Texas has 18 residency programs in the field of obstetrics and gynecology, but only one allowed me to observe how abortion is taught. Because of the political pressures facing abortion providers, NPR agreed not to reveal the doctors’ full names or the clinic’s location. The resident agreed to be identified by her middle name, Jane.

Medical residents can opt out of abortion training for religious or moral reasons, but Jane felt a professional obligation to learn the procedure.

“This is part of OB-GYN — it’s not an optional part, per se,” Jane said. “Women can choose if they want an abortion or not, but you as their doctor need to be able to provide them with all the choices available.”

“Some of them want very much to be able to train residents,” she said. “But they are fearful of the other sectors of the university coming down on them and saying, ‘You’re threatening our funding.’ ”

Academic medical centers in Texas receive tens of millions of dollars a year in state funding. Many of those centers sponsor residencies, which are the training programs that come after medical school. They last four or more years and allow doctors to focus on a specialty.

It’s understandable why an OB-GYN resident in Texas might think twice about providing abortions. Doctors who provide the service must think about security issues for themselves and their staff. They also have to deal with the scrutiny of state inspectors as well as anti-abortion protesters.

Last summer, hundreds demonstrated outside the Planned Parenthood affiliate in Houston after an anti-abortion group released a series of undercover videos purporting to shed light on problems with fetal tissue research. (Planned Parenthood maintains the videos are deceptively edited and denies wrongdoing.)

“Aren’t you glad you’re from Texas, a pro-life state?” a man shouted into a microphone. “We’ve got great, pro-life leaders, like Sen. Ted Cruz,” he added, as the crowd burst into cheers. Later, they prayed and sang The Battle Hymn of the Republic.

Surveys and other research show that doctors who do abortions may have fewer job opportunities. That’s because many hospitals and group practices refuse to employ doctors who do abortions, even if they do so during evenings or weekends, on their own time.

A few years ago, 48 doctors in Texas did abortions, but a recent study shows it’s nowÌý. And some of the remaining doctors are nearing retirement.

Dr. Bernard Rosenfeld, 74, hasn’t been able to line up a successor to lead his medical practice. He says he understands — he’s been dogged by protesters for years.

“They’ve picketed my house where I live,” he said. “They put bullets in our parking lot.”

Rosenfeld has two medical offices but provides abortions at only one, a modest brick building in Houston’s museum district. He bought the from other doctors in 1982, but now he can’t find anyone to buy it from him.

“I’ve talked to some doctors, but none of them are interested in the political consequences of providing abortions,” he said.

As the number of doctors in Texas dwindles, medical educators have raised the alarm about the need to train the next generation.

To find out how much abortion training was going on, I contacted all 18 OB-GYN residency programs in Texas. Although abortion is legal, and these programs are expected to provide some access to abortion training, my queries were frequently met with fear, evasion or even outright hostility.

One OB-GYN professor in Dallas hung up on me. Another agreed to an interview, then canceled.

Six of the programs, a third of the total, simply refused to answer questions about how the training takes place.

“UT Health does not want to participate in that story,” said a spokeswoman for the University of Texas Health Science Center in Houston. “It’s not a story that benefits us.”

UT Health two OB-GYN residency programs, both at Houston hospitals.

In the end, I could only confirm that three out of the 18 programs in Texas had made arrangements for residents to spend time learning at an outpatient family-planning clinic. Those types of clinics are where most abortions in Texas take place.

It’s unclear how some of the residency programs are handling the training requirement. Some directors point to the difficult fact that the nearest abortion clinic is now closed. Other directors may be providing some options for training, but wouldn’t talk about it publicly.

One doctor who would was , who was recently the residency director at Texas Tech University Health Sciences Center in Lubbock. The last clinic that provided abortions in Lubbock in 2013.

“As of now, there’s really nothing in a close radius to us,” Casanova said. “Our patients will go to Albuquerque; they’ll go to Dallas; they’ll go to Denver.”

Casanova was left in a similar bind, with no local clinic where the OB-GYN residents could learn.

