Texas bans all abortions after cardiac activity can be detected in the embryo, which typically occurs about six weeks into pregnancy — often before people realize they’re pregnant. Medication abortions via telehealth or mail were already illegal in Texas, and the new criminal penalties took effect on the day the Supreme Court heard arguments in a Mississippi case that ultimately could overturn Roe v. Wade, the landmark 1973 ruling that established a constitutional right to abortion.

In contrast to a surgical abortion, which usually takes place in a clinic, a medication abortion involves two pills, taken 48 hours apart, that manipulate the hormones to end a pregnancy. Many people prefer this process early in a pregnancy because the pills can be taken at home. The Food and Drug Administration approved the drugs in 2000, and the procedure is effective up to 10 weeks into a pregnancy.

Texas is not the only state that restricts medication abortion and telehealth. This year alone, five other states have passed laws against sending abortion pills through the mail, said Elizabeth Nash, a state policy analyst with the Guttmacher Institute.

“It’s a squeeze play on abortion,” she said.

Nash said this crackdown is partially a response to the pandemic, which propelled interest in medication abortions.

“We saw the increase and, really, sort of the coming out of telehealth as part of medical practice,” she said.

Texas’ new law, known as , also narrows the legal window for medication abortion to the first seven weeks of pregnancy. State legislators passed this new law on Sept. 17 during a special session — more than two weeks after the other abortion law, often called the “six-week ban,” took effect on Sept. 1. Attempts to halt that law as groups challenge it in court .

“We already have the most extreme abortion ban in the U.S. and yet our legislature made it a priority to add this additional abortion restriction,” said Sarah Wheat, chief external affairs officer with Planned Parenthood of Greater Texas.

Because of the six-week ban, the new limits on medication abortions won’t have an immediate impact. “Most people at this stage of a pregnancy are already banned from accessing abortion in Texas,” Wheat said.

But the new law could significantly affect future access to abortion.

By criminalizing the use of telehealth and mail-order prescriptions to acquire abortion pills, the state seeks to forestall a possible workaround to the shrinking number of reproductive health clinics in Texas.

Already, many Texans live hundreds of miles from the nearest clinic offering abortion services. Advocates have promoted the use of telehealth for medication abortions in places where clinics are few and far between, and — including for abortion pills — during the pandemic shutdowns.

The new law “is creating additional fear and additional stigma for people who may be seeking access to medication abortion,” Wheat said.

Anti-abortion groups in Texas hailed SB 4 as a victory — an important second step, after the six-week ban, in their efforts to curtail all access to the procedure in the state.

John Seago, legislative director for Texas Right to Life, said his group wanted to ensure that law enforcement officials could prosecute people who skirt the state’s strict limits by administering medication abortions.

“This piece is really important for this period but also moving into the future, when we see even after [Roe v. Wade] we have organizations and individuals advertising that they will mail abortion-inducing drugs,” he said.

Nash of the Guttmacher Institute said that in some states it has become easier for people to obtain medication abortions through telehealth services.

Seago said he wants to make sure that doesn’t happen in Texas.

“This is going to be a future public policy issue around abortion, no matter what happens to Roe v. Wade,” he said.

So far, no lawsuit has challenged Texas’ law restricting access to abortion pills. Mounting a legal challenge to halt the law is complicated because Texans already are effectively prohibited from all abortions after six weeks. Finding legal standing to sue would likely be difficult for any Texas plaintiff.

Ultimately, Wheat said, Texas’ latest law is a sign of what could happen elsewhere. She said it shows there is no end to efforts aimed at making abortions harder to get.

“Take note of Texas, because what you see is that our politicians, they do not quit, and they can find endless ways to add fear, intimidation and restrictions,” Wheat said.

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, chief public strategies officer for the Safe Alliance, said the girl’s father didn’t let her leave the house.

“She got pregnant,” Nelson said. “She had no idea about anything about her body. She certainly didn’t know that she was pregnant.”

The girl eventually got help, but if this had happened after Sept. 1, when the state law took effect, her options would have been severely curtailed, Nelson said.

In Texas, abortions are now banned as early as six weeks into a pregnancy. Known as SB 8, the new law represents the nation’s most restrictive ban on the procedure currently in effect. According to a recent Texas’ law is unpopular across the political spectrum.

Notably, the law makes no exceptions for victims of rape or incest, which runs counter to public opinion. For decades, Americans consistently have favored exceptions to strict abortion bans — even in Texas. Social workers in the state said that is causing serious harm to sexual assault survivors.

While many people don’t realize they are pregnant until after six weeks, Nelson said, the time frame is a particular problem for those who are repeatedly raped or abused. To cope with the trauma of the abuse, she said, they often grow numb to what’s happening to their bodies.

“That dissociation can lead to a detachment from reality and the fact that she’s pregnant,” Nelson said. “And so, there again, she is not going to know that she is pregnant by six weeks and she’s not going to be able to resolve that pregnancy.”

, a social worker in Austin who has worked with sexual assault survivors, said not having the option of terminating a pregnancy will make recovering from an assault harder.

“The impact of finally coming forward and then being told there are no options for you is devastating,” said Faulkner, who directs the Texas Institute for Child & Family Wellbeing at the University of Texas-Austin.

Being forced to carry a pregnancy to term can be harmful financially, psychologically and, sometimes, physically. For survivors, Nelson said, that burden further strips away agency after their sense of safety and control has already been violated.

“And so, when you have something like SB 8,” Nelson said, “what it is doing is, it’s further taking control and power away from the survivor right at the moment when they need that power and control over their lives to begin healing.”

Faulkner said it’s important to give sexual assault survivors options on how to move forward in their lives. She said SB 8 “clearly is taking away any choice that they have.”

