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Amina Srna: It's The Brian Lehrer Show. I'm producer Amina Srna, filling in for Brian today. The federal government may have reopened, but for millions of Americans who rely on Affordable Care Act subsidies, the uncertainty around their health insurance hasn't gone anywhere. Congress ended the 43-day shutdown without extending the enhanced subsidies that keep premiums affordable for roughly 24 million people. In a recent MS NOW op-ed, my guest Dr. Uché Blackstock writes about treating those subsidies as something that can be bargained over has real consequences for how people get and pay for their care.

If you don't know what MS NOW is, it's new identity of MSNBC. Dr. Blackstock has also written about a viral TikTok video of a Black woman in active labor being ignored by hospital staff. She uses that moment to show how inequities in the healthcare system play out in real time and how fragile the safety net already is for families of color. Now we'll look at what this ongoing fight over subsidies means for New Yorkers and people across the country, how instability deepens racial and economic inequities, and how the concerns raised in her piece about maternal health fit into the larger picture of what patients and communities are experiencing right now.

Uché Blackstock is an emergency medicine physician, founder and CEO of Advancing Health Equity, author of LEGACY: A Black Physician Reckons with Racism in Medicine, and a former MSNBC and NBC News medical contributor. Dr. Blackstock, welcome to WNYC.

Dr. Uché Blackstock: Hi, Amina, thank you so very much for having me on today.

Amina Srna: Thank you so much for being here. Listeners, we'll open up the phones to you right away. How is the uncertainty around ACA subsidies or your marketplace premiums affecting you? Have you already seen changes in your renewal notices? Are you worried about what your coverage will look like in the new year? On the maternal health side, have you experienced delays, dismissiveness, or other barriers when trying to get care? 212-433-WNYC. That's 212-433-9692. You can call or text that number.

Dr. Blackstock, a lot of people are starting to get their renewal notices for next year and trying to figure out what their coverage will cost or whether they can stay insured at all. From your vantage point, what moment are we in right now when it comes to affordability and access to care?

Dr. Uché Blackstock: Again, thank you so much for having me on, Amina. I think we can say that this moment we're in, we're headed to a public health crisis. We're in a crisis that's only going to worsen as a result of these expiring subsidies. I think when we look at just even the numbers, about 24 million people use the marketplace. Of those, about 20 million use the subsidies. It's projected that if these subsidies expire, about 4 million people will actually go without health insurance because they're going to have to make this really difficult decision of, "Do I pay for health insurance, or do I pay for my rent? Do I pay for my health insurance, or do I pay for groceries?"

I also just want to make a point that these folks-- many of these, like 20 million people, these are people who do not qualify for Medicaid, and they make too little to afford private insurance. Really, these are working folks, these are middle-class folks who are trying to get by every day. They are doing all the right things, and we have a system that is not supporting them and not acknowledging that investing in health is a public good.

Amina Srna: The possibility that these subsidies could lapse has been described as a warning about where the system may be headed. What is the warning here?

Dr. Uché Blackstock: I really agree. I think, unfortunately, there's a lot of information that I think has not been communicated well or thoughtfully to the public, and the public is bearing the brunt of the situation. For example, a lot of what we're seeing right now is because healthcare costs are rising everywhere, and it looks like the patients have to pay for that. We know that premiums may increase, deductibles have actually tripled in the last 10 years. In this country, drug prices remain among the highest in the world.

We also have this consolidation of hospitals and hospital systems, which actually raises prices due to labor shortages, and then also the consolidation piece. There are all these reasons, these market reasons that prices are going up, up, up, and up that actually our business folks and legislators need to address. Instead, it's as if it's the public and people who are just trying to get by that are being the most impacted by-- Essentially, we have a for-profit healthcare system that is deeply fragmented, and we're seeing what happens when there is a prioritization of profit over people.

Amina Srna: Let's go to a call, Mandy in Frederick, Maryland. Hi Mandy, you're on WNYC.

Mandy: Hi. I was just telling the screener that I'm self-employed, so I got a plan on the marketplace, and I do receive those tax credits, and I knew they could be going away. I went back in to see a patient navigator to help me shop other plans. My assumption had been that I may be able to get a lesser plan that maybe isn't as robust and isn't as great a coverage, but it's better than no insurance coverage and reduce my cost. What I found was there wasn't that option. That was really surprising to me.

