With Democrats now in control of the U.S. House of Representatives, it might appear that the fight over abortion rights has become a standoff.

After all, abortion-rights supporters within the Democratic caucus will be in a position to block the kind of curbs that Republicans advanced over the past two years when they had control of Congress.

But those on both sides of the debate insist that won’t be the case.

Despite the Republicans’ loss of the House, anti-abortion forces gained one of their most sought-after victories in decades with the confirmation of Justice Brett Kavanaugh to the Supreme Court. Now, with a stronger possibility of a 5-4 majority in favor of more restrictions on abortion, anti-abortion groups are eager to get test cases to the high court.

And that is just the beginning.

“Our agenda is very focused on the executive branch, the coming election and the courts,” says Marjorie Dannenfelser, president of the anti-abortion organization Susan B. Anthony List. She says the new judges nominated to lower federal courts by President Trump and confirmed by the Senate, reflect “a legacy win.”

The Republican majority in the U.S. Senate is expected to continue to fill the lower federal courts with judges who have been vetted by anti-abortion groups.

Meanwhile, abortion-rights supporters believe they, too, can make strides in 2019.

“We expect 25 states to push policies that will expand or protect abortion access,” said Dr. Leana Wen, who took over as president of the Planned Parenthood Federation of America in November. If the landmark 1973 Supreme Court decision Roe v. Wade is eventually overturned, states will decide whether abortion will be legal, and under what circumstances.

Here are four venues where the debate over reproductive health services for women will play out in 2019:

Congress

The Republican-controlled Congress proved unable in 2017 or 2018 to realize one of the anti-abortion movement’s biggest goals: evicting Planned Parenthood from Medicaid, the federal-state health insurance program for people who have low incomes. Abortion opponents don’t want Planned Parenthood to get federal funds because, in many states, it functions as an abortion provider (albeit with non-federal resources).

Though Republicans have a slightly larger majority in the new Senate, that majority will still be well short of the 60 votes needed to block any Democratic filibuster.

Because Democrats generally support Planned Parenthood, the power shift in the House makes the chances for defunding the organization even slimmer, much to the dismay of abortion opponents.

“We’re pretty disappointed that, despite having a Republican Congress for two years, Planned Parenthood wasn’t defunded,” says Kristan Hawkins of the anti-abortion group Students for Life of America. “This was one of President Trump’s promises to the pro-life community, and he should have demanded it,” she says.

Another likely area of dispute will be the future of various anti-abortion restrictions that are routinely part of annual spending bills. These include the so-called Hyde Amendment, which bans most federal abortion funding in Medicaid and other health programs in the Department of Health and Human Services. Also disputed: restrictions on grants to international groups that support abortion rights, and limits on abortion in federal prisons and in the military.

However, now that they have a substantial majority in the House, “Democrats are on stronger grounds to demand and expect clean appropriations bills,” without many of those riders, says Wen of Planned Parenthood. While Senate Republicans are likely to eventually add those restrictions back, “they will have to go through the amendment process,” Wen says. And that could bring added attention to the issues.

With control of House committees, Democrats can also set agendas, hold hearings and call witnesses to talk about issues they want to promote.

“Even if the bills don’t come to fruition, putting these bills in the spotlight, forcing lawmakers to go on the record — that has value,” Wen says.

The Trump administration

While Congress is unlikely to agree on reproductive health legislation in the coming two years, the Trump administration is still pursuing an aggressive anti-abortion agenda — using its power of regulation.

A final rule is expected any day that would cut off a significant part of Planned Parenthood’s federal funding — not from Medicaid but from the Title X Family Planning Program. Planned Parenthood annually provides family planning and other health services that don’t involve abortion to about 40 percent of the program’s 4 million patients.

The administration proposal, unveiled last May, would effectively require Planned Parenthood to physically separate facilities that perform abortions from those that provide federally funded services, and would bar abortion referrals for women who have unintended pregnancies. Planned Parenthood has said it is likely to sue over the new rules when they are finalized. The Supreme Court upheld in 1991 a similar set of restrictions that were never implemented.

Abortion opponents are also pressing to end federal funding for any research that uses tissue from aborted fetuses — a type of research that was authorized by Congress in the early 1990s.