, a professor and sociologist who studies abortion policy at the Bixby Center for Global Reproductive Health at the University of California-San Francisco, said that, despite prevailing public opinion, most of the anti-abortion bills introduced across the country in recent years have not included exceptions for rape or incest.

“What we have seen over the years is a dramatic escalation,” she said. “I think what Texas shines a bright spotlight on is what disdain we have for the needs of women and girls, or people who can get pregnant even if they don’t identify as female.”

The history of abortion exceptions is complicated. Joffe noted that toward the end of the 20th century it was more common for states to include exceptions for rape and incest. She said the trend to eliminate exceptions for rape and incest started about 10 years ago, after the tea party gained power in Congress and in many statehouses. As some legislatures became more politically conservative, anti-abortion groups gained influence in the lawmaking process. Meanwhile, as some state legislatures have increased restrictions on abortion, public views have remained quite stable in the sentiment that abortion should be allowed in cases of rape and incest, Joffe said.

“The kind of restrictions we are seeing are the product of growing power in state legislatures of the anti-abortion movement,” she said.

In 2019, a coalition of anti-abortion groups sent letters to national Republican Party officials following the passage of a controversial abortion law in Alabama. In it, groups to “reconsider decades-old talking points” regarding exceptions for rape and incest.

In Texas, the growing power of hard-line conservatives in the state has helped anti-abortion advocates successfully push for more restrictive laws.

John Seago, legislative director with Texas Right to Life — an influential anti-abortion group that pushed for SB 8 — said the political shifts in the Texas legislature have made it easier to enact stricter abortion laws.

“In the last 10 years, in Texas, our Republican majority has been growing,” he said. “And kind of right around 2011 and/or 2013 we were really having enough votes to pass strong legislation.”

By “strong” Seago means not having to compromise on things like allowing abortions when severe fetal abnormalities are detected. Texas dropped those exceptions a few years ago. And now that the new law in Texas makes no exception in cases of rape or incest, Seago said, it’s more consistent with the underlying philosophy that groups like his hold.

“We are talking about innocent human life — that it is not their crime, it was not their heinous behavior that victimized this woman,” he said. “And so, why should they receive the punishment?”

The problem of pregnancies arising from sexual assault is not a small one. One study estimates that women in the U.S. have become pregnant following a rape.

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Lorraine Birabil, McKinnon’s daughter-in-law, said she is still grieving that loss.

“She was such a vibrant woman,” she said. “Just always full of energy and joy.”

Health insurance for roughly 2.2 million Americans is on the table as Congress considers a spending bill that could be as high as $3.5 trillion over the next decade.

This plan would extend health coverage to residents of that have yet to expand Medicaid to their working poor through the Affordable Care Act. In those states, people who earn too little to qualify for Medicaid — but who can’t afford to buy insurance in the individual marketplace — are left in what’s referred to as the Medicaid gap. Like McKinnon, most of these people work in jobs that don’t offer affordable health insurance.

If Congress approves the measure, those individuals would have access to .

This could be a lifeline to some of the , the highest rate in the country.

McKinnon was a descendant of runaway slaves who settled in Chicago. As an adult, she moved to Dallas and worked in health care her entire career. Her last job was as a home health aide, taking care of the elderly and people with disabilities. Birabil said she didn’t make a lot of money, though, and didn’t get health insurance.

And that’s why, when McKinnon started feeling sick, she put off going to the doctor.

“She didn’t have the coverage,” said Birabil, a lawyer in the Texas House of Representatives. “She was doing everything she could do to live a healthy lifestyle. And so, when she realized that something was wrong and she went to find out what it was, it turned out that it was stage 4 breast cancer.”

In the year after her diagnosis, she bounced around hospitals. Doctors would stabilize her and send her home. Without coverage, consistent treatment was hard to find. Her family looked for insurance but found nothing.

All they could do in the end was be there as she slowly died.

“At the time that we found out, you know, we were also pregnant,” Birabil said. “And she kept saying, ‘I just want to meet my grandbaby.’ And she didn’t make it.”

A month before her granddaughter was born, McKinnon died. She was months away from getting Medicare.

Birabil said the health care system her mother-in-law spent her life working in ultimately failed her.

Laura Guerra-Cardus, deputy director of the Children’s Defense Fund in Texas, said advocates like her have been pleading with state lawmakers for years to cover uninsured Texans.

“But purely political opposition from our highest leaders, the governor and the lieutenant governor,” she said, “is enough to block progress on an issue that is a basic right.”

That’s why Guerra-Cardus, and other health care advocates across the country, are now looking to President Joe Biden and Congress to fix this problem. The Democrats’ $3.5 trillion spending bill — Biden’s “human infrastructure” bill — includes money to cover the uninsured via the health insurance marketplace and state Medicaid programs.

Most of those who would benefit are people of color in the South.

“We are asking them to choose to make America a country that does not block health care from anybody,” Guerra-Cardus said.

The racial disparity is stark in Texas, where about 70% of people in the coverage gap are Latino or Black.

Jesse Cross-Call with the Center for Budget and Policy Priorities said this is the first time since the Affordable Care Act went into effect that Congress may have enough votes to address this issue.

“This really is the unfinished work of the ACA to ensure that everybody in this country who is poor or of moderate incomes has access to affordable health care coverage,” he said.

But this insurance lifeline is competing for money and attention with other priorities.

that this plan could be curtailed as Democrats negotiate a trimmed-down version of the spending bill.

For example, some lawmakers have suggested they would be willing to scale back health coverage for people in the Medicaid gap to just five years.

U.S. Rep. Lloyd Doggett (D-Texas), chair of the House Ways and Means Health Subcommittee, said in a statement Tuesday that Congress “must permanently close this coverage gap” so people in the 12 Republican-controlled states are never again denied health care.