I wasn't happy about the notion of maybe a lesser quality health insurance plan. What she basically explained is once you take those credits away, even that plan that's a lower-tier HMO and has poor coverage in your area, and all that, is still going to be really, really high. I renewed for the plan, and I'm crossing my fingers because I don't want to go without any health insurance coverage.

Again, my coverage, for example, currently I pay 153 for a premium. It is set to be, next year, $688 for the premium with no tax credits. The other plans are about the same, $700, even ones that are lower tier, less robust. Most providers in my area don't take it. I was really surprised. People may not realize it's not just that you may not have the same plan, it's that you really are left with no option for an affordable plan.

Amina Srna: Mandy, thank you so much for your call. Please call us back. Dr. Blackstock, are you hearing that from other patients as well? People paying more or anticipating to pay more for less?

Dr. Uché Blackstock: Yes, we're hearing that. What's interesting is that we actually haven't been at a better place. I know this sounds odd to say now. Actually, a few weeks ago, we could have said that we've never had broader enrollment in the marketplace. We've never had more plans in the marketplace than as we do now. We're seeing that it really was thriving, but we're also seeing that it was so tenuous and that now some plans are going to come out of the marketplace, and we're going to see maybe some inferior plans costing more than they were previously. Folks not being able to afford even inferior or slightly superior plan, and I've been hearing that.

Amina Srna: Mandy did tell us that she definitely doesn't want to go without health insurance. Earlier in our segment, you were talking about how a lot of people don't have a choice and are probably weighing rent, as you put it, or groceries over health insurance, which means that maybe some people will not have health insurance. How do delayed doctor's visits or skipped appointments, or not showing up to those, because you don't have healthcare, how do they show up in the ER?

Dr. Uché Blackstock: Amina, I'm so glad that you mentioned that because I think for me as an emergency room doctor, that was one of the reasons-- one of the big motivations of writing this piece because, I'll have to admit, as a medical student, I had romanticized the emergency department just being able to care for all comers, discriminate against anyone. Just care for everyone who needs it. Obviously, what I realized during my practice, that we are where our society's social problems come home to roost.

When people do not have health insurance, they're more likely to go without preventive care. That's the care like the cancer screenings, blood pressure screenings, diabetes screenings, that are so important to keeping people healthy. They're more likely to go out with their medications because they're not able to afford their medications because they don't have coverage. What we end up seeing in the emergency department are actually people who are much, much, much sicker than they would otherwise be. We see the heart attacks, we see the strokes, we see the late-stage cancer.

What I wish our legislators would understand is that all of that is actually more expensive to care for. It's more expensive to care for a heart attack than it is to prevent one. It actually costs our healthcare system even more when people end up having to come to the emergency department because they've gone without care, because of lack of insurance. We spend exorbitant amounts on that in hospital care. That actually worsens the situation for everyone because that itself drives the premiums as well.

Amina Srna: To that point, listener texts, "I lost my job three weeks ago, and I'm already skipping on diabetes medication until I figure out how in the world-- when or how I'm going to afford coverage." Listeners, we can take a few more of your calls with Dr. Uché Blackstock, 212-433-WNYC. That's 212-433-9692. Dr. Blackstock, you write that letting these subsidies lapse would widen racial and regional inequities. Can you take us there? How did these inequities show up? Go ahead.

Dr. Uché Blackstock: Yes. I think it's important for people to recognize that these subsidies, which started at the beginning of the pandemic, they actually helped close the gap in health coverage for Black and Latino families and actually for rural families. A lot of the beneficiaries of these subsidies are actually in the southeast part of this country. We know that there is a correlation, and that there's some data out there that shows that if you are more likely to be insured, you're more likely to get that preventive care, you're more likely to be able to purchase your medications, and take your medications.

If we're seeing these subsidies expire, we're going to see the same folks who benefited from them now not have access to them. We already know that communities of color, rural communities, are already carrying a higher burden of chronic disease. They're already dealing with access issues as well. I just see, as you mentioned, the expiration of these subsidies worsening the progress in closing the gap in racial health inequities that we've seen over the last few years.