To compensate, Casanova created special seminars that cover elective abortion. He even arranged for guest speakers to fly down from Denver.

Since 1996, all OB-GYN programs in the U.S. must offer the residents at least to learn abortion techniques, even if the training happens elsewhere. If the residency programs don’t do so, it can affect their accreditation.

In Texas, all 18 programs are currently accredited — even in places like Lubbock, where there are no longer any clinics that perform the procedure.

Given the political climate in Texas, and the dwindling number of such clinics, residency directors have had to scramble to find other ways to fulfill the curricular requirement.

, the residency director at the University of Texas Medical Branch, in Galveston, said it’s one of the thorniest logistical problems he’s encountered. His OB-GYN residency program is a large one, with slots for 32 residents.

“We cannot teach them the procedure itself,” Wen said. “Can we teach them the concept and describe the procedure and that sort of thing? Yes, we can do all that.”

Wen explained he is hampered by three factors:

• Like most hospitals in Texas, UTMB does not allow elective abortions. Doctors must obtain special approval to do abortions for other reasons, such as severe abnormalities in the fetus or a threat to the mother’s life.
• Galveston does not have an outpatient abortion clinic. Wen has arranged for his residents to be able to travel for training to a clinic in Houston, an hour’s drive away, but almost none have gone.
• The faculty physicians at UTMB accept reimbursement from the , a state-funded program for the medical treatment of low-income patients. The doctors cannot be paid if they perform elective abortions or affiliate with an organization that does. The upshot is that Wen and his colleagues cannot teach the procedure, even at an off-site clinic.

Most of his residents don’t seem bothered by the situation, Wen said.

“If this part of the training is very important to them, more likely they will probably rank and choose another residency program to go to, instead of come to Texas,” he said.

That’s not to say the politics haven’t affected the curriculum in other ways, explained Wen.

Because getting an abortion has become more difficult in Texas, more patients may beÌý to try to induce a miscarriage, and those pills don’t always come with clear instructions.

“Here in Texas, they could easily cross the border and get that medication,” Wen says. “A lot of people’s thinking process is ‘If five tablets [are] good, ten must be better!’ ”

Wen has started teaching the residents how to diagnose a woman who has overdosed on abortion drugs, and what to do to save her life.

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“There are places in Texas where there are OB-GYN residents who can’t get anywhere to be trained,” said a senior doctor at one Texas clinic who is also a medical school professor. The physician asked not to be named to avoid backlash from anti-abortion groups and politicians.

Clinics that used to perform abortions have closed recently in Lubbock, Odessa and other Texas cities. But the professor’s clinic, which still does abortions and trains some OB-GYN residents, can’t take up the slack.

That procedure is known as a , or “D and C.” The cervix is dilated, and then a suction instrument is inserted to remove tissue from the uterus.

D and Cs are also used to treat excessive bleeding, or to take a biopsy from inside the uterus.

“I like to say that a D and C, a suction D and C even, is bread and butter gynecology,” she explained.

OB-GYNs have always learned the D and C procedure. There’s nothing controversial about it, per se. But when it’s done because a woman chooses to end a pregnancy, it’s called an elective abortion, and to be able to perform the procedure in such a case, the doctor needs to have additional training.

Elective abortions are almost always done on an outpatient basis. To do them, doctors learn how to counsel the patients and manage their pain during the five-minute procedure. They also need to learn how to administer — the ones that use pills.

In addition, many states like Texas require doctors to perform extra steps, such as reading out loud a state-mandated script to the woman or having her listen to the fetal heartbeat.

OB-GYN residents can’t learn all that’s required without spending time at an outpatient clinic, which is where most abortions in Texas .

But in Texas, there are only 18 of those clinics still in operation.

(Story continues below)

Use the “+” sign above to zoom in and see how residency programs responded to the question: “How are ob-gyn residents trained in abortion?”

• Green dots indicate the residency is located in an area where clinics still offer elective abortion (12).
• Yellow dots indicate that a nearby clinic still provides abortion, but the clinic could close soon depending on the U.S. Supreme Court’s interpretation of Texas law (2).
• Red dots indicate that none of the clinics left in the area provide abortion (4).