“It’s very important we get to a point of banning [fetal tissue research] and pursuing aggressively ethical alternatives,” says Dannenfelser.

State capitols

Abortion opponents having pushed through more than 400 separate abortion restrictions on the state level since 2010, according to the Guttmacher Institute, an abortion-rights think tank. In 2018 alone, according to Guttmacher, 15 states adopted 27 new limits on abortion and family planning.

“Absolutely some [of these are] an exercise in what they can get to go up to the Supreme Court,” says Destiny Lopez, co-director of the abortion-rights group All* Above All. “Sort of ‘Let’s throw spaghetti against the wall and see what sticks.’ “

But 2018 also marked a turning point. It was the first time in years that the number of state actions supporting abortion rights outnumbered the restrictions. For example, Massachusetts approved a measure to repeal a pre-Roe ban on abortion that would take effect if Roe were overturned. Washington state passed a law to require abortion coverage in insurance plans that offer maternity coverage.

Federal courts

The fate of all these policies will be decided eventually by the courts.

In fact, several state-level restrictions are already in the pipeline to the Supreme Court and could serve as a vehicle to curtail or overturn Roe v. Wade.

Among the state laws closest to triggering such a review is an Indiana law banning abortion for gender selection or genetic flaws, among other things. Also awaiting final legal say is an Alabama law banning the most common second-trimester abortion method — dilation and evacuation.

Kaiser Health News is a nonprofit news service and editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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The skyrocketing cost of many prescription drugs in the U.S. can be blamed primarily on price increases, not expensive new therapies or improvements in existing medications as drug companies frequently claim, a new study shows.

The report, published Monday in the journal Health Affairs, found that the cost of brand-name oral prescription drugs rose more than 9 percent a year from 2008 and 2016, while the annual cost of injectable drugs rose more than 15 percent.

“The main takeaway of our study should be that increases in prices of brand-name drugs were largely driven by year-over-year price increases of drugs that were already in the market,” says Immaculata Hernandez, an assistant professor of pharmacy at the University of Pittsburgh, and the lead author of the study.

The price of insulin, for example, doubled between 2012 and 2016, according to the Health Care Cost Institute. And the price of Lantus, an insulin made by Sanofi, rose 49 percent in 2014 alone, according to the University of Pittsburgh.

The researchers used the wholesale acquisition cost data for more than 27,000 prescription drugs from First Databank, a company that collects prescription drug sales data. It then compared that data to claims data from the University of Pittsburgh Medical Center’s health plan, which the researchers say is a sample that mirrors the population as a whole.

They then compared new and existing drugs and separated the data into brand-name, generic and specialty categories to come up with cost increase estimates.

Brand-name drugs like Lantus and others account for an average 44 percent of total prescription drug spending, Hernandez says. That share is declining as drugmakers focus more on developing high-priced specialty medications, she says.

Gerard Anderson, professor of health policy and management at Johns Hopkins University, says price increases on existing drugs not only benefit drug makers, but also insurers, who can make more money through rebates on higher priced drugs.

“Research and development is only about 17 percent of total spending in most large drug companies,” he says. “Once a drug has been approved by the FDA, there are minimal additional research and development costs so drug companies cannot justify price increases by claiming research and development costs.”

The study did find that innovation was behind price increases for certain types of drugs. Hernandez and her team found that from 2008 to 2016, the price of so-called specialty drugs rose 21 percent for oral medications and 13 percent for injectable drugs. These increases were driven by new, innovative drugs like Sovaldi and Harvoni, two medications made by Gilead Sciences, Inc. that can cure Hepatitis C. Both drugs were initially priced at over $80,000 for a course of treatment.

Total spending by the government, consumers and insurers on prescription drugs was $333 billion in 2017, according to National Health Expenditure data. That was an increase of just 0.4 percent from the previous year. But that spending rose more than 41 percent over the previous decade, from $236 billion in 2007.

The researchers say their study is based on the list prices of medications and doesn’t take into account the discounts most insurance companies get for prescription drugs because those discounts are kept secret.

