Insurers, hospitals and health advocates are waiting for Gov. Jerry Brown to deal the drug lobby a rare defeat, by signing legislation that would force pharmaceutical companies to justify big price hikes on drugs in California.

“If it gets signed by this governor, it’s going to send shock waves throughout the country,” said state Sen. Ed Hernandez, a Democrat from West Covina, the bill’s author and an optometrist. “A lot of other states have the same concerns we have, and you’re going to see other states try to emulate what we did.”

The bill would require drug companies to give California 60 days’ notice anytime they plan to raise the price of a drug by 16 percent or more over two years. They would also have to explain why the increases are necessary. In addition, health insurers would have to report what percentage of premium increases are caused by drug spending.

Drugmakers have spent $16.8 million on lobbying since January 2015 to kill an array of drug legislation in California, according to data from the Secretary of State’s Office. The industry has hired 45 lobbyists or firms to fight the price transparency bill alone. Against the backdrop of this opposition campaign, Brown must decide by Oct. 15 whether to sign or veto the bill.

This is the second go-round for this drug price bill. Last summer, the same legislation crashed and burned. Its intended regulations were gutted so extensively that Hernandez decided to pull it. But, he said, two key things happened after that, stetting the stage for a successful second attempt.

First, in August 2016, less than a week after Hernandez pulled the bill, a firestorm of controversy erupted nationally over the price of EpiPens spiking nearly 500 percent. The increase sparked outrage from parents who carry the auto-injectors to save their children from life-threatening allergic reactions.

Momentum grew among federal lawmakers last September to do something. They called for hearings. Several proposed bills aimed to reign in drug prices across the country.

But then, the election of November 2016 disrupted all order of health care business in Washington. After Donald Trump was elected and Republicans took control of Congress, the number one health policy priority became repealing and replacing the Affordable Care Act.

As federal lawmakers focused on dismantling the ACA, Hernandez said he saw another opportunity for state lawmakers to act on drug prices. He reintroduced his bill in early 2017, and this time political support grew quickly, beyond the usual suspects.

“It wasn’t just labor,” he recalls. “It was consumer groups, it was health plans. It was the Chambers of Commerce, it was the hospital association.”

Hernandez is optimistic the governor will sign SB 17 into law. But he knows nothing’s certain. That’s because of what happened on Sept. 11, the day the bill came up for a key vote in the state Assembly — the same place it went down the year before. Hernandez thought he’d secured all the votes he needed, but at the last minute the votes started slipping away.

The bill needed 41 votes to pass the Assembly. During the roll call, the tally stalled around 35. Hernandez said he had plenty of colleagues willing to cast the 42nd vote, but with drug lobbyists swarming the Capitol, no legislators wanted to be the one to cast the deciding vote.

“If the bill fails and you’re stuck out there, then you’re the person that’s attacking the industry,” Hernandez says.

But, the bill crossed the 41-vote threshold and the remaining lawmakers joined in. In the end, the bill passed with 66 votes. All the Democrats and half the Republicans in the state Assembly voted for it.

This was much to the dismay of drug companies, which lobbied hard and issued a blitz of advertising in the last weeks before the vote.

The Pharmaceutical Research and Manufacturers of America, or PhRMA, a drug industry’s trade group, argued that SB 17 was full of “false promises” that wouldn’t help consumers pay for their medicines, and would instead stifle innovation with cumbersome regulatory compliance.

“That takes up a lot of resources and will take up a lot of time,” says Priscilla VanderVeer, deputy vice president of public affairs for PhRMA. “And that could mean pulling resources from research and development and having to put it into the reporting structure.”

Experts say the drug industry doesn’t want a large influential state like California forcing them to share their data.

“When they have to justify in California, de facto, they have to justify it to the other 49 states,” says Gerard Anderson, a health policy professor at Johns Hopkins Bloomberg School of Public Health in Baltimore. “Other states essentially get to piggyback on the good efforts of California, and hopefully, because they might have difficulty justifying the price increases, everybody’s prices around the country will be lower.”

