Ngozi Ezike, MD (Host): Hello, everyone, I'm Dr. Ngozi Ezike, and thank you for tuning in to another episode of More Than Medicine. Today, we have the great pleasure of talking about addressing equity as a healthcare priority with Congresswoman Lauren Underwood. She serves Illinois' 14th Congressional District. She is a registered nurse and also the co-founder and co-chair of the Black Maternal Health Caucus, which addresses America's Black maternal health crisis in Congress and advances policy solutions to improve maternal health outcomes.

Prior to her election to Congress in 2018, she worked at the US Department of Health and Human Services. I am so excited to have you join us today. Welcome, welcome, welcome.

Lauren Underwood, Congresswoman: Thank you so much. It's good to see you.

Host: So as I normally like to kick it off, I think everybody knows who you are, but can you just spend a minute or two telling us about yourself and how you've progressed along your journey, this incredible career that you have?

Lauren Underwood, Congresswoman: Sure. I'm a registered nurse and grew up in Naperville. I spent my career working to implement the Affordable Care Act at the federal level and then joined the Obama administration working on public health emergencies and disasters. I didn't want to help the Trump team take away healthcare coverage from people. So, I came back home and I was working for a Medicaid-managed care plan in Chicago, ultimately decided to run for Congress after the Republican majority was working to repeal the Affordable Care Act, and my congressman was not honest about his intentions to support that initiative. And so, I decided to run. I ultimately flipped a seat in the far western suburbs as you head into the rural areas, and I have served my community since January of 2019.

Host: That's amazing. And of course, you did not mention, the humble woman that you are, that you were the first woman, the first person of color, the first millennial to represent this community in Congress. So, thank you for being such an amazing trailblazer.

Lauren Underwood, Congresswoman: Yes, ma'am. I'm also the youngest black woman ever elected to the Congress.

Host: So, as you look at the passion that you have for really certain key areas around equity and narrowing disparities, really thinking about the outcome of this past election, how will that impact your work that you've pledged your life and your career to?

Lauren Underwood, Congresswoman: Well, you know, this past election was so important. We heard as a candidate, Donald Trump reopened the conversation around repealing the Affordable Care Act with his vague concepts of a plan. And that had me on high alert, because we know that those kind of idle threats are not insignificant. He means what he says. And for those of us who have preexisting conditions, people like me, you know, maybe you have asthma or diabetes. I have a heart condition. We need to be able to have access to affordable healthcare coverage. The tax credits that I expanded and wrote in legislation to expand and make more generous that President Biden signed into law in 2021 has facilitated the lowest number of uninsured Americans in history. And all of that progress would be erased if the Affordable Care Act were to be repealed, if these tax credits were to be repealed. And, you know, ultimately what this means is that more people will die.

So, the ACA and the programs they're in are more popular than they've ever been. They're helping more Americans than ever, and this kind of a policy proposal is deeply unpopular. And yet, we know that as President Donald Trump would make good on that promise. And so, it's up to all of us to protect our care, all of us to stand up and say not on our watch and, through our advocacy efforts, to make sure that we are able to preserve these life-saving policy changes that were first enacted in 2010.

Host: Thank you so much. And thank you for all the work you did first with HHS and now as a congresswoman. And so, you have really prioritized health equity and access in your legislative career. Can you talk about some specific initiatives that you have stood up or that you have worked really hard to support and what are some of the outcomes of that work?

Lauren Underwood, Congresswoman: Okay. So, let's talk about these tax credits. So, before the legislation that I wrote, people were getting really cut off of their financial assistance when they would visit healthcare.gov or Get Covered Illinois, and they would sign up, they would put in some basic information about their salary history, and that would determine whether or not they were eligible for tax credits to help make that premium truly affordable.

And so for a lot of families, if they worked an extra overtime shift or worked weekends instead of days, you know, they would get bumped out of eligibility for that tax credit because it was tied to a specific dollar amount. What we did is we changed the eligibility for those tax credits to be a percentage of your income. So now, no American would pay more than 8.5% of their income for Silver Level Marketplace Plans. In effect, it made those tax credits more generous and available to more Americans. And now, four out of five people can get a plan for $10 or less a month. I mention it, because we are in the middle of open enrollment right now.