The study also showed big cost increases in generic drugs, with oral generics rising 4 percent a year and injectables increasing 7 percent annually. But Hernandez says that spike can be attributed to what she calls a “patent cliff” that hit the drug market during the study period in which several blockbuster drugs, including several anti-depressants and anti-psychotics, lost their patent protection and became generics.

“We’re talking here about highly used drugs,” Hernandez says. “And it takes some time to file generic applications and therefore in the first years after a patent expiration there’s less competition in the market.” So at first, prices are set very close to the brand name price.

So those high-volume, expensive generics drove up prices in the generic market overall. But, as more generic competitors hit the market, the prices begin to fall more, she says.

Since rising costs aren’t paying for improved treatments, policy makers may want to take action, says Dr. William Shrank, chief medical officer of the UPMC Health Plan, who is also an author on the study.

“This observation supports policy efforts designed to control health care spending by capping price inflation to some reasonable level,” he says.

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Doctors told Steve Dillman the throat cancer he was diagnosed with in 2008 came from smoking. He knew it didn’t.

“I thought it had to be job-related because I’ve never smoked a day in my life. I don’t chew. I don’t drink excessively … and that’s the three main criterias,” he says.

But Dillman did spend 38 years as an Indianapolis firefighter — and that included running into burning buildings.

Dillman, who’s now retired, recalls one fire on Aug. 1, 1985. That day, his fire station responded to a call at the American Fletcher National Bank warehouse in downtown Indianapolis.

Firefighters noticed something strange and painful after they put out the flames. Everywhere they sweated – under their arms, around their groins – their skin peeled, like it had been sunburned.

Dillman later learned the warehouse was filled with boxes treated with a flame-retardant chemical that sent toxic gases into the air – including formaldehyde, a known carcinogen.

Dillman was diagnosed with prostate cancer 16 years later, and throat cancer seven years after that.

“It’s just an evil thing that we have to deal with,” 74-year-old Dillman says.

Research from National Institute for Occupational Safety and Health (NIOSH) published in 2013 shows that firefighters are diagnosed with and die from cancer at higher rates than the general population. It confirmed earlier research finding elevated risk for the profession for certain cancers.

The correlation between firefighters’ on-the-job exposure to carcinogens and their subsequent illnesses is concerning enough to policy makers that a growing number of states have passed laws — 42 states and Washington, D.C. — designed to help firefighters who develop cancer, according to the non-profit Firefighter Cancer Support Network.

Generally, these laws say that firefighters diagnosed with cancer while on the job or within a certain time after retirement are presumed to have become ill because of their work. And that should make it easier for them to get workers’ compensation, disability benefits or death benefits for their families.

But firefighters say those protections often fall short.

Leaders of organizations that work with firefighters say, despite these laws, firefighters are often denied workers’ compensation claims after a cancer diagnosis. Firefighters have challenged denials in a number of states, including California, Pennsylvania, Texas, and Washington.

“Presumptive laws aren’t the golden ticket that people think they are,” says Jim Brinkley, director of occupational health and safety for the International Association of Fire Fighters, a Washington, D.C.-based lobbying organization. “Our detractors are the ones who will say it’s not connected to the job because they don’t want to pay the benefits.”

It’s difficult to estimate how many firefighters have been denied benefits, says Keith Tyson, vice president for education and research for the Firefighter Cancer Support Network. He’s a prostate cancer survivor who spent 34 years on the job in Florida, where there is no presumptive law.

Tyson doesn’t know of any organization that tracks such workers compensation claims nationwide. And other than his organization’s analysis of state laws, there isn’t a comprehensive listing of the states offering protection.

“That’s the problem. Nobody is consistent on any of this,” Tyson says. “It’s unfortunate that there couldn’t be a one-standard-fits-all [law]. That would make it so much easier.”

Exposed to contaminants

Heart disease was the leading cause of firefighter deaths until the mid-1990s, when “the burden of cancer significantly surpassed heart disease,” according to a paper on firefighters and cancer published last year in the American Journal of Industrial Medicine.

That study surveyed 2,818 Indiana firefighters who died between 1985 and 2013, and found that they had a 20 percent greater likelihood of dying due to cancer than non-firefighters.