“Closing the coverage gap means getting access to a family physician, essential medicines and other health care for [millions] who have been left out and left behind for more than a decade,” he said.

Some Democrats have that extending coverage in non-expansion states would reward the Republican leaders in those states that have blocked Medicaid expansion for years.

Guerra-Cardus said that argument “is so far from the point” when it comes to why Congress should address the coverage gap.

“This is about people who are dying and suffering from preventable, treatable illnesses in the 21st century in our rich country,” she said.

In every state where Medicaid expansion has been put on a ballot, it has been approved by voters, most recently in and .

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Esta recomendación llega en un momento en que los médicos de todo el país informan de un aumento en el número de embarazadas no vacunadas que deben ser hospitalizadas con casos graves de covid.

La baja tasa de vacunación en este grupo es sorprendente, señalan médicos. Al 31 de julio, solo el 23% de las embarazadas habían recibido al menos una dosis de la vacuna contra el coronavirus, según estadísticas de los CDC.

“Los CDC recomiendan que las personas embarazadas se vacunen contra covid-19, basándose en nueva evidencia sobre la seguridad y efectividad de las vacunas”, dijo la agencia en una guía actualizada que se suma a la recomendación urgente de las principales sociedades médicas.

“La vacuna contra covid-19 se recomienda para todas las personas mayores de 12 años, incluidas las embarazadas, las que intentan estarlo o las que están amamantando”, indica la guía.

Según la agencia, las preocupaciones entre algunas personas de que las vacunas de ARN mensajero podrían aumentar el riesgo de aborto espontáneo cuando se administran al principio del embarazo no se confirman con los datos de las investigaciones.

Los oficiales de salud dijeron que las tasas de aborto espontáneo después de vacunarse eran similares a la tasa esperada de aborto espontáneo en cualquier grupo de personas embarazadas. Recibir una vacuna contra covid también es seguro más adelante en el embarazo y durante la lactancia, enfatiza el nuevo análisis de la agencia.

La , especialista en medicina materno-fetal y profesora de la Escuela de Medicina Dell de la Universidad de Texas-Austin, dijo que ha estado promoviendo la vacunación a todo el que quiera escuchar. Trabaja principalmente con personas embarazadas que están enfermas de covid y ve el daño que puede causar el coronavirus.

Cahill recordó haber tratado a una mujer no vacunada que llegó al hospital con dificultad para respirar. Contó que, en 24 horas, el cuadro empeoró mucho y la mujer necesitó una enorme cantidad de oxígeno para mantenerse con vida.

“Estaba en su segundo trimestre. Si hubiera tenido que dar a luz, habría tenido un bebé extremadamente prematuro con un alto riesgo de tener una discapacidad de por vida o incluso la muerte”, dijo Cahill.

Dijo que a los dos días de haber sido internada, la mujer ya no podía respirar por sí misma. La intubaron y luego le pusieron un ventilador.

Finalmente, la mujer necesitó ECMO, oxigenación por membrana extracorpórea, una máquina que “saltea” los pulmones oxigenando directamente la sangre. Cahill dijo que estuvo en ECMO, un proceso que a menudo es un puente hacia un trasplante de corazón o pulmón para personas en estado crítico, durante varias semanas.

“Eventualmente pudo salir adelante”, dijo Cahill. “Milagrosamente no requirió un parto prematuro. Permaneció embarazada y después de dos meses y medio en el hospital pudo irse a casa”.

El bebé nació sano, pero la mujer puede enfrentar toda una vida de discapacidades a causa de covid. Cahill dijo que todo podría haberse evitado si se hubiera vacunado.

“Creo que es una oportunidad increíble que tenemos en los Estados Unidos, y todos deberían aprovechar esta tremenda vacuna para evitar que sucedan ese tipo de cosas”, dijo. “Es realmente trágico”.

Estos casos son la razón por la que el Colegio Americano de Obstetras y Ginecólogos (ACOG), y la Sociedad de Medicina Materno-Fetal, las dos organizaciones líderes que representan a médicos y científicos que se especializan en atención obstétrica, que todas las embarazadas reciban la vacuna contra covid.

“Es una ‘tormenta perfecta’”, dijo el doctor Mark Turrentine, profesor de obstetricia en Baylor College of Medicine, quien también es copresidente de un grupo de trabajo sobre covid para ACOG. “Tenemos una variante altamente infecciosa del virus que causa covid-19 en un grupo en el que la mayoría no está inmunizada. Así que sí, estamos viendo mucha gente enferma”.

“ACOG anima a sus miembros a recomendar enfáticamente ”, dijo el doctor J. Martin Tucker, presidente de ACOG, en una declaración escrita. “Esto significa enfatizar la seguridad conocida de las vacunas y el mayor riesgo de complicaciones graves asociadas con la infección por covid-19, incluida la muerte, durante el embarazo”.

Vacunar a las embarazadas se ha vuelto especialmente urgente en estados como Texas, donde la variante delta altamente contagiosa representa actualmente más del 75% de los casos nuevos. El porcentaje de personas en Texas que están completamente vacunadas , en comparación con el 50,3% de toda la población del país.

A medida que aumentan las tasas de infección en el estado, la doctora Jessica Ehrig, jefa de obstetricia del Centro Médico Baylor Scott & White en Temple, Texas, dijo que ha visto un aumento significativo en la cantidad de embarazadas hospitalizadas e intubadas; con algunas muertes. Y esos casos graves de covid también son peligrosos para el feto, remarcó.

“Las complicaciones incluyen el parto prematuro y un mayor riesgo de preeclampsia para estas mamás, lo que también puede requerir un parto prematuro”, dijo Ehrig recientemente en una conferencia de prensa en Austin sobre el tema. “Y, desafortunadamente, también aumenta el riesgo de muerte fetal”.

