As Republican-led states pass laws restricting abortion in hopes the Supreme Court will overturn its Roe v. Wade decision, supporters of abortion rights are pushing back.

Thousands of women who’ve had abortions have taken to social media to share their experience. Many argue they would have been worse off economically, had they been forced to deliver a baby.

“I didn’t know what I would do with a baby,” said Jeanne Myers, who was unmarried and unemployed when she got pregnant 36 years ago.

“I was horrified,” she said. “I had no job. I would have been in no financial position to care for a kid.”

By the time she knew she was pregnant, Myers was already in her second trimester — too late for an abortion in Janesville, Wisc., where she lived. So she saved up her money for a trip to a specialty clinic in Madison, where a doctor terminated the pregnancy.

“I cried through the whole procedure,” Myers recalled. “I had guilt probably for a year. But you know what? I don’t regret it. Because if I hadn’t had that procedure when I was young, I would not be where I am today.”

Myers is among the thousands of women who’ve been sharing their stories under the hashtag YouKnowMe in recent days, in an effort to reduce the stigma surrounding abortion and preserve the right for other women. They cite a wide variety of reasons for getting an abortion but a common theme is the economic hardship that having a baby would have posed for both mother and child.

Amanda Payne of Durham, N.C., was just 15 when she got pregnant and totally unprepared to raise a kid.

“I probably would have had to drop out of high school,” she said. “My boyfriend, who ended up being my husband, he had low-paying jobs. We didn’t have anything. I don’t think my life would be what it is today if I had continued that pregnancy.”

A study published in the American Journal of Public Health backs that up. Researchers reached out to more than 800 women who sought abortions around the country, including some who were denied because their pregnancies were too far along. The most common reason the women gave for wanting an abortion was they couldn’t afford to support a child. Researchers then kept tabs on the women and their families for the next five years.

“When we actually look at the outcomes for women, we see that they were right to be concerned,” said Diana Greene Foster, the study’s lead author. “Because women who are denied an abortion and carry the pregnancy to term are more likely to be poor for years after, compared to women who receive the abortion.”

Three out of four women who seek an abortion in the U.S. are already low-income. Foster, a professor at the University of California, San Francisco, argues that restricting their access just makes poor women poorer. After all, it’s hard to work full-time with a baby or toddler. And government safety-net programs don’t make up for that lost income or the additional cost of an extra person in the family. About 10% of the women denied abortion in the study put their babies up for adoption.

Of course, to people with a strong moral objection to abortion, economic arguments are beside the point. Opponents often liken abortion to slavery. And just as abolitionists didn’t worry about imposing unwanted costs on plantation owners, anti-abortion forces are not deterred by the high price of child rearing. But polls show most Americans don’t hold such absolutist views about abortion. And with conservative state lawmakers challenging Roe v. Wade, economic research may provide important context.

“If the government is going to step into reproductive decision-making, it’s going to have to consider the economic implications of doing that,” Foster said.

She noted that many women seeking abortion already have other children. And many others want to have kids, once they’re in better circumstances.

That was true of Jeanne Myers, who had a baby daughter three years after her abortion. By that time she was married and both she and her husband were working.

“I wanted to give my kids the best I could. And I did,” Myers said. “I didn’t want to raise a child knowing I couldn’t afford to do it.”

Myers now has two grown daughters. And she worries that when it comes to timing child rearing, they may not have the same options she did.

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Surprise medical bills — those unexpected and often pricey bills patients face when they get care from a doctor or hospital that isn’t in their insurance network — are the health care problem du jour in Washington, with President Trump and congressional lawmakers from both sides of the aisle calling for action.

These policymakers agree on the need to take patients out of the middle of the fight over charges, but crafting a legislative solution will not be easy.

A hearing of the House Ways and Means health subcommittee Tuesday, for example, quickly devolved into finger-pointing as providers’ and insurers’ testimony showed how much they don’t see eye to eye.

“I’m disappointed that all participants that are going to be here from critical sectors of our economy could not come to find a way to work together to protect patients from these huge surprise bills,” Rep. Devin Nunes, R-Calif., the ranking Republican on the subcommittee, in his opening statement.