This builds on the findings of the 2013 NIOSH study, which included nearly 30,000 firefighters from Chicago, Philadelphia and San Francisco. It found that firefighters are exposed to contaminants that are known or suspected to cause cancer — everything from asbestos in old buildings to the diesel exhaust from fire trucks — and they are more likely to develop respiratory, digestive and urinary system cancers than the general public.

For one rare cancer, mesothelioma, which is linked to asbestos exposure, the rate is two times greater in firefighters than the general U.S. population.

In July 2018, President Trump signed the Firefighter Cancer Registry Act directing the Centers for Disease Control and Prevention to collect national data about the issue. Fire stations can send information on cancer rates among their staff to the National Institute for Occupational Safety and Health.

NIOSH will look for trends in how cancer affects male and female firefighters, firefighters of different races and those in urban and rural areas.

Brinkley hopes this data will make it “very clear to the legislators and those controlling the purse strings that we need better protection for firefighters.”

Presumptive laws in action

State presumptive laws vary in many ways. Some cover only certain cancers. Some states limit how long after retirement a cancer diagnosis is covered. And in some states, a diagnosis alone isn’t enough to trigger protections such as disability benefits.

Of the states with presumptive cancer laws, the Firefighter Cancer Support Network found one that extends coverage up to three months after retirement. Six states, including Indiana, provide coverage up to five years. One state allows seven years, one state allows 600 weeks and three cover up to 20 years.

This reflects a misunderstanding of science, says Dr. Jefferey Burgess, an environmental health researcher at the University of Arizona College of Public Health. He says cancer can develop “anywhere from less than five years to over 30 years” after exposure to carcinogens.

Burgess, who has researched firefighters and cancer for more than 25 years, says the evidence shows firefighters are regularly exposed to carcinogens in the field, and that firefighters are diagnosed with cancer more than the general public.

“From my perspective, I believe we’ve clearly demonstrated that firefighting is associated with cancer,” he says.

Future research is needed, Burgess says, to determine more specific links between those exposures and a firefighter’s cancer diagnosis. At this point, it’s not possible to prove that a single exposure to a carcinogen caused a specific cancer. In fact, there isn’t definitive research that shows even a career of exposure causes a specific cancer diagnosis.

Instead of demanding documentation of possible exposures from fires long ago, Burgess says fire departments should understand that firefighters’ health is affected by their work.

“To tell you whether it was an individual fire or was a lifetime exposure, I don’t know we have that particular information right now,” Burgess says. “Every fire tends to have these chemicals, and therefore it should just, from my mind, be a question of whether you’re a firefighter and you’ve gone to fires rather than documenting that a specific fire was a problem.”

Even with presumptive laws in place, municipalities across the country often fight firefighter’s cancer-related workers’ comp claims. And firefighters are pushing back.

In Texas, the Houston Chronicle found that in the past six years, nine in 10 Texas firefighters with cancer have had their workers compensation claims denied.

In Philadelphia, the city denied a firefighter’s claim in 2012, leading to a lengthy process of appeals. Ultimately, the Pennsylvania Supreme Court ruled in 2018 in favor of the firefighter, arguing that firefighters diagnosed with cancer must only show that their cancer could be caused by exposure to a known carcinogen. It’s up to their employers to prove it was not work-related.

Brinkley says the International Association of Fire Fighters has tried to develop more information about these claims nationwide. It has asked municipalities for data on workplace injury claims related to cancer — and how often they’re denied. The requests have been refused.

The National Council on Compensation Insurance, which gathers and analyzes data related to states’ workers compensation systems, released a report in 2016 on the impact of presumptive laws.

The report noted that firefighters are typically employed by state and local governments, which are often self-insured. Self-insured entities aren’t required to report claims to the council. Still, the NCCI stated in the report that it “expects that the enactment of such presumptions will result in increases in workers compensation costs.”

‘A moment of weakness’

In Indiana, as in some other states with presumptive laws, when a firefighter makes a cancer-related claim, the city wants to know the specific fire that led to the cancer diagnosis.

But firefighters traditionally haven’t kept records of chemical exposures, Brinkley says.