That worries , a medical sociologist at the University of California, San Francisco. “How can you have abortion provision if you don’t have trained doctors?” Freedman said. “Especially the ones likely to stay in your state.”

Abortion training has become more common in the U.S. but only in some areas in the country. “We’ve trained a lot of people, but they’re staying in relatively liberal, urban areas,” Freedman said.

Texas has 18 OB-GYN residency programs. All of them undergo periodic reviews by the Accreditation Council for Graduate Medical Education, or ACGME, in Chicago.

One of the things the reviewers look for is whether residents have opportunities to learn about induced abortion, called that to distinguish it from a miscarriage.

All 18 residency programs in Texas are currently accredited, even though some of them are located in cities where outpatient abortion providers have closed.

Programs without abortion providers nearby have other options for fulfilling the training obligation, said , ACGME’s senior vice president for surgical accreditation.

He explained the residents don’t have to perform elective abortions. They can practice terminating pregnancies in the hospital, for other reasons.

“As long as they’re getting sufficient experience in some form of abortion, you know, where the mother’s life is in danger, where there’s significant neonatal abnormalities,” Potts said.

In other words, to become an OB-GYN, the resident must know how to safely empty a woman’s uterus if her pregnancy is experiencing a medical complication. For situations when it’s the woman choice to end pregnancy, residents can hear lectures about it, perform simulations or practice counseling skills on each other.

Some Texas professors maintain that minimal standard of experience is good enough — or, at least, the best they can do under the circumstances.

But I asked , who has been providing abortions in Houston for decades, if he thought it really was enough to learn how to perform elective abortions.

“No, absolutely not,” he said.

When residents are learning to do D and Cs, they usually do them in the hospital, and the patient is often asleep, Rosenfeld pointed out. But most abortions in this countryÌý in outpatient clinics.

At the clinics, patients get a local anesthetic or none at all. That makes the abortion safer for the patient, but it requires more skill on the part of the doctor, according to Rosenfeld and other experts.

“Time is a big factor, and causing as least pain as possible, and having a very gentle touch,” Rosenfeld said. “But all that is learned.”

Residents won’t have competence in performing abortions until they do dozens of outpatient abortions, Rosenfeld said.

“Nobody would ever say that about a cesarean delivery or a regular delivery: ‘Well, OK, you just saw one or two, so you can just do them,’ ” he said. “Lots of time you’ll have uterine abnormalities and you’re not going to know unless you’ve done many procedures what to do with a uterine abnormality.”

There’s one more intangible, but critical, experience residents get from abortion training, many doctors say.

Jane summed it up this way: “Every woman has a different story and a different reason why she chooses to end her pregnancy.”

Hearing those stories from patients is crucial to a an OB-GYN’s professional development, said , an OB-GYN professor and researcher at theÌý at UCSF.

The experience teaches valuable bedside skills like compassion, empathy and political awareness.

“When they spend time in a setting that provides abortion care, they have real epiphanies,” Steinauer said. “They become more aware of their biases. They’re surprised that more than half of women having abortion are already mothers, for example.”

Steinauer’s also shows that OB-GYNs who have access to training during their medical residencies are more likely to provide abortion later in their careers.

But some doctors question the need for more training, saying if residents really want abortion skills they can leave Texas to acquire them, and then come back to the state to practice.

Other OB-GYNs, like , executive director of the American Association of Pro-Life Obstetricians & Gynecologists, condemn the entire concept. Harrison believes abortion is killing an unborn child.

“It should not be part of any kind of medical training to do elective, induced abortions,” she said.

Residents have always been able to “opt out” of abortion training if they have moral or religious objections, Harrison acknowledged. But some residents might feel pressured to do the rotation, she said, and they could end up indoctrinated with the view that elective abortion is OK.

“If you do a procedure that you have moral qualms with, there’s a kind of desensitization that goes on,” Harrison said. “The attempt to force residents to participate in abortion is an attempt to desensitize those residents, so they will have less ability to think clearly about what that procedure is actually about.”