As Congress weighs addressing the problem, here’s a guide to the bills and what to watch for.

Senate: Cassidy and Hassan

Last week, Sen. Bill Cassidy, R-La., and Sen. Maggie Hassan, D-N.H., introduced their version of surprise-billing legislation. It would set out specific protections for patients who are at risk of surprise bills in the following scenarios: receiving emergency care from an out-of-network facility or provider; getting elective care from an out-of-network doctor at a facility that is in the patient’s insurance network; or receiving additional, post-emergency health care at an out-of-network facility because the patient cannot travel without medical transport.

The protections would mean that people in these situations could not be billed by their health providers for amounts outside of what their insurance covered. Similar protections would also be put in place for laboratory and imaging services as well as providers who aren’t physicians, such as nurse anesthetists.

Patients would still have to pay their insurance plan’s usual deductibles and copayments, which would count toward their health plan’s out-of-pocket maximum.

Doctors would be automatically paid a predetermined amount based on what other health plans in the area are paying for a similar service. It’s called the “median in-network rate.”

House: “No Surprises Act”

On the House side, the “No Surprises Act” has emerged as the primary bill. Though it has not been formally introduced, drafts include many of the same protections as in the Cassidy-Hassan measure, including curbs on out-of-network bills for emergency care.

Co-authored by Reps. Frank Pallone, D-N.J., and Greg Walden, R-Ore., respectively the chairman and ranking member of the Energy and Commerce Committee, the measure would require health care facilities to provide 24-hour notice to patients seeking elective treatment that they are about to see an out-of-network provider. It would prohibit the facility or provider from billing patients for whatever amount their insurance companies did not cover for that service. And it would set provider payment rates based on the market in that specific area.

One key difference between the House and Senate proposals: The Cassidy-Hassan measure includes a mechanism by which health providers can challenge that basic median pay rate They would have 30 days to initiate an independent dispute resolution between only the health plan and the provider; patients would be exempted.

“The patient needs to be the reason for care, not the excuse for a bill,” Cassidy said at a press conference when the bill was unveiled.

The approach is often referred to as “baseball-style” arbitration because it’s the model used by Major League Baseball for some salary negotiations. Here’s how it works: The plan and the provider each present a final offer to an independent arbitrator for what the procedure should cost. The arbitrator then picks one of those two options.

Senate, coming soon: Alexander and Murray health care bill

The Senate Health, Education, Labor and Pensions Committee has primary jurisdiction over the way the federal government regulates employer-sponsored plans, and Chairman Lamar Alexander, R-Tenn., and Sen. Patty Murray, D-Wash., the top Democratic member, are preparing legislation.

That legislative package is being billed as a broader measure designed to address health care costs, which would likely include provisions aimed at surprise medical bills.

If Alexander does proceed on the broader path, his legislation could also incorporate elements such as curbs on drug pricing and price transparency, according to some industry lobbyists.

But this triggers concerns that expanding the measure’s focus — which could perhaps draw more opposition — could slow the momentum behind surprise-billing legislation.

“There’s a lot of other things going on that aren’t directly related to surprise bills,” says Molly Smith, the vice president for coverage and state issues at the American Hospital Association. “We’re paying attention to what else is getting glommed on.”

Alexander and Murray are expected to unveil details of their proposal Thursday. And, at a White House event earlier this month, Alexander said he would like to pass it through the committee by July.

That won’t be the end of players joining in the debate.

In addition to the House Education and Labor Committee hearing and possible legislation, Ways and Means health subcommittee Chairman Lloyd Doggett, D-Texas, is focused on this issue, having introduced surprise-billing legislation in the last three congressional sessions.

Issues to watch

Some Capitol Hill insiders, say arbitration provisions such as those proposed in the Cassidy-Hassan measure could become a hurdle to getting surprise-bill legislation over the finish line.

At the Ways and Means hearing, for instance, a representative from the trade group that represents employer plans called the idea a “snipe hunt” used by providers and hospitals to distract Congress from fixing the problem.

But the idea of the government setting payment rates for doctors is also sensitive. Groups such as the American Medical Association have pushed back on this idea.