Amina Srna: There's also a question of trust, people losing faith that their coverage won't be there when they need it. How does that mistrust show up in your conversations with patients or community groups?

Dr. Uché Blackstock: I'm so glad that you brought that up, because I think that's something that we're not talking about enough in this moment that people are seeing, "Oh, wait, I thought that my government was looking out for me. I thought that here I had this opportunity to have health insurance for me and my family, and now we may have to lose it. I may not even be able to buy my children's medications." That trust, which we already know between Black communities, communities of color, even rural communities, we see that trust has been eroded just due to the legacy of poverty, racism in this country, that in these moments it worsens any trust that was already there or had formed again.

People are going to be less likely-- When you don't trust social institutions to be doing the work for your good, that actually leads into-- It bleeds into the mistrust of other social institutions as well. It actually makes people less likely to believe clinicians when they talk to them or less likely to believe public health information when it's disseminated.

Amina Srna: We have a listener who I believe is calling in with ties to Amsterdam. Hi, Katherine, you're on WNYC. Katherine in Brooklyn, excuse me, you're on WNYC.

Katherine: Hi. Yes, I'm calling-- My sister lives in Amsterdam. Something that I've really noticed is that when I have gone to the ED in the US-- I'm fortunate to have very good healthcare. When I've gone to the ED, I tend to get every single test imaginable. I tend to hear, "It's very, very unlikely that this is a problem, but we're just going to test it to be sure." I know that that is because of fear of malpractice lawsuits.

We see it also with-- Breast cancer screenings in the US are recommended every year. In Holland, it's every two years, and it starts at age 45. They're a little bit less, "Oh my gosh, we have to check for every possible thing." It's very, very difficult to sue for malpractice there, which keeps healthcare costs much, much lower, which I think contributes to being able to have pretty good socialized medicine that the government pays for. Now, obviously, the US is very far from that system, but it's a piece of the puzzle that I don't hear discussed very often.

Amina Srna: Katherine, thank you so much for your call. Dr. Blackstock, what were you thinking as you were listening to Katherine?

Dr. Uché Blackstock: I'm thinking several things. I think, one, the Commonwealth Fund does a lot of really wonderful work around health policy and comparing the United States to other high-income countries. Yes, we actually do spend the most on administration, or we're the most administratively inefficient. I would say that. We have the worst health outcomes. I think, obviously, we have a lot to learn from the Netherlands and other countries in Western Europe and other high-income countries that provide universal health coverage to people and have better health outcomes than we do.

I do think that there are things that are very specific about the United States [unintelligible 00:16:24] related is that we have a for-profit healthcare system, and we have a healthcare lobby that is very, very strong. I believe it's the largest lobby in the country. We actually have-- Even the American Medical Association, which is the oldest and largest organization of physicians, have pushed back against socialized healthcare and a nationalized health insurance program.

We actually have practitioners who are worried about profits being cut into if we have a national health program. I also do think, yes, there is something about the US population where I think there is a patient population that we know is more likely to sue. There are a lot of lawsuits involving medicine, and I do think that we know that there is reactive clinical practicing to that response. As the caller mentioned, getting all of these studies done in the emergency department, knowing that I actually don't need all of this.

I actually also would like to look at, I think at baseline, Americans are just unhealthier than in other high-income countries. I'm not saying they need all of that, but it's like a perfect storm. It's a perfect storm of dealing with an unhealthier group of people because of systemic and structural issues, and the fact that it's a more litigious population as well.

Amina Srna: Let's go to another call. Mark in East Village. Hi, Mark, you're on WNYC.

Mark: Yes, thank you. Thank you for taking my call. Hello, Dr. Blackstock. I'm a professional community organizer in healthcare. Our paths have crossed over the years, so hello.

Dr. Uché Blackstock: Hello.

Mark: I know you've done a lot of work over the years on the economic and social determinants of health and healthcare. I wanted to ask you to comment a little bit on another set of determinants. That is what we often talk about as the political determinants of healthcare. The current Trump administration Congress has made conscious decisions, both in last summer's big ugly bill and now this situation around the Affordable Care Act premium subsidies, to step away from a federal government role in assuring that people have access to affordable healthcare. I wondered if you could comment on that and the importance of people contacting their members of Congress right now about this. We have three weeks to solve this situation.