But Freedman, the medical sociologist, disagreed that abortion training amounts to indoctrination.

“If you look at medicine in general, how many things do we do to teach people empathy, sensitivity, compassion about a lot of things?” she asked.

Doctors will always have patients whose life decisions they privately disagree with, Freedman said, but it doesn’t help the patient when doctors judge them or withhold a treatment or procedure.

“Things happen to people that they don’t want, health-wise, all the time,” she said. “We just need doctors to know how to do this.”

According to a , 97 percent of OB-GYNs have had a patient who wanted an abortion. But only 14 percent of those doctors actually provide abortions.

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The county, which includes Houston, stretches across 1,777 square miles and is the third most populous county in the U.S. The area’s warm, muggy climate and snaking system of bayous provide an ideal habitat for mosquitoes — and the diseases they carry.

The county began battling mosquitoes in earnest in 1965, after an of St. Louis encephalitis. Hundreds of people contracted the virus and 32 died.

These days, mosquito control efforts include chemical spraying: on foot, by truck and occasionally from airplanes. But spraying happens strategically, after careful research reveals the geographic distribution of infected mosquitoes, and sometimes birds, which carry West Nile.

To that end, the county employs 50 scientists and technicians year-round. In the summer, the county hires two dozen more workers. They set traps, sort mosquitoes by species and conduct lab tests for five viruses: , West Nile, Ìý²¹²Ô»å . This year, they’ve added .

The county’s tab for mosquito control runs $4 million or more a year.

More KHN Zika Coverage

“We have the , which is the yellow fever mosquito. And also the , also known as the Asian tiger mosquito, and the mosquito,” Debboun explained. “These are the three that we are after. And thank God, we’re only dealing with three.”

Debbun says they mostly find West Nile — 1,286 cases in 2014, 406 in 2015, none so far this year. He says in the past five years, they’ve had four positive tests for St. Louis encephalitis (also carried by Culex), and none for dengue or chikungunya. Zika — as well as dengue and chikungunya — is transmitted by the Aedes mosquitoes and has not been found in Harris County mosquitoes.

In many municipalities, mosquito control simply means spraying chemicals, Debboun says. But in Harris County, spraying is done strategically. “We go hit the area where we know the mosquitoes have the disease in them,” Debboun explained. “We don’t just go randomly and just spray, and not only waste the pesticide, but also put a pesticide in the environment when you don’t need to.”

Selective spraying also keeps the insects from developing resistance, he says. Occasionally, the county will conduct aerial spraying, but that’s happened only twice recently — after Hurricane Ike in 2008 and during a West Nile outbreak in 2014.

Debboun says his team is prepared for Zika. In 2013, he diversified the traps, purchasing models that are especially attractive to Aedes species, so his employees have had a few years to learn to use those traps. He’s planning to ask the county commissioners for 74 more of the traps, at a cost of $300 each.

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The survey, conducted by marketing research firm Nielsen, assessed attitudes about the health care system, and possible solutions, in five populous states: Texas, California, Florida, New York and Ohio.

The 5,000 respondents were also asked about their party affiliation and insurance status — and height and weight. Those measurements were used to estimate the rates of obesity, for questions about interventions.

The Affordable Care Act allowed states to expand Medicaid to cover more poor adults, but 19 states still have not done so.

Garson noted that more residents in Texas and Florida complained about the quality of health care and felt it was worse than two years ago. Texas was also the state with the most people — 65 percent — saying they were paying more out-of-pocket for health care than two years ago and were cutting down on other expenses to do so.

“This isn’t necessarily a political statement, this is simply, ‘What’s the data?’ And the data are Texas and Florida, the two without Medicaid expansion, are having perceived problems with cost and quality worse than the other three,” Garson said.

The survey did not ask Texans or Floridians if they thought those problems were because political leaders had not expanded Medicaid.

But 63 percent of Texans and 68 percent of Floridians did favor expansion.

Over all five states, the cost of health care was a common complaint, with 58 percent of respondents reporting that they paid more out-of-pocket for health care than they did two years ago.