“Proposals that use in-network rates as a guideline should be avoided,” said Dr. Bobby Mukkamala, an American Medical Association board member, in testimony to the Ways and Means panel. “Setting payments at these discounted rates would further disrupt the increasing market imbalance favoring health insurers.”

Cassidy, though, was optimistic at the press conference announcing his bill’s introduction.

“Greg Walden on the House side … said that he would be OK with arbitration, so obviously this is a process, we’re in negotiations,” he said at a press conference.

In fact, negotiations between the House and Senate versions of the proposed bills could lead to promising outcomes, says Claire McAndrew, the director of campaigns and partnerships at Families USA, a nonprofit group that advocates for accessible and affordable health care: “There could be an interesting potential to merge these two bills and do a really forward-thinking, consumer-friendly piece of legislation.”

What’s missing

Expensive air and ground ambulance bills have caused controversy in the past, but neither the Senate nor the House proposals appear to address them.

Helicopters are sometimes deployed to get patients in dire need to a hospital quickly, or to service patients in remote areas, often at exorbitant costs.

In addition, Smith, from the hospital association, says none of the bills address insurance network adequacy.

“At the end of the day, surprise billing happens because they don’t have access to an in-network provider,” Smith says.

At some point, legislators will also have to hammer out how the federal law will interact with the more than 20 state laws that address surprise billing, says Adam Beck, the vice president of employer health policy and initiatives at America’s Health Insurance Plans, or AHIP, the trade group representing health insurance plans.

Some states have stricter protections for patients, some use a different method to determine how doctors will be paid, and states want to preserve those extra protections when necessary.

“They’re not necessarily sticking points, but there are real questions they’ll have to figure out,” Beck says.

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Taylor Walker is wiping down tables after the lunch rush at the Bunkhouse Bar and Grill in remote Arthur, Nebraska, a tiny dot of a town ringed by cattle ranches.

The 25-year-old has her young son in tow, and she is expecting another baby in August.

“I was just having some terrible pain with this pregnancy and I couldn’t get in with my doctor,” she says.

Visiting her obstetrician in North Platte is a four-hour, round-trip endeavor that usually means missing a day of work. She arrived to a recent visit only to learn that another doctor was on call and hers wasn’t available.

“So then we had to make three trips down there just to get into my regular doctor,” Walker says.

This inconvenience is part of life in Arthur County, a 700-square-mile slice of western Nebraska prairie that’s home to only 465 people. According to census figures, it’s the fifth least-populated county in the nation.

It’s always been a chore to get to a doctor out here, and the situation is getting worse by some measures — here, and in many rural places. A new poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that one out of every four people living in rural areas said they couldn’t get the health care they needed recently. And about a quarter of those said the reason was that their health care location was too far or difficult to get to.

Rural hospitals are in decline. Over 100 have closed since 2010 and hundreds more are vulnerable. As of December 2018, there were more than 7,000 areas in the U.S. with health professional shortages, nearly 60 percent of which were in rural areas.

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In Arthur County, it’s a common refrain to hear residents talk about riding out illnesses or going without care unless the situation is dire or life-threatening. Folks will also give you an earful about what happens when they do visit a clinic or hospital. Because of high turnover, doctors don’t know them or their family histories and every visit is like starting all over again, they say.

“It’d be nice to have some doctors stay and get to know their patients,” says Theresa Bowlin, the lone staffer working at the Arthur County courthouse.

Arthur’s population has been in a slow decline for decades. No one knows for sure, but it’s likely the town hasn’t had a full time doctor since the 1930s, though there was a mobile health clinic that used to park on the highway once a week up until the 1990s. But it got too expensive.

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Bowlin says it’s a perennial challenge to find a doctor who knows the community and understands the cowboy mentality about health care common here.

“The younger doctors coming in, they really don’t know how a cowboy can go that long with pain and not come to the doctor until he absolutely has to,” she says.

A generational shift

There’s a changing of the guard going on in the health care industry, and its effects may be most apparent in rural America. As baby boomer doctors retire, independent family practices are closing, especially in small towns. Only 1% of doctors in their final year of medical school say they want to live in communities under 10,000; only 2% were wanted to live in towns of 25,000 or fewer.