And so if you are looking for an affordable healthcare option, and you might be someone who gets healthcare coverage through your employer, but maybe it's just a little bit too expensive, or maybe all of your medications aren't covered, it's worth just checking out healthcare.gov to see what type of plan you can get and the type of tax credit you would be eligible for. So, that's one example. And when I say that we have the lowest number of uninsured Americans in history, that includes people of all racial and ethnic backgrounds. That includes making major coverage in roads and rural communities like I represent in Northern Illinois. And I think it's, you know, really important because everybody needs to be able to see a provider, fill a prescription, or get a procedure when they need one. And for too many Americans, we've gone without for a very long time. So when we talk about efforts and successes in terms of lowering costs, this is really important topic.

In the Congress, I also co-founded and co-chaired the Black Maternal Health Caucus, which is committed to ending our nation's maternal health crisis. We see that black women in particular are more likely to die of pregnancy-related complications than their white counterparts. And 80% of the deaths in this country are preventable. You know, it's really important that we take action because when we do this, we are able to improve maternal healthcare for all moms in every ZIP code, right? So, these solutions are not just going to help black moms or just going to help moms in certain communities. No, no, no. It helps improve the quality of care for everybody.

So, I wrote a bill called the Momnibus. It combines a legislative word, omnibus, with the word mom, and it's a big bill for moms designed to address every clinical and non-clinical factor contributing to our nation's maternal health crisis. One of our bills has been signed into law to help veteran moms, and we're working to get the rest across the finish line right now.

Host: That's incredible work. You know, as the former director of public health, we had a lot of work in that space. We had sessions with this incredible team to be able to look and examine and research every death that happened to a woman within one year of pregnancy. And so, we had the reports that showed what some of these causes were, how so many of them were preventable, and we also saw that so many of them didn't happen in that immediate postpartum period, and that it actually happened outside of the six weeks. And so, therefore, going back to your earlier point about how important access is, that's why it was so important to have Medicaid extend for people who are pregnant well beyond the six weeks and last a year.

And so, really excited to be able to follow up with the incredible work that you've done. Sinai also has a social services arm. And so, we are part of that work to help sign people up for the Affordable Care Act. And so, we understand how important access is, how important access to insurance is. And so, again, we're just happy to support the incredible work that you've been doing.

Lauren Underwood, Congresswoman: If I can just add on postpartum Medicaid, postpartum Medicaid is not in the Momnibus. It is a priority that we certainly support. And with the vice president's leadership, Kamala Harris, Illinois obviously led the way in extending postpartum Medicaid coverage to a full year, but now we're up to 46 states plus the District of Columbia. So, rapid progress has been made. We want to get all 50 states included in this important policy, and I believe it should be mandatory. And so, I'm supporting that legislation in the Congress, but I do just want to note it's something that we're working towards, right? Some of our neighboring states, in fact, have not made this policy shift, and we're hoping that they do so as quickly as possible.

Host: Yeah. And like you said, when you do these improvements in health, even though there might be one group that's disproportionately affected, when you raise the level, it benefits all. And so, this is a great thing. So in general, what do you think is government's role in addressing the healthcare disparities that are so, so clear? How can government really be effective in this and maybe what are the barriers to us being able to do more?

Lauren Underwood, Congresswoman: Well, I think at the federal level, we have a really important It's an important responsibility around data collection and transparency to make sure that not only scientists and researchers and clinicians are aware of trends, but that the American people understand what's going on in terms of the health of our communities, the health of our neighbors and our population. So, timely data collection, accurate data collection, making sure that that data is available and accessible to the American people is essential. We have some work to do there.

I think it's our responsibility to set really ambitious goals. So when it comes to disparities in particular, we need to have really specific goals around reducing the differences or ending those disparities, but also improving overall health and well being, right? So, for example, on maternal mortality, if we said we wanted to end the disparity seen by Black and mostly Native American moms, well, that would basically improve the overall maternal health picture in this country, right? Because that's just as an example, right? So, really focused goal setting, I think, is important. Offering financial resources is essential. So, funding the evidence-based programs that we know work to improve health and well-being, to improve public health. It's very important. We can't rely on philanthropy to do this public health mission, this essential public health mission in this country.

I think that there's a lot of states who believe that through the generosity of the wealthiest Americans and corporations, we'll be able to find a cure to cancer, we'll be able to tackle the next pandemic, or we'll be able to do all these different things. And I think the generosity of some of these really wealthy Americans and institutions, they certainly play an important role, but it does not replace the role of federal funding.