“To ask a member who is fighting a horrific disease that could end their life to then find that one call that they were exposed to one chemical that causes that one cancer is just a way of holding on to the money and not paying the claim,” he says. “That’s not taking care of your firefighter, who risks their life every day.”

Indianapolis Fire Department division chief for health and safety Kevan Crawley advocates for firefighters’ benefits. He says he spends months arguing with city officials and Broadspire, the company that manages workplace injury claims.

Asked about the issue, a Broadspire spokeswoman said the company won’t comment on how it manages its clients’ claims.

Brett Wineinger, risk manager for Indianapolis, oversees the city’s insurance policies. He says that few of the claims have dealt with cancer.

“We’re going to monitor any claim that’s filed with us against [Indiana’s presumptive law],” Wineinger says. “If it’s something that is linked to a fire instance that’s clearly something they’ve gotten through an exposure, obviously we’re going to take that as a workplace injury because that should be the first line of defense.”

Crawley says he understands that the city is trying to protect its budget. And he doesn’t believe that the insurers who deny claims are “bad people.”

But he says they don’t understand what it’s like to sit down with a newly-diagnosed firefighter and explain that the city won’t help with cancer-related costs.

“Guys you’ve looked up to in your career, and you don’t ever expect to see them in a moment of weakness,” Crawley says.

Growing a culture of safety

Firefighters at the Indianapolis Fire Department say they can’t rely on the state’s presumptive law for protection, so they’re focusing on what is in their control: preventing exposure to carcinogens.

Firefighters can wear a protective mask that filters out gases and particles. Otherwise, they breathe in a lot of smoke.

In the old days, firefighters were called “smoke-eaters,” recalls retired firefighter Dillman, and they wore their charred, soot-covered gear as a badge of honor.

At fires, Dillman didn’t wear hisprotective mask.No one did. If you did you were a “sissy,” he says.

“It was just the way the job was,” Dillman recalls.

Procedures during fires have changed since Dillman retired in 2005. It’s now standard practice for firefighters to wearthese masks at a fire.

Dillman now travels to fire departments around Indiana to urge firefighters to use masks and practice other preventive cancer measures.

To make his point, Dillman brings a couple of props.

“The last thing I tell them, ‘You can either wear your [protective] air mask … ‘” he says, holding one up for emphasis.

Then he shows the oxygen mask he needed to breathe when his cancer was at its worst.

And he says, “Or you can wear this mask. And trust me, you don’t want to wear this mask.”

This story was produced by Side Effects Public Media, a news collaborative covering public health.

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There seems to be no end in sight for the current partial government shutdown, the third since the beginning of the Trump administration.

For the vast majority of the federal government’s public health efforts, though, it’s business as usual.

That’s because Congress has already passed five of its major appropriations bills, funding about three-fourths of the federal government, including the Department of Health and Human Services and the Department of Veterans Affairs.

But seven bills are outstanding — including those that fund the Interior, Agriculture and Justice departments — and that puts the squeeze on some important health-related initiatives.

The shutdown itself isn’t about health policies. It’s the result of differences of opinion between the administration and congressional Democrats regarding funding for President Trump’s border wall. But it’s far-reaching, nonetheless. Here’s where things stand:

Funding for “big ticket” health programs is already in place, alleviating much of the shutdown’s immediate potential impact

Since HHS funding is set through September, the flagship government health care programs — think Obamacare, Medicare and Medicaid — are insulated.

That’s also true of public health surveillance, like tracking the flu virus, a responsibility of the Centers for Disease Control and Prevention. The National Institutes of Health, which oversees major biomedical research, is also fine. It’s a stark contrast to last January’s shutdown, which sent home about half of HHS’s staff.

But some other public health operations are vulnerable because of complicated funding streams

Although the Food and Drug Administration falls under the HHS umbrella, it receives significant funding for its food safety operations through the spending bill for the Department of Agriculture, which is entirely caught up in the shutdown.

Last year, that tallied an estimated $2.9 billion to support among other things these FDA oversight efforts, which involve everything from food recalls to routine facility inspections and cosmetics regulation. Not having those dollars now means, according to the FDA contingency plan, that about 40 percent of the agency — thousands of government workers — is furloughed.