Es una situación especialmente peligrosa cuando una mujer embarazada tiene un caso sintomático de covid, anotó Turrentine.

“Hay un aumento de tres veces en la admisión a la unidad de cuidados intensivos”, dijo, “un aumento de dos veces y medio en el riesgo de recibir ventilación mecánica o soporte de bypass, e incluso hay un aumento en el riesgo de muerte”.

Los profesionales médicos y los científicos no saben exactamente por qué las embarazadas corren un riesgo tan alto cuando se infectan con el virus, pero les preocupa que esta población sea especialmente vulnerable porque muchas de ellas siguen sin vacunarse.

Los CDC han recomendado las vacunas para las embarazadas como la mejor manera de protegerlas a ellas y a sus bebés del coronavirus, . Aunque las embarazadas de las tres vacunas contra covid autorizadas para uso de emergencia en los Estados Unidos, los datos recopilados desde entonces han demostrado que son para este grupo.

Turrentine dijo que es importante enfatizar que los beneficios de vacunarse superan con creces cualquier tipo de riesgo. Especialmente para una mujer embarazada, dijo, los costos de no vacunarse son demasiado altos.

“He visto a algunas mujeres embarazadas muy enfermas. He visto a algunas morir”, dijo. “Y, ya sabes, entras en este negocio como obstetra-ginecólogo porque las pacientes son jóvenes y están sanas. Y la mayoría de las veces tienes excelentes resultados. Este es un virus muy malo”.

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This recommendation comes at a time when doctors across the country are reporting an uptick in the number of unvaccinated pregnant people getting hospitalized with severe cases of covid.

The low vaccination rate in this group is striking, doctors note. As of July 31, only 23% of those who are pregnant had received at least one dose of vaccine against the coronavirus, according to CDC statistics.

“CDC recommends that pregnant people should be vaccinated against COVID-19, based on new evidence about the safety and effectiveness of the COVID-19 vaccines,” the agency said in updated guidance that echoes the urgent recommendation of leading medical societies. “COVID-19 vaccination is recommended for all people 12 years and older, including people who are pregnant, breastfeeding, or trying to get pregnant now or might become pregnant in the future.”

According to the agency, concerns among some people that the messenger RNA vaccines might increase the risk of miscarriage when given early in pregnancy are not borne out by the data.

Officials said miscarriage rates after getting vaccinated were similar to the expected rate of miscarriage in any group of pregnant people. Getting a covid vaccine is also safe later in pregnancy and while breastfeeding, the agency’s new analysis indicates.

, a maternal-fetal medicine specialist and professor at the Dell Medical School at the University of Texas-Austin, said she has been telling all within earshot to get vaccinated. She works mostly with pregnant individuals who are sick with covid and sees the damage the coronavirus can do.

Cahill recalled treating an unvaccinated woman who came into her hospital with shortness of breath. Within 24 hours, she said, things got much worse, and the woman needed a tremendous amount of oxygen to stay alive.

“She was pregnant in her mid-trimester. So, if she had needed to be delivered, she would have had an extremely preterm baby with a high risk of having lifelong disability or even death,” Cahill said.

She said that within two days of being admitted to the hospital the woman could no longer breathe on her own. She was intubated and then put on a ventilator.

Eventually, the woman needed ECMO, extracorporeal membrane oxygenation, which is a machine that bypasses her lungs and oxygenates her blood for her. Cahill said she was on ECMO, which is often a bridge to a heart or lung transplant for critically ill people, for several weeks.

“She was eventually able to come off all of those things,” Cahill said. “She miraculously did not require a preterm delivery. She remained pregnant and after 2½ months in the hospital was able to go home.”

The baby was born healthy, but the woman was sent home and may face a lifetime of disabilities from covid. Cahill said it all could have been prevented if the woman had gotten vaccinated.

“I think that it’s just an incredible opportunity that we have in the United States, and everybody should avail themselves of this tremendous vaccine to prevent those types of things happening to people,” she said. “It’s really tragic.”

Such cases are why the American College of Obstetricians and Gynecologists, or ACOG, and the Society for Maternal-Fetal Medicine — the two leading organizations representing physicians and scientists who specialize in obstetric care — that all who are pregnant get a covid vaccine.

“It’s kind of a perfect storm situation,” said Dr. Mark Turrentine, an obstetrics professor at Baylor College of Medicine, who is also the co-chair of a covid workgroup for ACOG. “We have a highly infectious variant of covid-19 virus in a group of individuals that the majority are not immunized. So yeah, we are seeing a lot of sick people.”

“ACOG encourages its members to their patients,” Dr. J. Martin Tucker, president of ACOG, said in a written statement. “This means emphasizing the known safety of the vaccines and the increased risk of severe complications associated with COVID-19 infection, including death, during pregnancy.”

Vaccinating those who are pregnant has become especially urgent in states such as Texas, where the highly contagious delta variant currently makes up more than 75% of new cases. The percentage of people in , compared with 50.3% of the entire U.S. population. As infection rates climb in the state, Dr. Jessica Ehrig, obstetrics chief at Baylor Scott & White Medical Center in Temple, Texas, said she’s seen a significant increase in the number of pregnant women being hospitalized and intubated; some have died. And those severe cases of covid are also dangerous for the fetus, she noted.

“Complications include preterm birth and prematurity, increased risk of preeclampsia for these moms — which can require preterm delivery,” Ehrig said recently at an Austin press conference on the topic. “And, unfortunately, also increased risk of stillbirth.”

It’s an especially dangerous situation when someone who’s pregnant gets a symptomatic case of covid, Turrentine noted.

“There is a threefold increase of intensive care unit admission,” he said, “two-and-a-half-fold increased risk of being put on mechanical ventilation or bypass support, and there’s even, you know, a little over a one-and-a-half-fold increased risk of death.”