And then, finally, I think, we have a really important role around accountability and oversight. So, we know that there are environmental contaminants. We know that there are disasters. We know that there are just different carcinogens and exposures that people have that lead to poor health outcomes. And it is up to federal regulators to protect the American people. And while we certainly see in this political environment that the incoming administration is less interested in that particular function, it doesn't make it less important. And so, that is an area that I'll be watching closely.

Host: So, you definitely talked about the public health needs and what federal government's role is. Bring it down to the level of the healthcare institutions. I know you've been, you know, involved and connected with a lot of healthcare institutions over the years. Sinai is the largest private safety net system in Illinois. How do you see Sinai as a critical part of the work that needs to be done?

Lauren Underwood, Congresswoman: The exciting thing about the work that Sinai is doing is that you're a trusted partner in communities, right? You are there in places that there is no other healthcare resource. So, you're able to see in real time what's going on in a community to be responsive. You have the ability to do truly community-based work. So, you know, whether that's home visitation or neighborhood-specific initiatives, that's how we are able to improve population health. it's through relationships and it's through visibility and it's through being present. And I think that at an institutional level, Sinai has been clearly very effective and really a model. And I think that safety net institutions have an important role to play, but the idea that only in extremely underresourced neighborhoods do they get that kind of care and attention, I think, is more challenging, right? And so, we know that local public health, for example, is underresourced and, in some communities, some, not all, but some communities absent, right? And so, that means that that local healthcare system often is stepping in to bridge the gap.

And particularly, I'm thinking about rural communities, which have different healthcare needs, but similarly would need a healthcare system to be vibrant and present. We don't see that same type of physical-- I don't know what I'm trying to say-- like they I just don't have a Sinai, and I would love for my communities to have a Sinai. And so, it's my hope that, you know, this model could be adapted into rural communities across the country as well, because healthcare is a human right. Everybody needs to have it. And I think that local healthcare systems that shine brightly should be commended. And then also, we should learn the lessons of what they're doing so that we can replicate them other places.

Host: Yeah. And I just want to highlight that because in case anybody missed that, healthcare is a human right. Like we cannot say that loud enough or often enough because I think sometimes we may have forgotten that. And so, you have worked in various roles, various parts of government, what are some of the key lessons that you've learned that you take with you as you move forward in this important work?

Lauren Underwood, Congresswoman: Well, storytelling is really important, especially when we are in an environment where people are trying to cut and eliminate programs, being able to tell the story of success, not just in terms of dollars and cents. Not just in terms of statistics, but the human impact, the community impact of the work is essential, and that's where we can all work together. I think that that's going to be very important.

A second lesson that I've learned is that, even if I am standing by myself, lifting up the importance or power of a program, that doesn't mean that this is an insignificant voice. During these times, you know, when it feels like the world's on fire, sometimes you fall into the trap of saying, "My voice doesn't matter," "My voice isn't powerful," "I'm not enough," right? Like, "We're not going to be able to drive change," all those different iterations of this kind of negative thought. And as members of Congress, sometimes we believe that too. And I'm here to say that, like, "It is not true. It's darkness where they thrive." And as soon as we shine a light, we can attract additional light and attention and eyes. And that is how we save programs, communities, and lives. But if we shrink away, or we are intimidated, then they're going to play in the darkness. And I just would encourage us to lean in in this moment, even if that means that we have to take on a battle seemingly by ourselves. It is righteous, it is certainly necessary, and you will not ultimately be alone.

Host: That is so beautifully said. And obviously, you're sharing this wisdom for others. Like, You never felt like that. I mean, thinking about you running out there and saying, "I'm going to run for Congress," trying to break all kinds of barriers. Like, what inspired you to do that, to be the first woman, person of color, the youngest ever? Like, how did you know that your voice needed to be heard, that you had a message to share, and that you were going to move forward with this great, ambitious goal?