The FDA will continue work that’s critical to public health and safety. It will be able to respond to emergencies, like the flu and foodborne illnesses. It will continue recalls of any foods, drugs and medical devices that pose a high risk to human health.

The FDA’s responsibilities for drug approval and oversight are funded by user fees and will continue product reviews where the fees have already been paid. Regulation of tobacco products is also continuing.

Health services for Native Americans are also on hold

Because Congress has yet to approve funding for the Indian Health Service, which is run by HHS but gets its money through the Department of the Interior, IHS feels the full weight of the shutdown. The only services that can continue are those that meet “immediate needs of the patients, medical staff, and medical facilities,” according to the shutdown contingency plan.

That includes IHS-run clinics, which provide direct health care to tribes around the country. These facilities are open, and many staffers are reporting to work because they are deemed “excepted,” said Jennifer Buschik, an agency spokeswoman. But they will not be paid until Congress and the administration reach a deal.

Other IHS programs are taking a more direct hit. For example, the agency has suspended grants that support tribal health programs as well as preventive health clinics run by the Office of Urban Indian Health Programs.

Public health efforts by Homeland Security and the EPA face serious constraints

The Department of Homeland Security’s Office of Health Affairs assesses threats posed by infectious diseases, pandemics and biological and chemical attacks. It is supposed to be scaling back, according to the department’s shutdown contingency plan. This office is just one component of the 204-person Countering Weapons of Mass Destruction Office, which is retaining about 65 employees during the funding gap.

Other DHS health workers are likely to work without pay — for instance, health inspectors at the border, said Peter Boogaard, who was an agency spokesman under the Obama administration. According to DHS’s plan, the vast majority of Border Patrol employees will continue working through the shutdown.

The Environmental Protection Agency has also run out of funding. According to its contingency plan, it’s keeping on more than 700 employees without pay, including those who work on Superfund sites or other activities where the “threat to life or property is imminent.” (More than 13,000 EPA workers have been furloughed.)

That limits the agency’s capacity for activities including inspecting water that people drink and regulating pesticides.

But it’s not just regulation. The public health stakes are visceral — and sometimes, frankly, pretty gross.

Just look at the National Park Service, which has halted restroom maintenance and trash service for lack of funding. On Sunday, Yosemite National Park in California closed its campgrounds. On Wednesday, Joshua Tree National Park, also in California, did the same.

Why? Per a park service press release: “The park is being forced to take this action for health and safety concerns as vault toilets reach capacity.”

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

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With a newly configured U.S. Supreme Court, the stakes are high for abortion-rights battles at the state level. Abortion-rights advocates and opponents are preparing for a busy year — from a tug-of-war over Roe v. Wade to smaller efforts that could expand or restrict access to abortion.

Supreme Court Justice Brett Kavanaugh is known for his conservative record on issues including reproductive rights. And with his confirmation, many abortion-rights opponents see new opportunities to restrict the procedure at the state level.

“The pro-life movement has been talking about more pro-life-friendly courts for years, and we see Kavanaugh really tilting that balance,” says Jamieson Gordon with Ohio Right to Life.

Activists in Ohio just pushed through a law banning a common second-trimester abortion procedure called dilation and extraction. Gordon says her group is feeling optimistic and is working to pass more restrictions in the new year.

“It really has been encouraging for us knowing that if our bill … got picked up to go to the court, that we would have a more favorable court,” she says. “So I do think that we’ve seen the tide turn.”

A “watershed moment”

Abortion-rights advocates also are preparing for a wave of bills to be introduced in statehouses across the country, says Elisabeth Smith, chief counsel for state policy and advocacy at the Center for Reproductive Rights.

“We think this will be a watershed moment in terms of the number [of bills] that are filed, and then potentially the number that will actually be enacted in various states,” Smith says.

She says advocates are working to protect abortion rights, repeal existing restrictions and fight new efforts to limit access to the procedure.

“I think the specter of the Supreme Court will be behind both the proactive bills — in terms of shoring up the right and access [to abortion] at the state level — and on the other side, I think states that are hostile to reproductive rights are going to be jockeying to be the state that sends a law to the Supreme Court,” Smith says.