“Clearly, we as a country, we as a state — couldn’t we find ways to decrease the overall cost of health care?” Garson asked.

The ACA has helped additional Americans get insurance, but Garson says the law didn’t do much to control the actual prices being charged in the health care industry. Consumers feel the financial pressure in their deductibles, copays and monthly premiums.

“Of the uninsured, 87 percent said when they went to the exchange they couldn’t afford it,” Garson said, referring to the online marketplaces where people can buy individual or family insurance plans if their employers don’t provide coverage.

The survey did not ask respondents if they liked the idea of a government-funded “single-payer” system. But many did say universal coverage was important.

“One of my biggest surprises is that 85 percent of everybody asked was looking for ‘coverage for all,’” Garson said. “They are worried about their sisters and brothers. And I think that, at some point, is going to show up in the voting rolls.”

But , a political scientist at Rutgers University in New Jersey, is skeptical about the power of health care as a campaign issue. Baker is not connected to the survey but examined it at the request of Houston Public Media.

Although candidates will talk about Obamacare and health costs, Baker is not convinced it’s the kind of pivotal issue that will motivate voters to choose one presidential candidate over another.

“Generally, people are mindful of the health care issues because they are very practical, day-to-day concerns, but whether or not they would get out of bed on Tuesday morning in November, and go to the polls based on their feelings about whether or not Medicaid should be expanded in their state is, I think, subject to challenge,” Ross said.

Rather, the expected contest between Clinton and Trump will probably be decided on their personality differences, Ross said.

The poll also asked about emergency room usage and interventions to combat obesity.

Forty-six percent of respondents admitted they had gone to an ER even when they knew it wasn’t an emergency. The primary reason they gave was the doctor’s office was closed, Garson said.

Respondents also answered questions about extra taxes on sugary drinks and fast food, with more than half of people in all five states saying they would favor such taxes. That held true even in the two more conservative states of Texas and Florida.

The majority of people picked a 25 percent tax as “reasonable,” while almost half (44 percent) said the tax could be as high as 50 percent on sugary drinks.

Politicians should take note that such taxes, often called “fat taxes,” might be acceptable to their constituents as an effective obesity intervention, Garson said.

It’s worked before, he noted: “When you go and look back and ask the World Health Organization about smoking, what was it that really led to the real decrease in smoking? It was the cigarette tax,” Garson said.

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And because Zika can cause birth defects in newborns, many women — and their doctors — are nervous. In the waiting room at Houston IVF, patients are handed a map of Zika-affected countries and asked to fill out a questionnaire.

“The first thing I’m discussing now is Zika,” saidÌý.

Public health officials said there have been 15 travel-related incidences of Zika in the Houston area. Nodler said at least a few couples have had toÌýdelay startingÌýfertility treatment because the woman or her partner already may have been exposed to the virus while traveling south.

“Especially in Houston a lot of our patients and families are in the oil and gas industry,” Nodler said. “These aren’t people who are traveling to Mexico and Puerto Rico for fun or vacation. These are people who have to work in some of these offshore drilling areas.”

Even for patients who haven’t traveled, Nodler is advising they slather on repellant, just in case the virus is already here, but we don’t know it yet.

“No one wants to see an affected child,” he said.

Nodler says couples will need to manage Zika risk together. If his partner is already pregnant, a man should use condoms to avoid sexually transmitting the virus.

All over the city, parents and would-be parents have been absorbing the news about Zika.

“My first thought was ‘I’m pregnant, I’m not going to put DEET all over myself!’ But I guess that’s what we do this summer,” she said.

She’s now wondering if she and her two other kids should move to her parent’s house for the summer, in a less buggy part of Houston.

“The probability is low,” that she’ll contract Zika, she said, “But the potential impact is so great and those are the kinds of threats that can be scary and disproportionately sort of taking up space in my brain.”

Health officials say because U.S. cities have a lot of closed spaces with air conditioning or screens, people are generally better shielded from mosquitoes than in some other countries.

Nonetheless, doctors in Houston have already opened a special clinic where women who have traveled to affected countries can get blood tests and counseling. A second clinic will open this summer.