Lauren Underwood, Congresswoman: Well, I absolutely felt that way. You know, my community was one that, you know, the insiders thought could never ever be won by a Democrat. And people were like, "Why are you even trying?" And I just couldn't let it go. You know, to play political games with people's healthcare to me is unacceptable. Like I can take it if we just don't agree, right? But why are you going to lie about it? I just believed that the fight was worth it. And I was obviously pleasantly surprised to see that the community was with me. But I guess what I'm saying is, it doesn't have to be running for Congress, but speaking up in the face of injustice, even if you believe that you are alone, it's still worth it and it's still necessary because you are shining a light when they are counting on taking action in the dark, and they are perpetuating this lie that nobody cares and that is inconsequential; and therefore, it's fine. And so, I just really encourage people, especially right now where people, some, are hurt, confused, sad, wondering what's next and making decisions about what they're going to be doing themselves. I'm saying, lean in, join us in this work because it matters. It matters certainly in our community here in Illinois, and you can make a lot of difference and you won't be alone.

Host: Thank you for that inspiration. And thank you for shining like a diamond, shining bright like a diamond. So as we keep moving towards more equitable healthcare, a more equitable system, obviously there are barriers in the form of people, people trying to undermine or create policies that will move us in the wrong direction. Do you think that the future still is bright despite clear barriers?

Lauren Underwood, Congresswoman: I absolutely think that the future is bright. I'm really encouraged by particularly the young people, the next generation of clinicians and public health advocates. Just earlier today, I was having a meeting and a young public health advocate came up to talk to me about the dangers of smoke from wildfires and how this is a public health emergency that's going underresourced. And like literally, over the course of like three minutes, I went from, completely oblivious to like, "You're right. We need to do something about this." And I love those kinds of experiences, whether it comes from reading an article or talking to someone or listening to a podcast, right? You hear about a small problem that you feel like you can make a difference, that gives me inspiration. And especially when it's our young people who are so passionate and energetic that are leading us forward, I am happy to do my part and support them.

Host: That's incredible. So, I see that the generations coming up behind you give you hope, get you excited. What else makes you hopeful for the future?

Lauren Underwood, Congresswoman: Well, I think that we are in a position where technology and data have enabled us to tackle problems that had just been seen as norms for decades. And now, not only do we have like the political will, but we have some solutions available to us. You know, implementation is hard, creating change is hard. But when you have resources at your disposal, I think sometimes it makes those challenges a little bit easier. And when I think about the work that we can do to advance maternal health, there has been tremendous innovation since I came to Congress in 2019, tremendous innovation. And this is a great chance for us to not only continue to fight, to pass the mom to bus, but to really take stock of how the landscape has shifted and the kinds of ways that we can shape federal programs to be additive and to offer additional incentives. But I don't want people to think that we're in a sort of status quo position with maternal health. You know, certainly the statistics have gotten worse. It's driven by the pandemic and the inequality that we saw during COVID. Our maternal death rates increased by 89%. It's terrible.

But at the same time, tremendous innovation. We need to just keep that equity lens. So, that is getting to the people who need those innovations the most, that we are expanding access. But I get excited about people who would have never tackled this issue except for learning about the challenge and then deciding to apply their skill set towards a solution. I think we can expect more of that kind of innovation and breakthrough in the years to come.

Host: That's great. I know here at Sinai, you know, our population is largely Latinx and African American. And so, I had to pose the question to our ED, our emergency department physicians where in the screening process do we ask every woman that's coming into the ED whether they've been pregnant in the last 12 months? And I uncovered that we didn't have such a process. And so, we're trying to create that. And, you know, we were talking through why this was so important and thinking about the maternal morbidity and mortality statistics. And if we don't even ask the question, you know, that's a very low tech way to at least reorient our minds and our potential differential diagnoses to make sure that this is not a complication of pregnancy.

I mean, of course, everyone gets screened for a pregnancy test, but you don't have to be pregnant. Like, what if you were pregnant recently? And so, we're still trying to make sure that that is routine and that's one small piece. But I'm just so excited for all the different pieces that will help us get further and further down the path to have more equitable healthcare and have a better result for our moms following pregnancy.

So, thank you again for leading the way. I am so grateful that you were able to carve out some time, Congresswoman Underwood, to be with us. Thank you for just the example of your amazing career and so young and have accomplished so much. Thank you for your tireless work and advocating for true equity in all spheres, healthcare, economic opportunity, education, housing, and so much more. We're so excited to follow your career. And I'm grateful for this time that you were able to share with me.

Lauren Underwood, Congresswoman: Thank you, Dr. Ezike. It's so good to be with you today.

Host: Thank you.