Tug-of-war over Roe v. Wade

Many abortion-rights opponents say they’re hoping to overturn Roe v. Wade, the 1973 decision that legalized abortion nationwide.

“States want their bill to be the one to go to the Supreme Court. They want to be the one,” says Sue Liebel, state director for the anti-abortion-rights group Susan B. Anthony List.

Possible test cases for Roe already are working their way through the courts — including an Iowa law banning abortion after a fetal heartbeat is detected, and one in Mississippi prohibiting the procedure after 15 weeks.

Liebel says anti-abortion-rights activists want to pass similar bills in as many states as possible.

“So I think they’re hopeful; they’re energized and rarin’ to go,” Liebel says.

If Roe were weakened or overturned, more power for regulating abortion would fall to the states. Several anti-abortion-rights groups are pushing to increase the number of states banning abortion after 20 weeks or earlier.

Meanwhile, lawmakers supportive of abortion rights in several states are sponsoring bills to guarantee the right to abortion in state law, in places including Massachusetts, Virginia and even Texas, according to Smith, with the Center for Reproductive Rights.

“It’s unlikely that [Texas] bill will pass,” Smith says. “But I think more and more state advocates are bringing up this bill — either as a messaging vehicle, or to actually get it enacted.”

Big steps, and small ones

NARAL Pro-Choice America is promoting those bills. But Deputy Policy Director Leslie McGorman says it is also working on incremental efforts to improve abortion access, including legislation allowing a broader range of medical providers — such as nurse practitioners and physician assistants — to provide abortions in more states.

“We know that as long as abortion is sort of a one-off procedure, or care that’s delivered in a standalone clinic and people sort of don’t know what it is, that it’s gonna be this part of health care that’s sort of viewed that way, that’s viewed as sort of marginal,” McGorman says.

Abortion-rights opponents also are continuing to pursue their own incremental strategy.

Americans United for Life has close to 60 model bills aimed at restricting abortion. Among them is the Abortion Reporting Act, which requires medical providers to submit detailed reports to health officials about abortion-related complications.

“This is really designed to make sure that women are informed about those abortion providers that are especially dangerous,” says the group’s president, Catherine Glenn Foster.

Abortion-rights advocates say the requirements are intrusive and vaguely defined. Planned Parenthood sued last summer to block a similar law in Idaho.

“There’s also a big push to defund abortion facilities, to stop them from getting Title X funding,” says Ingrid Duran, of the National Right to Life Committee.

It’s already illegal for federal funds to pay for abortions in most cases, but anti-abortion activists want to ban organizations such as Planned Parenthood, which offer abortions, from receiving any public money for reproductive health services. The Trump administration has proposed blocking such groups from getting funds through Title X, the federal family planning program for low-income people; Duran says similar efforts are underway in many states.

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The federal judge in Texas who ruled the Affordable Care Act unconstitutional earlier this month said that the law can remain in effect while under appeal.

U.S. District Court Judge Reed O’Connor wrote in his ruling filed on Sunday that “many everyday Americans would otherwise face great uncertainty during the pendency of appeal.”

But O’Connor still stands by his initial decision, he wrote, that a recent change in federal tax law that eliminated the penalty on uninsured people, in turn, invalidates the entire health care law, which is also referred to as Obamacare.

Before issuing the stay, O’Connor struck down the ACA on Dec. 14, siding with a group of 19 Republican attorneys general and a governor, led by Texas Attorney General Ken Paxton.

As Julie Rovner of Kaiser Health News wrote for NPR following the district court judges decision, “The plaintiffs argued that because the Supreme Court upheld the ACA in 2012 as a constitutional use of its taxing power, the elimination of the tax makes the rest of the law unconstitutional.”

Judge O’Connor agreed with that reasoning.

“In some ways, the question before the Court involves the intent of both the 2010 and 2017 Congresses,” O’Connor wrote in his 55-page decision. “The former enacted the ACA. The latter sawed off the last leg it stood on.”

Democrats, meanwhile, say they plan to challenge O’Connor’s partial judgment. A spokesperson for California Attorney General Xavier Becerra — who’s joined by 16 other states defending the ACA — said his state is “prepared to appeal the December 14 decision imminently.”