Medical professionals and scientists don’t know exactly why those who are pregnant are at such high risk when they become infected with the virus, but they are concerned this population is especially vulnerable because so many of them remain unvaccinated.

Since April, the CDC for those who are pregnant as the best way to protect them and their babies from the coronavirus. Although people who are pregnant were of the three covid vaccines authorized for emergency use in the U.S., significant data gathered since then has .

Turrentine said it’s important to stress that the benefits of getting vaccinated far outweigh any kind of risk. Especially for someone who is pregnant, he said, the costs of not getting vaccinated are just too high.

“I have seen some pregnant women get really sick. I mean, I have seen some die,” he said. “And, you know, you go into this business as an obstetrician-gynecologist because patients are young and they are healthy. And most of the time you have great outcomes. This is a bad virus.”

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Travis County Judge , the county executive in the Austin area, put together a vaccination event recently. Brown said he’d been hearing concerns that there weren’t enough places to get a covid-19 shot on the east side of Austin, which has more Black and Latino residents and more poverty than other parts of the city.

So, Brown asked a hospital for extra doses. And with 600 in hand, he worked with other local officials to set up a temporary drive-thru vaccination site in a southeast Austin parking lot. 

“They all realized that we need to get the vaccines in the arms of people who are in the hardest-hit ZIP codes,” Brown said. “People who are Latinx, who are African American — and especially who are over 65, because those are the people who get sickest.”

When Texas first released its distribution plan, advocates and local officials raised concerns. Twenty-three states, including Texas, are tracking vaccination rates by race, and Texas, like all the others, is vaccinating Black residents at a slower rate.  

Texas House Member , a Democrat who represents Black and Latino communities in East Austin, said she pointed out that the initial plan had 65 vaccine sites for Austin, but only nine on the east side.  

“Without a doubt, we are seeing disparate treatment of distribution and providers,” she said.

Part of the reason is that the plan relied heavily on chain stores, such as H-E-B, Kroger, Randalls, Walgreens and CVS. Brown said those big grocery and drugstores just aren’t as prevalent in East Austin.

“The fact is, this part of town, frankly, does not have as many H-E-Bs, pharmacies, [and] has a higher uninsured rate,” he said.

Mayor said his office has been lobbying state health officials to turn over the bulk of the vaccines to local governments, which know best how to get them to the hardest-hit communities.

“I believe that it goes out much more quickly and goes out to the people who most need it,” he said.

And this lobbying has worked. Recently, Texas health officials have started giving vaccines to local health departments, which are set up to vaccinate thousands of people. 

But there have been hiccups.

State officials against city leaders in Dallas who planned to use their hub vaccine distribution solely for Black and brown communities. The city has since decided to abandon that plan, according to The Texas Tribune.

Then there is the issue of scarcity. For example, the week of Jan. 18, Austin officials got about 12,000 doses for a city of about 1 million people. 

Jeremy Lopez, who lives in East Austin, signed up to get a vaccine from the city as soon as he could. Lopez had a kidney transplant in 2006 and is in a high-risk group. But he still has no idea when he’ll get vaccinated.

“There’s no definite time frame of like ‘Oh, in a week. Oh, in two weeks,’” he said. “It’s like ‘Don’t call us; we will call you.’”

Local officials are urging people to be patient.

Austin City Council Member said she thinks everyone, including state and local government, should have done more planning.

“I am a member of Austin’s governing body, and I’ve got to tell you that I don’t think we have done everything we could have to make certain that we were prepared for what we knew was coming,” she said.

That includes having plans to prioritize the hardest-hit communities, Harper-Madison said.

Cole said Black and Latino Texans have already been through enough.

“The underserved community already has to deal with economic disparity and loss of jobs with covid — and then to add this additional burden is not good. It’s not fathomable,” she said.

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“Just when I started to get to feeling better and I would have a couple of good days,” Alvarez said. “I felt like I’d backtrack and I was just really run down. This thing lingered and lingered.”

Alvarez, a Tejano musician who lives in the San Antonio area, said he eventually got a free COVID-19 test provided by the city of San Antonio. A week later, he found out he tested positive for the coronavirus.

Alvarez and his wife — who also became infected — never ended up in the hospital, and they feel fine now. But, he said, there were some scary days — he knows a lot of people who got sick with COVID-19. A friend around his age — mid- to late 40s — has been in an ICU and on a ventilator for weeks now.

But it was not just their health that worried Alvarez. Financial fears loomed large, too.

“We thought if something happens and this starts getting much worse, we need to start thinking about how we are going to deal with it, how we are going to pay for it,” he said. “It was just abject terror as to what was going to happen and what we were going to do.”

Money is tight because the pandemic shut down most of his musical gigs. Alvarez also lost his health insurance a year ago when he was laid off from his day job in construction safety. While he was sick with the coronavirus he paid for remote doctor visits, some prescriptions and over-the-counter medicine all out-of-pocket, he said.

“I use discount cards for those prescriptions as much as possible,” Alvarez said. “If something is not generic, that’s just absolutely too expensive, I have to consider doing without it.”

Texas’ uninsured rate has been climbing along with its unemployment rate as COVID cases also surge in the state. Before the pandemic, Texas without insurance among all states. And 20% of in the U.S. live in Texas.

The uninsurance problem has only gotten worse in Texas in 2020. According to recent data from Families USA, a consumer health advocacy group that supported the Affordable Care Act, don’t have health insurance so far this year.

The group found that about 659,000 people in the state became uninsured between February and May as job losses soared. Texas is one of under the ACA.

“Texans who lose their health insurance that is tied to jobs simply have fewer options for new insurance because we do not have Medicaid expansion,” said Elena Marks, the president and chief executive officer of the Episcopal Health Foundation in Houston.