Other states, including Maryland, Vermont, Nevada and New York, have passed similar laws aimed at bringing more transparency to prices and curbing price gouging. But the pharmaceutical industry has fought the hardest in California. If drug companies don’t like the disclosure laws in smaller states, they could decide not to sell their drugs there, Anderson says, but the market in California is just too big to ignore.

“States like Maryland are just not as powerful,” he says. “It just doesn’t have the clout that a state like California has.”

But drugmakers are likely already devising ways to work around the California bill, Anderson warns. They’ve filed lawsuits to try to slow or stop laws from being implemented in other states, or to weaken the rules if and when they go into effect. Policy experts are watching to see what kinds of legal challenges the California law might be vulnerable to, and if it can withstand them.

“We learn from the mistakes of other states,” Anderson says. “Legislation is an iterative process. We have 50 states and hopefully, by some time, we’ll get it right. We’re looking for California to take the lead on this.”

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

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There’s a clinic that’s right in Kelsey’s town of Sioux Falls, S.D., that performs abortions, but she still drove hours away to get one.

Back in 2015, she was going through a difficult time — recently laid off, had to move suddenly, helping a close family member through some personal struggles — when she found out she was also pregnant.

“I kind of knew right away that this was just not the time or place to have a child. I mentally wasn’t ready, financially wasn’t ready,” she says. “The whole situation really wasn’t very good.”

When Kelsey decided to end her pregnancy, she found herself navigating a maze of legal restrictions, in a part of the country where providers are few and far between. NPR is not using her last name to protect her privacy.

South Dakota has a 72-hour waiting period for abortions and requires women to meet with their doctor in advance of the procedure. Kelsey, a nurse, had recently started a new job and couldn’t take the time off to go to two appointments at the clinic in her city.

She was just a few weeks along, and it was important to her to end the pregnancy early.

“I just knew that I didn’t want to wait on this too long,” she says. “Everybody has their own feelings about what is appropriate for them to have an abortion … how far they want to wait and things like that. I just knew I just wanted to do it.”

She called several providers throughout the region, some hundreds of miles away, before she finally found an appointment in Minneapolis, about a four-hour drive away, on a day she happened to have off work.

Kelsey’s story is similar to that of many women across the country, according to a report released Tuesday by the Guttmacher Institute, a reproductive health research organization that supports abortion rights.

The report, published in The Lancet Public Health, includes an analysis by Guttmacher researchers of the distances women must travel to obtain abortions in the United States. For 1 in 5 women, the report finds, the trip is more than 40 miles one way.

The trip is often longest for women in rural areas, with some in South Dakota driving more than 330 miles, according to Jonathan Bearak, a senior research scientist with Guttmacher and lead author of the report.

“I think there’s an unfortunate extent to which access to abortion is a bit contingent on your ZIP code, and that doesn’t need to be the case but it is,” he says.

Bearak says that increasing the use of options like telemedicine to provide medication abortion and reducing legal barriers to the procedure, like cumbersome health regulations on clinics and providers, could help improve access.

Social pressure is another factor that deters some doctors, midwives and nurse practitioners from providing those services, Bearak says.

“I think right now the issue is that it’s hard to do that because there are so many barriers in place to providing that care — not just the patients, but the doctors are affected by stigma,” Bearak says.

In South Dakota, where patients like Kelsey struggle with limited access to abortion services, Planned Parenthood has had to find creative ways to staff its local clinic. There’s no full-time abortion provider there, so Planned Parenthood flies a doctor from Minneapolis to Sioux Falls and back twice each week — first to consult with patients, as required by law, and then to perform the abortions.

Dr. Carol Ball has been making that trip for about a decade. She said local doctors are unwilling or unable to provide abortion services.

“I’ve been told by a supportive physician here that basically providing abortions for a South Dakota physician in Sioux Falls would be — quote unquote — ‘career suicide,’ ” Ball says. “Because I believe that the feeling is that there would be consequences to their practice.”

Ball says many of her patients travel hundreds of miles, some from out of state, to obtain an abortion at the clinic in Sioux Falls.

“It means that they have to find time away from their jobs and find child care for their children and all of the other sort of logistical things that it takes for us to stop and go to a doctor’s appointment,” Ball says. “They have to do that twice.”