, a professor at Baylor College of Medicine, said doctors are offering those clinic patients an ultrasound 15 weeks into pregnancy.

“We’ve actually developed a protocol around looking for very special views of the fetal brain and the eyes to look at for any evidence of fetal malformation with the Zika.”

Aagaard reminds her patients that Zika is just one of many possible risks during pregnancy — and risks can be managed, whether that’s through prenatal vitamins, genetic screening, or bug spray.

Zika is tough to talk about, though, because the studies are just not there yet.

“As much as we wish we could give them a very set of clear facts around: this is your risk, this is the time in pregnancy you’re at highest risk, or this is the time prior to planning a pregnancy you’re at highest risk. We simply don’t have that information,” she said. “We don’t know.”

Despite the unknowns, doctors in Houston aren’t telling people not to get pregnant.

What they are telling them is that they need to add mosquito bites to the list of cares and calculations that surround any pregnancy.

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For the moment, Texas Republicans still consider the Affordable Care Act to be political kryptonite. Sen. Ted Cruz continues to criticize it. Attorney General Ken Paxton just filed attacking part of it. Gov. Greg Abbott has said he won’t consider the Medicaid expansion, because he considers Medicaid a dysfunctional entitlement program that should not be allowed to expand.

But the story on the local level is different. Harris County is home to Houston, where Judge Ed Emmett, a moderate Republican who is chief executive for the county, has supported it for years. The CEO of the taxpayer-supported Harris Health System,, says he needs the revenue that Medicaid expansion would bring. He’s had to lay off more than 100 employees and cut back on charity care.

“What is even more profound is that money is going to other states that expanded Medicaid, like New York, California, Connecticut,” Masi says. “And so the taxpayer of Texas is being penalized, if you will, for not taking advantage of that option.”

By emphasizing the impact on taxpayers, Masi and others are framing the issue in terms of economics rather than humanitarian concerns.

“We call it a paradigm shift,” Masi added. “It’s a different way of thinking.”

Government leaders and health advocates from across Houston point out that the costs of caring for the uninsured fall heavily on local institutions. Those patients strain the budgets of hospitals, first responders and even jails.

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During his stay at Texas Presbyterian Hospital in Dallas, two nurses also contracted Ebola. Duncan died, but the nurses survived, as did a handful of Americans who fell ill in West Africa but were transported back to the U.S. for care.

The Ebola outbreak in West Africa, and its spillover into the U.S., launched a national media frenzy and forced hospital officials to take a hard look at their readiness for a serious epidemic.

By February, four months after Duncan died, the CDC had designated 55 hospitals nationwide as future “Ebola treatment centers.” Two are in Texas: and Texas Children’s Hospital in Houston. Many of the 55 hospitals renovated rooms and increased training and simulations for staff in case of an outbreak.

“After the case in Dallas a year ago, we knew there would be a need,” said , medical director for infection control and prevention at Texas Children’s. Campbell helped design the isolation unit, which the hospital began planning to build last fall after Duncan’s death. The $16 million project was paid for out of the hospital’s capital funds and $1 million in donations.

“A year ago in the United States, there were only twelve beds for the entire country for patients that had a need to be isolated in a biocontainment unit. And not surprisingly, zero of those beds were designated for children,” she added.

In the special pediatric unit, each of the eight patient rooms has an antechamber, where doctors and nurses put on protective gear, gloves and ventilated hoods. After treating the child inside the room, they will leave through a separate door and enter a third room, where they strip the equipment off.

The whole time, nurses will observe through large glass windows.

“So if there’s any question they can say ‘Wait, stop. You need to clean your hands again.’ Or ‘Wait, stop. Let’s take this glove off more carefully,’” Campbell explained.

The unit has its own biosafety laboratory, so infected blood samples never have to be carried to other parts of the hospital. There’s also a separate medical waste room, where carts full of used clothing and equipment can be wheeled inside six-foot autoclaves. There’s also a locker room with showers. After every shift, medical workers will shower before leaving the unit.

TCH officials say Ebola was the catalyst for the decision to build the unit, but it is designed to handle any globe-trotting superbug.

