're talking about 15,000 deaths in one study. So, you know, the American Rescue Plan did have provisions to incentivize states, these holdout states to expand Medicaid. And, you know, I'm hopeful that these states will take up both that larger Medicaid expansion incentive and our postpartum Medicaid expansion in order to do this. But, you know, I think that they need to embrace this new political reality around Medicaid as well, like we've seen in Congress, which is this is a winner. It's a political winner. It's a financial winner for states. I mean, this is real money that helps states with their tight budgets. And then also, by the way, saves lives. By the way. Yeah. Hello. This is what we are for. I am. I'm all about it. Great. All right. I'm going to read a question from the from the audience. Okay. I am a contract gig economy worker, and I never know how much my annual income will be or when in the year I will be paid leaving me to guess on the amount I submit on my ACA marketplace application. This has caused great stress. I worry every month that I will be denied continued health insurance coverage. Yeah. So we know that there are so many people who are in a similar situation. And that's really why we move forward with the Healthcare Affordability Act, because under the Affordable Care Act as written, there was what we call a subsidy cliff. And if you worked an extra overtime shift or had that differential usually worked days, but you picked up one extra night shift or a weekend shift and pushed your salary above that cliff, you lose the access to your tax credit. This new framework as being tied to a percentage of your income should help. It should help that contract or gig worker be able to maintain their coverage, estimate their costs, have more confidence in knowing that that tax credit would be with them, and not just rely on reconciling it when they file their tax return the following year, right? We know that this advanced premium tax credit, which allows someone to pay a lower monthly premium is the key to folks being able to afford their health care. And we want to make sure that the system is working well, no matter how you work, right? This is the one flexible option, the marketplace. And let's just be real, right? Gig work wasn't as popular in 2009 when the ACA was written, then 2010 when it passed, right? These are the kinds of updates that are necessary to make sure that we have a program that continues to work for everybody. And that's why it's so important to make sure that it's permanent. Great. All right, another audience question. You have mentioned costs, drug costs and other medical expenses. Does price transparency actually work to reduce those costs? There was a Wall Street Journal article today that showed that hospitals are hiding price data from search results. Yeah, I think that it's part of the solution. I don't think that it solves the problem on its own. And I think that we need to have an approach that has accountability, not just public shaming or consumer, counting on consumers to be savvy enough to discover what that price is and then make an informed decision, right? Like that is, it's fine. I'm not going to say, you know, I'm not going to just dismiss it, but I think that true accountability will not rely on just transparency. Thank you. All right. So you were elected in 2018 and that just seems like worlds ago, right? So it is worlds ago, the world as we know it. So I'm sure you're relatively short time in Congress has felt like years and years, but you've been serving through an incredible time in American history and world history. So can you talk a little bit about what have been some of your greatest challenges, the greatest surprises that you face, just really, you know, what's bringing you joy and satisfaction? Okay. So running for office is hard. Serving in Congress is hard, but it's also really fun. It's all consuming. I've been surprised by many, many, many things. This is not, you know, first of all, I'm millennial. I've been on, I've had an email address forever, right? Like we do not like hand write letters and deliver them to people as forms of normal correspondence, but in California, that's how you get things done, right? There's so much paper. I had to learn how to file. Instead of a file cabinet and a filing system, there's so much paper, right? It's just like so, I didn't have the email address of my chairman and we've been working remotely during COVID and it's still you're working through staff and a clerk and you know, like whatever, it's just, you know, there's so many inefficiencies. That's been a surprise. I think that the hardest part for me on both the campaign side and the congressional side is just been finding staff and recruiting talent and retaining people. And I don't mean because I'm just like so tough and demanding, but it's, it's a hard job as a member, but it's also a hard job as a staffer. And that's been, that's been a challenge. And so if you are a smart go-getter and you like politics, there are opportunities on Capitol Hill, trust me, we are all looking for great minds to bring onto our teams. And then the last thing I'll say is the work that brings me joy is are the things that one, my community understands. It's not so obscure and it's not, you know, these like lofty DC bubble conversations is when you can like sit down and have a solutions-oriented conversation with a mom or a senior. And to talk about the things that will improve their lives or save their life. And I think that so many of my colleagues, unfortunately, are obsessed with power, obtaining power, maintaining power, exerting power, you know, displaying power. Right. Look at me. I'm so important. And throughout my career, I have been really motivated by what can we do to protect and improve the health and well-being of the American people, period. And I think that there's a really incredible opportunity