Republican leaders in Texas have long refused to expand health coverage to more low-income adults through Medicaid, despite the state’s having had the highest uninsured rate in the country for years.

Marks said the pandemic has made the state’s existing health insurance crisis much worse.

“Everything that’s happening now was happening before — it’s just on a path of acceleration,” she said, because there are “so many more people who are sick and who are getting very sick and the costs are very expensive.”

And this is hurting patients. Stacey Pogue, a senior policy analyst at a think tank in Austin called Every Texan, said uninsured Texans could face steep costs for COVID treatment and testing.

Although some Texans are able to find free COVID-19 testing, others have had to pay as much as a few hundred dollars. Pogue said for people who are already financially strained, that’s prohibitively expensive.

“We need to do everything we can to make sure people are not afraid to get tested because of cost, or are not afraid to get treatment because of cost,” she said. “And states like Texas with such a huge uninsured population, that’s a huge barrier to our public health response.”

And when uninsured, poor Texans have no choice but to go to the hospital, those hospitals end up with much of the cost.

John Hawkins, senior vice president for advocacy and public policy at the Texas Hospital Association, said that even before the pandemic the cost of care provided to people without insurance in Texas hospitals amounted to more than $7 billion a year.

“We’ve been able to make it work, frankly, because of the growth in the state,” he said. “But as we look at COVID going forward, it really does make the case that we have to look at addressing the coverage piece.”

Hawkins said federal relief money will be directed to health care providers in the coming months. Long term, however, he said this is unsustainable for Texas hospitals. If unaddressed, this financial burden on hospitals could lead to future cuts and possibly closures, he warned.

If state lawmakers don’t start addressing the state’s coverage issues soon, Hawkins predicted, it will become a significant issue during the state’s upcoming legislative session early next year.

Even before the pandemic, health care advocates in the state had begun organizing in an effort to make Texas’ uninsured rate a political liability for state lawmakers in November.

And for Texans currently living without insurance, not having health care coverage has been an added financial stressor.

Alvarez said he and his family are already doing everything they can to defer payments and bring in money so they don’t lose their house.

“But that bottom is going to fall out soon enough,” he said. “And that’s what I am really dreading right now. And I know that that’s not an uncommon thing that’s going on.”

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The law, which takes effect Jan. 1, wavered last month when the Texas Medical Board drafted the rules for its implementation. The board, made up of health care providers, tried to get a blanket exception to the law for virtually all nonemergency cases.

Instead, after an outcry from advocates and media coverage by KUT, NPR and Kaiser Health News, the board decided to relinquish its rule-making authority.

The Texas Department of Insurance instead writing the rules that health care providers will have to follow. On Wednesday, the agency a set of rules that advocates say are good for patients.

“Patients should never be asked to sign away their protections and pay a much higher price when they have no realistic alternative and incomplete information,” said Stacey Pogue, a senior policy analyst with the Center for Public Policy Priorities in Austin. “This new approach ensures there are no loopholes for patients.”

At issue is a piece of the law meant to allow patients to freely choose a doctor out of their insurance networks when they wish. In those cases, patients can sign a form saying they realize they may have to pay more for out-of-network care. The medical board tried to interpret that part of the law broadly, so that every patient would sign such a form before any nonemergency procedure. Earlier this year, Republican and Democratic lawmakers came together to pass legislation that would shield people with state-regulated health insurance plans from getting expensive bills for out-of-network care ― particularly in cases when patients cannot choose their provider.

creates an arbitration process for insurers and providers to negotiate fair prices for that out-of-network care without involving patients. Currently, patients can get a “surprise bill” when both sides can’t agree on a fair price.

Consumer advocates ― who had championed SB 1264 ― began raising concerns when agencies started writing rules for the law. Pogue and others said that patients would essentially be signing away most of the rights guaranteed to them in the new law.

After news media flagged the exception, Lt. Gov. Dan Patrick released a stern statement expressing his unhappiness with the board’s proposed rules.

“After passing the strongest ‘surprise billing’ protections in the nation, I am not happy to learn that attempts may be being made at the Texas Medical Board to create a loophole to undermine this important law,” he said in the statement. “Members of the Texas Medical Board should be aware that the Texas Senate approves all appointments to the TMB. I believe it is unlikely the votes would be there to confirm new interim appointments or approve the reappointment of any member who votes to circumvent the intent of clearly written legislation.”

Jamie Dudensing, the CEO of the Texas Association of Health Plans, said the state insurance agency’s new rules “correctly implement the consumer protections in Senate Bill 1264 and ensure Texas patients no longer have to worry about surprise billing.”

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Earlier this year, lawmakers from both parties came together on legislation to protect people in state-regulated health plans from getting outrageous bills for out-of-network care. The new law, known as Senate Bill 1264, creates an arbitration process for insurers and providers to negotiate fair prices in those cases. The intention of the law is to establish those fair prices without ever involving patients.

But that protection is at risk of becoming “irrelevant,” consumer advocates in Texas say.

“The financial struggle that legislators were trying to remove us from ― trying to protect us from ― patients might be right back in the middle of that situation,” said , a senior policy analyst with the Center for Public Policy Priorities.

State agencies are writing the rules to implement and enforce the new law. Some of those rules, which will be discussed publicly in early December, will let hospitals and other care providers send patients bills in nonemergency situations, such as scheduled surgeries.

One state agency hashing out how the law will work is the Texas Medical Board, which is run by physicians and regulates other doctors in the state. Pogue said the board has proposed a rule that would expand the use of a narrow exception in the law. SB1264 created an exception for patients who knowingly want to receive nonemergency care from a doctor who is out of their health plan’s network. In those cases, patients would sign a waiver with the expectation of paying those out-of-network costs.