“These rooms are equipped to take care of TB, MERS, pandemic influenza, bird flu and even a pathogen that we might not know what it is yet,” Campbell said. “That’s why we wanted to build something with the highest level of isolation ability.”

Before designing the unit, teams from Texas Children’s visited adult biocontainment units at hospitals in Atlanta and Omaha. , a pediatric intensive care specialist, said the medical architecture in the new unit is impressive, but none of it will work without proper training protocols and motivated staffers.

The initial training for working on the biocontainment unit included eight hours of general orientation, followed by 16 hours of learning how to don, doff and maneuver in the biocontainment suits.

“I describe it as a space suit,” Arrington said. “It’s a full-body suit that you put on, that has footies and arm holes and covers you up completely.”

Doctors and nurses who volunteered to work on the unit undertook simulations and mock drills, relearning skills such as inserting IVs while wearing the suit.

“When you put three pairs of gloves on, you [can] lose sensation in your hands because they’re so tight,” said Arrington, “But you really lose that tactile feel that, as physicians and nurses, is really important in taking care of any patient, let alone a child,” Arrington said.

Children have always been especially vulnerable to infectious diseases. During the Ebola outbreak in West Africa, children died at a higher rate than adults.

As pediatricians – and parents – know, sick children need close monitoring. They need encouragement to eat and drink, and comfort when they are scared and confused.

And that’s the drawback to a pediatric biocontainment room – the parents of a very sick child will probably not be allowed inside.

But Campbell says Texas Children’s Hospital is ready for that challenge. At least six doctors or nurses will be assigned to each child, and one of them will act as a family liaison. The kids can also use tablets and video chat to talk with their families, and can see them through the large windows.

And the hospital is developing a special doll — one that will wear the same biocontainment suit as the doctors and nurses.

“So that when the health care providers come in, they understand that, yes, we’re dressed up a little differently but that their little doll has similar attire on,” she said.

The pediatric isolation unit will be ready for patients in late October, with a formal ribbon-cutting expected in November.

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Two years ago, when Texas passed one of the toughest laws in the country regarding abortion, the number of clinics offering the procedure dropped from 41 to 19.ÌýAmy Hagstrom Miller, chief executive of Whole Woman’s Health, has alreadyÌýclosed two clinics in Texas because of the law and was about to close two more.

“Honestly I just can’t stop smiling,” Hagstrom Miller said.Ìý“It’s been so much up and down …Ìýso much uncertainty for my team and the women that we serve.”

The Texas law says doctors who perform abortions must have admitting privileges at a nearby hospital. But some hospitals are reluctant to grant those privilegesÌýbecause of religious reasons or because abortion is so controversial.

The law also requires that clinics meet the same standards as outpatient surgery centers. Those upgrades can cost $1 millionÌýor more.

“It’s an example of the rash of laws …Ìýthat have taken a sneaky approach by enacting regulations that pretend to be about health and safety but are actually designed to close down clinics,” said Nancy Northrup, chief executive of the Center for Reproductive Rights, which is representing clinics in their fight to overturn the Texas law.

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The new law will tighten rules for girls under 18 who are asking a judge to grant an abortion — a small but politically significant fraction of those who seek the procedure. Gov.ÌýGreg Abbott, a Republican, has until June 21 to veto the legislation, but observers say that’s highly unlikely given his longstanding opposition to abortion.

Under current Texas law, a minor must get permission from a parent to get an abortion. But there is a built-in exception if a girl’sÌýparents are in jail, deported or unreachableÌý— or if she fears abuse or retribution from a parent. In those cases, she can anonymouslyÌýask a judge for permission through a process called judicial bypass.

Among other things, the new law would make it so teens would no longer receive automatic permission to get abortions if judges don’t issue timely rulings. The law also would limit the venues in which a teen could apply for permission.

Anti-abortion groups contended the process was too easy and the new law providesÌýa much-needed revamp of the rules. Supporters say Ìýthe new rules will help rescue teens from abusive situations and motivate other teens to involve their parents if at all possible.