Dr. Uché Blackstock: Yes. Thank you--

Amina Srna: Mark, thank you so much for your call. Dr. Blackstock.

Dr. Uché Blackstock: Yes. Mark, thank you so much for your call. When I was writing the piece about the expiring subsidies, I was thinking about if people are going to say, "What do I do next?" One is you need to call your legislators to make sure that they understand what the impact of this is. Mark is absolutely right. We have a federal government in place now that has really directly attacked public health in terms of underfunding or actually cutting funding from a lot of public health initiatives, especially ones that were designed to close the gap, including maternal mortality.

The subsidies are uncertain. We see equity programs, or programs, actually, that were focused on closing the gap in health inequities have been directly attacked. We just see a lot of misinformation and non-evidence-based recommendations. I do think, again, we are at a crossroads. I think we probably have these signs that the system feels very, very broken. We really need our legislators who have a conscience to have the courage to fix it in this time. We are definitely, as Mark is saying, I think, thinking about the political determinants of health, thinking about the fact that vaccine advisory boards that had people on them, that had years of experience, who knew the studies well have been disbanded.

The fact that the CDC is softening its language to line up with RFK's vaccine skepticism is extremely worrying, especially after decades of clear evidence that vaccines don't cause autism. I think this is the political pressure that is shaping health decisions and in the way it's harming people. I think when scientific guidance is rewritten in a way to appease misinformation, as we mentioned earlier, that erodes trust between families, between communities, that puts real people at risk.

Amina Srna: One more caller before we move on to some of your other reporting, Dr. Blackstock. Here is Sarah in Queens. Hey Sarah, you're on WNYC.

Sarah: Hi, thanks so much for having me. My question is, what role states have in fixing the US healthcare crisis? There's a piece of legislature in the New York State Senate called the New York Health Act that would provide single-payer healthcare in the state. It's got majority support, but it's not being brought up for vote, in part, because I think people just don't think it's a priority. I would argue it's a huge priority for states to be taking up these issues. I'm wondering if you can also comment on how we can implore our elected officials at other levels of government to take up this issue. Thank you.

Amina Srna: Sarah, thank you so much for your call.

Dr. Uché Blackstock: Amina, I don't know all the details on this. What I will say is that, yes, what we're going to see is-- If subsidies expire, it will look different state to state, it will look different on local levels even. Yes, I am familiar with that piece of legislation that is stalled in our legislation here in New York. I'm not sure if it's just the political will that it takes constituents calling and writing and saying that this is important. I know that New York City has a public health fund that we're trying to get philanthropists to donate to, to address some of these health issues. I think it's really-- we're going to need larger systemic solutions to this.

Amina Srna: Moving on. For the listeners who haven't seen the TikTok you wrote about, the one showing a Black woman, excuse me, in active labor, being ignored by hospital staff. Can you describe what was happening in that video and what did it illustrate to you in the way that bias and racism can show up in medical settings?

Dr. Uché Blackstock: Sure, yes. I think also this political moment and all the energy from it could make these scenarios, which are already common, even more common. It was in a Dallas hospital. There was a Black woman who was actively laboring in significant discomfort, sitting in a wheelchair, actually riding around in a wheelchair. A white nurse triaged her and asked her questions in a very, very calm way. The family had called the hospital to let them know that she was on the way. There was no sign of urgency. There were no other workers that came over to assess how she was doing or if she needed anything for pain.

The baby was delivered 12 minutes later after this video, this very upsetting, disturbing video was taken place. For me, it really wasn't just about that moment. I want to also hold space for that moment with what she went through and her family and her baby. I think it's just an example of the larger-- I wrote, it was a real-time audit of our healthcare system, a system that consistently dismisses Black women's pain. I think in this moment now it was quite striking because we're seeing programs that were designed to protect Black mothers are being cut or politicized.

That's why I wanted to really take the opportunity to write and say this moment was so much more than a viral moment. It got, I think, tens of millions of views on TikTok. I also just had to say that I have very heavy concerns about just Black trauma and Black pain being circulated on social media for content and not being treated with care and respect. For me, it wasn't just about people seeing this video, but also saying, "What do we do in this moment?" It was interesting because some people said, "Oh, I think that nurse is just burnt out."