Taking over a small-town practice is too expensive, or in some cases, too time-consuming for younger, millennial physicians. And a lot of the newly minted doctors out of medical training are opting to work at hospitals, rather than opening their own practices.

The nearest hospital to Arthur is 40 miles south in the town of Ogallala. Christopher Wong, 36, is one of just two family practice obstetricians at Ogallala Community Hospital, which serves a vast area of some 15,000 people spread across several counties.

Wong grew up in suburban Denver, about a three-hour drive away, but world’s apart from western Nebraska

“Most of the people I take care of out here are ranchers and farmers,” Wong says.

Wong first got interested in rural health care during med school, doing volunteer work in rural Louisiana after Hurricane Katrina. Still, working full time in a small town in rural Nebraska has been an adjustment.

One day, he did rounds at the hospital, saw dozens of patients at the clinic and signed a birth certificate for a baby he’d just delivered. He and the mother had to get a little creative, Wong recalled. She had a history of going into labor fast, but lives more than an hour’s drive from the hospital. Plus it’s calving season on her ranch. And she wasn’t sure her husband would be nearby — or available — to drive her to the hospital.

“So we brought her into the hospital when she was 39 weeks so we could induce her,” Wong says.

Being a doctor in a small town, you’re always on, even when you’re not. It’s not like you can just clock out and leave work. Wong will bump into a patient at the grocery store who politely asks about this ailment or that problem. Everyone knows him and there’s no anonymity. He’s also on call every other weekend.

“It’s very hard to get away,” Wong says. “It’s hard to separate it all.”

He has a girlfriend in Denver and tries to get down there when he can. But it’s a tough sell to convince a partner to move to rural Nebraska where there are few other young professionals or opportunities.

“I think that’s why it’s also hard to get physicians into rural practice because it’s hard to maintain a personal life.”

Burnout is high. Wong is approaching three years on the job in Ogallala and has no plans to leave. But it’s a constant worry for hospital administrators.

“Work-life balance is a big piece, they want to go home at some time,” says Drew Dostal, CEO of Ogallala Community.

Doctors like Wong, who do both family practice and obstetrics are already in high demand. Dostal even offers $100,000 signing bonuses to help ease their debt burden. It may get them out here for a few years, he says, but they’re usually lured away by other offers and rarely become fully part of the community.

“Physicians who have to move on to help get their debt paid off …[that] challenges patients as well,” Dostal says. “They want to know [their doctor], they want them to stay forever, but it just isn’t a reality in today’s health care.”

Social matchmakers

Dostal is currently looking for a third family practice doctor and could probably hire a fourth. Retaining doctors is key to keeping critical access hospitals like this one open. In the NPR poll, close to one out of every ten respondents said their small town hospital had recently closed.

Recruiting and retaining doctors is so pressing that hospital officials even try to become social matchmakers. If a doctor likes sports, for example, administrators may suggest they volunteer as team physician at the high school; or if they are an arts lover, they could volunteer on the planning committee for the local arts festival.

“If we don’t do a better job of doing that, there is a risk for rural places to lose their hospital, or lose their providers that are in that hospital,” says Dr. Jeffrey Bacon, the chief medical officer for three Banner Health hospitals in northeast Colorado and western Nebraska, including in Ogallala.

Bacon and other hospital officials say a more effective solution than social matchmaking or signing bonuses might be if medical schools did more active recruiting in small towns.

In January, Ogallala Community was thrilled to hire Jessica Leibhart to join Wong as a second family practice OB-GYN. Leibhart, 36, grew up in Imperial, Neb., about fifty miles south of Ogallala.

“I was looking to get back to my roots,” Leibhart says. “This was really close and looked like the right fit for us.”

Leibhart relocated from the Omaha area and her family already had contacts in Ogallala, so the transition has been smooth. She knows that in a small town it’s virtually impossible to escape your job.

“If we’re at Walmart or my husband and I will be out for dinner and then pretty soon someone stops by, but that’s part of it,” Leibhart says. “And that truly is becoming part of the community and part of the family that the small town is.”

Finding doctors who want to be part of the small town family, may be one solution to addressing the worsening doctor shortage in rural America, and the growing urban-rural divide.

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