to do that from the Congress. But that type of a solutions-oriented mindset is not the way that Congress really works. And so it's been difficult to, you know, learn how to navigate. No doubt. But that's a nice segue into another question I had, which is about leadership. So, you know, University of Michigan leaders and best, it's part of the part of the mantra here. And then at the Ford School, we launched a leadership initiative a few years ago, where we just really simply define leadership as having a positive impact on others, organizations, and communities. It's not about power. It's not about control. It's not about hierarchy. It's just it's really about impact and influence. What do you think are the most important leadership skills for people who are wanting to go into public service? Just, you know, sort of sort of writ large. What do you, what's your advice to all the students listening in right now who are really, really interested in careers in public service and health policy or any other sort of aspect of that? Yes, I love this question. So, when I was an undergrad and graduate student, you know, I was just so anxious about my career and the anxiety came from, you know, am I going to be able to get a job? Am I going to be able to get this title? Am I going to be able to do, you know, certain things and have this impact that I wanted? And I was sort of chasing that instead of just doing the work. And I think about leadership so often in terms of just, you know, find work that you care about and you're passionate about doing and the recognition will come. The acknowledgement will come. The titles will come. The pay will come. And I'm not saying work for free because we cannot all do that. But I think that sometimes we lose sight of the opportunity to really make significant change because, you know, the job description doesn't come in at a certain level, right? Or a certain pay band or whatever. And I'm not saying don't provide for yourself and your family, but especially early in your career, really spend time and focus on, you know, what kind of impact you want to have or the work that you want to do. And then make some of that other stuff secondary. And I think that you'll be well served. And I only say that because when I was 21 and 22, if I had known that I would be running for Congress and then winning an election 10 years later, a lot of that anxiety would have gone away. And, you know, and I'm not the only one that I know from Michigan, from my class, 2008 School of Nursing, that would probably say the same thing. And so I think, you know, we can dream and step forward and take risks and have tremendous impact and change the world. And we should just do it fearlessly. That's awesome. That's great. And you mentioned earlier, you said you were you were making good trouble. So great. So do you want to talk about that a little bit more? What are the leadership skills needed to make, you know, good, good trouble? That's John Lewis said. Yes. Well, you know, to have the opportunity to learn from and work with him has just been, you know, incredible throughout my time in Congress. And we miss him so much. So, you know, I think of good trouble as being willing to take that hard vote to do something that might not be politically popular in the moment, but it's very much the right thing to do to have a vision. Let's use healthcare as an example for healthcare in this country where we're not losing moms just because they're black. And just because we have bias and racism in our healthcare system, but to be willing to call it out and be playing and to say no more, right? And to me, you know, sometimes it takes the youngest black woman joining Congress to do that work, right? But then if you're here, you have to be willing to take it there. You have to be willing to call out the problem and offer a solution and do the work of building support, right? Talking with colleagues and creating a safe space for people to come in and say, you know, I don't know that much about this. Teach me. I want to learn. You have to do the work of building the coalition. That's what I say about like good trouble. It's not just about, you know, taking a stand or it's not just about being an activist, but if you're going to do something that's risky or unpopular, right, you have to be willing to have the range of consequences that come with it and see it through, right? John Lewis spent his whole lifetime, his whole lifetime fighting for the cause of voting rights and equality in this country. And he did it as an activist. He did it in the church, right? He did it in the Congress. He did it leading organizations. And he did it until he died. Now he's a hero. He's a giant. And I don't know that any of us are going to have that same kind of impact, but maybe we will. And my only point is sometimes it takes that amount of time, but it doesn't mean that it's not worthwhile. We just have to do it. Well, and let me just say you are off to an amazing start in that amazing mold. And, you know, we're so grateful for the work that you've been doing and also for taking the time to be with us today. We have one minute left. Is anything you want to say in wrapping up? The University of Michigan has such a rich legacy of activism, of engagement, and that has been so critical to my ability to step forward and lead and dream and run and win and serve. And I am just so delighted. You know, I did an internship program, the public service internship program. I think that that's still going on. I would direct students there and welcome you to join us in Washington at any time. Our country needs your voice. Our country needs your leadership. And I hope that, you know, you will all step forward and serve even in ways that make you uncomfortable because we have so much to offer. Thank you for having me. Congresswoman, thank you so much for being with us today. Thank you. It's been a pleasure.