I want to say this, as a healthcare professional, I know clinician burnout is real. Burnout doesn't explain someone not giving a patient attention. Actually, we know that under stress, bias actually becomes more pronounced. We need accountability for our patient. We also need accountability for our systems in the way that healthcare professionals interact and respond to Black patients. I think that's not just about one individual person, but about how hospital systems work and how they hold themselves accountable.

Amina Srna: The US still has the highest maternal mortality rate among high-income countries. Black women die of pregnancy-related causes at three times the rate of white women. What does that mean on a policy level? What can be done, and what urgent steps can policymakers take to change that?

Dr. Uché Blackstock: I want to say this because I always-- I want to say this, I want to say that-- Just deeper in what you just said is that for all racial demographic groups in this country, we have higher maternal mortality rates than other high-income countries, higher than even some middle-income countries. We are an outlier in the very worst way. We have solutions, we have solutions that we know work from our fellow countries. We know that doulas and midwives, having them more involved in the birthing process, is actually not only cost-effective for people who care about cost, but lowers complications.

We know that doulas and midwives, depending on where you're located, geography, are not always covered by insurance. We know that there needs to be investment in community births. Especially Black birthing people need to understand what their options are. That you don't have to always have an in-hospital birth. You may qualify for an at-home birth or a birthing center. We know that the complications, if you're an appropriate patient for that setting, are improved.

I think also we need those structural changes. A lot of the research that was going on, that unfortunately has been cut, was around maternal safety bundles in hospitals. We know what is needed quality-wise to keep people safe. Then obviously, better staffing and burnout protection. We don't lack solutions, we do lack political will.

Amina Srna: To your point about America's high maternal mortality rate, we have a listener that texts, "I left a gynecologist's office in so much pain after a DNC without painkiller that I was barely able to stand. No admin acknowledged me or could look me in the eye. There was no attempt to call me a cab or help me. I stumbled into the street where I received sympathy and palpable concern from my fellow New Yorkers, but not at the doctor's office responsible for my care."

Dr. Blackstock, I know that over the years that we've done segments on maternal care and abortion care, this is not an outlier of a story. As we wrap up this segment, when you look at both the subsidy fight and the concerns you raise about maternal health, what is the bigger takeaway you want people to understand about the state of healthcare right now?

Dr. Uché Blackstock: I think one piece is that I think both crises reflect systemic inequity and policy neglect. We have a woman who's in active labor, who's being ignored. We have families that are losing affordable coverage. I think it's the same underlying forces. It's underinvestment, political backlash, racism. I think in both cases we're seeing what happens when we ignore inequity. People get hurt, and that's what we're seeing.

Amina Srna: One last question before you go, because you had mentioned it earlier today. There's news that the CDC's official website has walked back the assertion that vaccines do not cause autism. The site now reads, the claim "vaccines do not cause autism is not an evidence-based claim because studies have not ruled out the possibility that infant vaccines cause autism." The CDC also removed a page that had an overview for pregnant people about the benefits of the COVID-19 vaccine. How do you interpret these changes? I know we've talked a lot about trusting the healthcare system and doctors, and healthcare providers. What's your take?

Dr. Uché Blackstock: I would just say this is-- it's very upsetting because, again, as you mentioned, that trust piece is so important. I think there's a lot of information out there. For the CDC now to be posting this information despite the fact that we have decades of evidence that show vaccines don't cause autism and that actually COVID vaccination-- less time, but we have also studies that show COVID vaccination during pregnancy is safe and protective. It just feels like a punch to the gut, given all the work that has been done.

I would even say not even within the CDC, but just at community levels with community health workers. All the wonderful work that was done during the early days of the pandemic, and really talking to people and educating them about getting vaccinated, it feels like we're going back so, so many steps. I think ultimately what I worry most about is how this change in language, this change in messaging, it puts real people at risk and especially our most vulnerable.

Amina Srna: Dr. Uché Blackstock is an emergency medicine physician, founder and CEO of Advancing Health Equity, and author of LEGACY: A Black Physician Reckons with Racism in Medicine. Dr. Blackstock, thanks so much for your time today.

Dr. Uché Blackstock: Thank you for having me, Amina.

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