Planned Parenthood’s Upper Midwest region has been flying abortion providers in and out of Sioux Falls for more than 25 years. Communications director Jen Aulwes says women there have limited options for abortion services.

“They’re very few and far between. They’re very spread out.” Aulwes says. “There’s, over the years, fewer and fewer clinics that that are providing abortion.”

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Hospitals across the Las Vegas area were inundated Sunday evening when hundreds of people injured in the mass shooting at a country music festival on the Strip arrived at their doors by ambulances and private car.

And hundreds of doctors, nurses, and support personnel were called into work to help handle the patients that were lined up in ambulance bays and hallways, officials say.

Following the shooting, Clark County Sheriff Joseph Lombardo said at least 58 people had died and 515 were injured after a gunman opened fire on thousands of people at a crowded outdoor concert.

While the numbers still may be in flux, they are enormous by any standard.

The University Medical Center of Southern Nevada, the state’s only comprehensive trauma center, received 104 patients, according to spokeswoman Danita Cohen. Four people died and 12 remained in critical condition Monday, Cohen says.

Sunrise Hospital and Medical Center saw 180 people who were injured in the shooting, including 124 people with gunshot wounds, according to Dr. Jeffrey Murawsky, the hospital’s chief medical officer. It’s the closest hospital to the site of the shooting and is a Level 2 trauma center, which means it can provide definitive care for all injured patients.

St. Rose Dominican hospital in nearby Henderson treated another 58 patients, five of whom are in critical condition, according to spokeswoman Jennifer Cooper.

The victims need blood donations, local officials say, and people are lining up to give.

“No one can say they’ve seen anything like this,” Sunrise’s Murawsky told All Things Considered on Monday. “We’ve seen events that have brought us 30 patients at once.”

He said 100 extra doctors were called in to work Sunday night, along with another 100 people including nurses, technicians, and support staff.

“We have a relatively large emergency department. We were able to triage within our emergency department,” he says. “We used the hallway space to see patients, so it’s a lot fuller than it normally would be and it feels a lot more chaotic.”

At University Medical Center, patients were being triaged in the ambulance bays, Cohen told CNN. The hospital has an 11-bay trauma center, with three operating bays, as well as regular surgery suites, which they likely used in this situation.

“We can get patients from an ambulance into the OR [operating room] in one minute,” Cohen says.

As reports of the gunfire emerged shortly after 10:30 p.m. PST Sunday, the city’s trauma centers began calling in extra personnel.

People working in trauma centers train for such emergencies and would know they’re likely to have to report to work as soon as they heard about the shooting on the news or social media. But still, the scale of this incident may have been surprising. “When you think of more than one hundred shooting victims, ballistic injuries, that is an absolute giant number,” says Bruno Petinaux, the chief medical officer and co-chair of emergency management at the George Washington University Hospital in Washington, D.C.

“When you’re talking about a mass casualty incident like this, this is where you call in the backup, and you call in the backup to the backup, and you may have to message the rest of your medical staff that you may need their help,” he says.

Petinaux says trauma centers have incident command structures in place to determine what kinds of people they need. A mass shooting is very different than a chemical incident or a fire.

In Las Vegas on Sunday, calls were likely going out to surgeons first, but not just surgeons. “Surgeons don’t work in a vacuum,” Petinaux says. “We’re now talking anesthesiologists, we’re talking about nurses, we’re talking about even pharmacists coming in. You may need to bring in more cleaners to help clean the OR and turn it around quickly.”

The Southern Nevada Health District, which includes Las Vegas and Clark County, has a 65-page trauma system plan that lays out how emergency responders and hospitals should communicate, work together, and divide responsibilities in a mass casualty situation.

Most major cities have such a plan, says Ian Weston, executive director of the American Trauma Society, which advocates for victims of trauma and the trauma care system.

“Hospitals are prepared to build capacity,” he says. “They’ll get the most critical patients into surgery quickly, they’ll stabilize more in the ER and some will even be treated in the lobby.”

He says hospitals determine exactly how many people they can care for in such a situation, even taking into account how many people they can fit into hallways, at least temporarily.

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