The board’s proposed rule takes that narrow exemption ― intended to be used only when patients want a particular out-of-network doctor ― and instead would require all out-of-network providers in nonemergency situations to give patients that waiver.

In practice, advocates say, the rule could essentially require out-of-network providers — like anesthesiologists and pathologists — to give patients a confusing form that waives their right to the new law’s protection. The form would allow the patients to be balance-billed.

“Now it’s a loophole,” Pogue said. “It’s a loophole in the [law] where legislators wanted to give a protection ― a win-win. And now some patients are going to get a lose-lose.”

According to the Texas Medical Board, the proposed rules “require an out-of-network provider to provide written notice and disclosure to a patient no less than 10 business days prior to the date of a nonemergency procedure.”

“The patient must have five business days to consider whether to accept, and may not agree prior to three business days after the notice was provided,” Jarrett Schneider, a board spokesman, said in a statement. “This allows for a cooling-off period so the patient has adequate time to decide whether to proceed if there are, in fact, out-of-network charges.”

Pogue said the rule also forces patients to choose between “two terrible outcomes” ― either paying more for providers they didn’t choose or forgoing a needed medical procedure.

The proposed rules are expected to be discussed during the board’s meeting early next month and could possibly be adopted at that time.

“It creates a path for any provider that wants to continue to send out-of-network bills [and] continue to balance-bill,” Pogue said. “It creates a pathway where they can do that.”

Schneider maintains that this is not the intent of the proposed rule.

“The Board’s proposed rules do not waive any rights a patient has under Senate Bill 1264 or any statute,” he said in a statement. “The Board has put forward that it believes provide patients with enough advance notice to make a reasoned, economic decision in regards to the care they are receiving.”

Jamie Dudensing, CEO of the Texas Association of Health Plans, said in a statement that he believes the proposed rule “misinterprets the law’s intent” and makes surprise-billing protections weaker than they were before the law passed.

“Senate Bill 1264 has been praised as the strongest surprise billing law in the country — now we are in danger of making it almost completely irrelevant,” Dudensing said. “Instead of allowing for rare exceptions to surprise billing protections, the proposed rule would mandate the exception, resulting in patients losing all surprise billing protections in nonemergency situations.”

Blake Hutson, the associate director for the AARP of Texas, said he’s most concerned that the rules are vague about how the waiver would work. He said the state has created a unique exception in an effort to give people more freedom in choosing doctors, but it has come with a lot of confusion.

“Other states that have addressed the surprise medical bill issues haven’t created an exception for nonemergency, out-of-network physicians like we did,” Hutson said.

Among Hutson’s concerns are that the proposed rules do not make it clear that providers should mostly rely on the arbitration process set up under the new law to figure out payments. Instead, it requires them to use the proposed form, which various advocates say is hard to understand.

Hutson said the proposed waiver form also doesn’t make it clear that patients don’t have to sign it. And, he said, there’s no clear process for what happens if patients refuse to sign the waiver. Hutson said the medical board should create a way to ensure people can still receive care even if they refuse to be balance-billed.

“This is totally fixable,” Hutson said.

Advocates say they are worried that many of these concerns won’t be dealt with during the rulemaking process, though, and instead will have to be addressed during the next state legislative session in 2021.

State Sen. Kelly Hancock, a Republican from North Richland Hills, sponsored SB1264. He said “a rulemaking process that does not protect all patients … is not something we will be willing to accept.” Hancock said the intent of the legislation was to protect every Texan with state-regulated health insurance from getting balance-billed by any provider.

“We are trusting the process, but we are also verifying the process to make sure we get the end result we are looking for,” Hancock said. “And, frankly, what I think those who support the legislation voted for.”

State Rep. Tom Oliverson, a Republican from Cypress who co-sponsored the bill, said he’s not as concerned as others about the proposed rules. He said the waiver process included in the bill was supposed to be something that was rarely used and he thinks the board’s final rules will honor that.

Oliverson, who is an anesthesiologist in Texas, said he doesn’t anticipate providers will abuse the waiver system.

“It was designed to be something that was seldom used, but we are not going to let it become a pathway to avoid the law,” Oliverson said. “And if it gets abused, we will come back in 2021 and get rid of it.”

Hancock said it is fairly unusual for bills to go through a rulemaking process this bumpy. He said he thinks this is happening because the stakes for this process are high for many entities who may have been relying on surprise billing as a source of income.

“We have no intentions of seeing the efforts and the intentions of legislators being ignored ― just because associations want to get things their way,” he said.

Pogue said this situation is particularly disheartening because it was a bipartisan effort in Texas, a rare phenomenon.

“I haven’t seen a bill with a scope this big ― that could be this meaningful for the financial security of a family — pass in the 12 years I have been doing this,” Pogue said.

Hutson said SB1264 was “painfully created” and lawmakers took the time to find a compromise with both insurers and providers, which is no easy task.

“There’s a lot of money in health care ― and so the different interests are going to use whatever they can to collect money on the backs of consumers wherever they can, unfortunately,” Hutson said. “It’s frustrating.”

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There were more than providing abortion in Texas on July 12, 2013 — the day lawmakers tough new restrictions and rules for clinics.

Even though abortion providers fought those restrictions all the way up to the U.S. Supreme Court, and managed to get the restrictions overturned in 2016, most of the affected clinics remain closed.

Today, just 22 clinics are open in a state that is home to 29 million people.

Although abortion providers won the legal battle, they appear to be losing the war. Most clinics are clustered in the major cities of Dallas, Houston and Austin, while women who live in smaller cities and towns that once had clinics now have to travel long distances for an abortion.

The West Texas town of San Angelo, for example, once had a Planned Parenthood clinic, but it had to close in 2013. It had been one of the last abortion providers in the sprawling, dry and mostly rural region, where most residents must drive at least three hours to reach a major city.