“We’ve always said we’re going to protect the healthcare of Americans and make clear that the ACA is the law of the land,” Becerra said in a statement emailed to NPR. “Today the judge granted what we asked for when we filed our expedited motion but at the end of the day, we’re working to keep healthcare affordable and accessible to millions of Americans, so we march forward.”

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The benefits of retiring in South Carolina’s low country are clear to Joyce East. Her home, sandwiched between the Atlantic Ocean and downtown Charleston, overlooks 120 acres of lush marshland. Palm trees and Spanish moss dot the property.

But the drawbacks of retiring only a few meters above sea level have also become apparent to the 91-one-year-old retiree. Since 2016, her home within Charleston’s Bishop Gadsden Retirement Community has weathered one snow storm, one ice storm and three hurricanes. She has had to evacuate twice in two years.

For East, these evacuations are just the cost of growing old on the coast. Three decades ago, East and her husband decided they wanted to retire somewhere warm on the waterfront. Four days after arriving in Charleston, the couple was forced to flee inland as Hurricane Hugo ravaged the coast. East would evacuate again for Hurricane Matthew in 2016, and once more for Hurricane Florence this past September.

“Now that we’ve done it this much, it’s more of a routine,” says East. She packs her belongings in a navy evacuation suitcase with her name printed on it in white lettering. “I have to kind of look at it as a mini-vacation now.”

As unpredictable weather starts to feel inevitable, staff at Bishop Gadsden have worked to make evacuations feel as routine to residents as Monday night’s pub trivia. This year’s personalized suitcases were a new touch.

“Our planning is 24/7, 12 months a year,” says Kimberly Borts, one of the staff members charged with ensuring Bishop Gadsden is ready to depart come hurricane season. “This isn’t just let’s get on a bus and go.”

When Governor Henry McMaster mandated residents evacuate in the lead up to Hurricane Florence, he set in motion a sequence of events staff had spent the year fine-tuning. Ambulances arrived at 2 a.m. to whisk away the 14 seniors too frail to make the journey upright. The remaining 111 residents boarded buses bound for a mountaintop inn. A U-Haul was loaded up with walkers and a bus carted off residents’ pets.

It’s high stakes logistics. Any hiccup — too few oxygen tanks, lost medication — would have been disastrous. But even a well-executed journey carries risks for Bishop Gadsden’s retirees, many of whom are accustomed to a regimented routine.

“When that schedule is altered, that’s when you begin to have some challenges,” says Borts. During this year’s departure, she saw anxious residents who traditionally require one oxygen tank per day go through two tanks or more. As the seniors made their journey inland, Borts noted more upset stomachs and more bathroom trips.

Immediately after they returned from the shelter, Borts says staff began plotting how to make the journey smoother for their seniors — next year.

“We would sort of say to our fellow staff members, ‘Well, next time we do this,’ or ‘Next year we need to do X,Y, Z,’ ” she recalls.

Statistics show there will be a next time. Far beyond the marshy coast of Charleston, emergency evacuations are starting to seem commonplace.

Susan Burns monitors evacuations for Sedgwick, a company that deals with insurance claims for senior-living communities across the U.S.

After nursing home owners made the fatal decision not to evacuate residents in advance of Hurricane Katrina, Sedgwick began offering to reimburse facilities for part of their evacuation costs. But, until recently, no facility had taken the company up on the offer.

“I had not seen this coverage triggered at all until last year,” says Burns. She traces the uptick in recent claims to the “amazing number of natural disasters back to back” that have ravaged states like Florida, California and Missouri.

“They’re just trying to recover some of the costs and lessen the financial blow,” she says. This year, Bishop Gadsden spent $350,000 on shelter and transportation. The facility had shelled out a similar amount in 2016 for Hurricane Matthew.

And they’re prepared to do it again.

“You take care of a residents during good times and bad times,” says Borts. “The most important thing we can do is plan to do this again.”

This story is part of NPR’s reporting partnership with Kaiser Health News, an editorially independent news service of the Kaiser Family Foundation. Rebecca Ellis is a Kroc Fellow at NPR.

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