Susanne Fernandez, who worked at the San Angelo clinic for almost 30 years, gets emotional talking about its closure. “I loved working for Planned Parenthood.”

Fernandez blamed the closure on the 2013 state law, known as House Bill 2, which required abortion clinics to have the same sort of — and also required the doctors performing abortions to obtain admitting privileges at a nearby hospital. She said complying with those rules would have been extremely difficult and expensive. Still, the decision to close the San Angelo clinic was tough.

“The last day was sad. It was somber,” Fernandez said. “We did a lot of cleaning up. We all knew that was it.”

Abortion providers in Texas eventually sued the state. But as the legal challenge worked its way through the courts, many of the clinics were forced to stop providing services.

At one point, Texas had only 17 clinics, said , an investigator with the Texas Policy Evaluation Project at the University of Texas-Austin. She said women living in rural Texas were affected the most.

“What we saw is that [in] West Texas and South Texas, access was incredibly limited,” White said, “and women living in those parts of the state were more than 100 miles — sometimes 200 or more miles — from the nearest facility.”

White’s research team conducted surveys and interviews with women who were seeking abortions as clinics were shutting down. A 19-year-old woman told the researchers she considered giving up because it was so hard to find an open clinic.

“It was a very hard thing to do, like to keep calling and calling and calling,” the woman told researchers. “I almost was like, you know, ‘Well, forget it.’ … But then, because I knew at the end of the day it was something that I had to do, it was like ‘I don’t care how many people I have to call or how far I have to go. I have to do it.'”

That woman eventually found a clinic 70 miles away and was able to get the abortion. But in some other cases, women carried unwanted pregnancies to term.

Texas law requires women to have two appointments with an abortion provider. After an initial appointment at a clinic, they must wait 24 hours before getting the procedure. That means women often have to make a long trip at least twice, or pay for a hotel nearby. The waiting period is waived only if a woman lives more than 100 miles from the closest clinic.

A 23-year-old woman from Waco, a married mother of two, told researchers she made appointments to get an abortion at two clinics. But both appointments were canceled after the clinics were forced to close. She was unable to end the pregnancy.

“I was pretty upset, but I just decided that I guess I’ll have to just ride it out,” she told researchers. “I didn’t know what else to do, who else to call.”

Eventually, in the summer of 2016 — three years after H.B. 2 passed — the U.S. Supreme Court the tough new restrictions on clinics. But most of the clinics never reopened.

“There hasn’t been this rush of clinics reopening following the Supreme Court decision,” White said. “So there are still just clinics concentrated in the major metropolitan areas of Texas.”

The ruling has also been a mixed bag for anti-abortion activists, said John Seago, the legislative director for .

“The closures of clinics is definitely a victory for the movement, obviously,” he said. “However, how are we in this situation in the first place is what my organization looks at.”

Seago pointed to Roe v. Wade, the Supreme Court case that made abortion legal in the U.S. He said anti-abortion activists fight legal battles on the state level in an effort to reverse Roe, and the Supreme Court ruling on Texas’ law was a big blow to the larger goal of slowly dismantling Roe.

Some New Options In Recent Years

Over the past three years, a few abortion providers have decided to open clinics in Texas.

For example, earlier this year Kathy Kleinfeld opened a new abortion clinic in Houston — a city that already had a few clinics providing abortion.

Kleinfeld, a longtime consultant for abortion providers in Texas and other states, decided to open in Houston after carefully looking at the demand for services in that region. Her clinic provides medical abortions using pills, but not surgical abortions.

“Due to the closure of so many clinics, the remaining clinics that are open are very busy, and they are very strict in the scheduling,” Kleinfeld said. “So our goal was to offer flexibility in scheduling.”

Kleinfeld said her clinic could help take some pressure off the remaining clinics in Houston. She said so far her patients have been professionals, students and women who drive over from Louisiana.

But she emphasized that getting her clinic up and running was not easy, despite her intimate knowledge of the complex rules and mandatory paperwork and the surprise inspections involved in operating as a licensed abortion provider in Texas.

Kleinfeld predicted that opening and running a clinic, and keeping it open, will always be difficult in Texas.

“There’s always been volatility and conflict and struggles,” she said. “Always. And this is not for the faint of heart.”

Andrea Ferrigno agrees with that assessment. As the corporate vice president of , Ferrigno helps operate several clinics that offer abortion in Texas.

She recalls that after H.B. 2 passed in 2013, Whole Woman’s Health was forced to close two clinics — one in Austin and another in Beaumont, a small city near the Louisiana border. So far, Whole Woman’s Health has been able to reopen only the Austin clinic.

“It’s basically starting from scratch,” Ferrigno said. “You laid off the staff; you don’t have any physicians that work there anymore. Some of the doctors didn’t even renew their physician licenses.”

Ferrigno said clinics that closed may have lost the state-issued license needed to operate. Applying for a new one is a significant bureaucratic hurdle. Some clinics might have lost their leases and been forced to vacate their buildings and sell off equipment.

“There are a lot of different limitations,” she said. “There’s also the question of — or the fear of — security challenges. People picketing the clinic, picketing their homes. There’s a lot that goes into that.”

But the cost of not reopening — particularly in a community that had only one clinic to begin with — may be high.

Take San Angelo, for example: Fernandez said she doubts a clinic offering abortions will open in her town anytime soon. She sometimes wonders what happened to the women she used to help.

“Where did these women go? Where do they go now?” Fernandez said. “I don’t believe a lot of them found any other health care afterwards.”

This story is part of a partnership that includes , and .

Â鶹ŮÓÅ Health News' coverage of women’s health care issues is supported in part by .

Â鶹ŮÓÅ Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Â鶹ŮÓÅ—an independent source of health policy research, polling, and journalism. Learn more about .

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