“Oftentimes the minor is very young and very scared, and may not even know all of her options, may not even know what her parents may say,” Horne said. “It’s a very big decision for a parent to be cut out of.”

State Sen.Ìý, a Republican representing Plano and other Dallas suburbs, co-sponsored the bill in the senate.

“On an issue as paramount as the life of an unborn child, the state should not be severing parental involvement,” he said in a statement.

Tina Hester,Ìýexecutive director ofÌý, whichÌýworks with pregnant teens who seekÌýjudicial bypass, saidÌýthe real intent of the law is to stop abortions and score points among anti-abortionÌývoters.

“They’ve already dismantled the clinic system. They’ve basically shut down half the clinics in Texas,” Hester said. “And until Roe v. Wade is overturned, they’re just trying to chip away.”

As for concerns about girls skirting parental involvement, Hester saidÌý“there have been no complaints that I’m aware of from judges saying that girls are abusing this situation.”

Because the the court filings in the judicial bypass cases are confidential, it’s hard know if that’s happening.

Hester said the new lawÌýwill add so manyÌýÌýthat getting a bypass will be almost impossible.

For example, she said,ÌýÌýwould require most teens to see a local judge in their home county,Ìýeven if the abortion clinic is hours away in a big city. There is an exception for counties of less than 10,000 people.

Hester says that’s not enough to protect a girl’s anonymity in small towns. Everyone at the local courthouse willÌýeasily guess what is going on, she said.

“What normal 17-year-old goes down to the courthouse by themselves and without their parents?” Hester asked.

Less than 3 percent of abortions in Texas are among girls under 18. And most of those girls do get consent from their parents – it’s estimated that only about 10percent of those under 18Ìýseek judicial bypass.

,Ìýa family law attorney in HoustonÌýwho volunteers to represent teens through Jane’s Due Process,Ìýsaid girls using bypass are already facing difficult situations.

“[They are] kids who already have babies who are basically homeless, kids whose parents have kicked them out and they’ve sought shelter with another relative because their parents beat them.”

The parental notification law dates back to 1999 and was signed by then- Gov.George W. Bush. It included the bypass process. Later amendments required the teen to not only notify a parent, but obtain his or her consent.

The bypass process originally required a judge to hold a hearing quickly for the teenage girl, and if the judge refused to make a ruling, the girl automatically receivedÌýpermission to get the abortion anyway.

But the new regulations will do away with the automatic permission. Lucido fears her clients could be trapped in the pregnancy.

“If she comes across an ideologically motivated judge who refuses to schedule a hearing, the law doesn’t give her a way to force a ruling on her application. She’s in a sort of legal limbo,” Lucido explained.

Abortion rights advocates contend the new judicial bypass law could be stalled or stopped in the courts. The U.S. Supreme Court ruled inÌýÌýthat judicial bypass procedures for minors must be anonymous and expeditious, and the advocates claim the new Texas law could be unconstitutional on those grounds.

Despite passage of the new law, anti-abortion groups did not get everything they wanted from the Texas lLegislature this year.

The bypass bill originally included a controversial amendment that would have required women of all ages to show government identification before getting an abortion. The amendment did not survive.

In addition, one bill failed that would have forbiddenÌý insurance plansÌýsold through the Affordable Care Act exchange from covering abortion, except in emergencies.ÌýRape and incest were not included as exceptions. The bill would have allowed enrollees to purchase a supplementary insurance rider to cover abortion.

The bill passed the full Texas Senate but stalled in the House.

Ten states restrict coverage of abortion in all private insurance plans, and another 15 states restrict abortion coverage in ACA exchange plans,ÌýÌýto the Guttmacher Institute, a nonprofit organization focused on sexual and reproductive health research and public education.

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“A spider bite that’s two or three weeks old,” says Jeff Jacobs.

“A headache, or a laceration,” says Ashley Histand.

Tyler Hooper sums it up: “Anything from simple colds to toothaches, stubbed toes to paper cuts.”

The Ìýlogged more than 318,000 incidents last year, but only 13 percent of them were actual fires. The rest were medical calls, making a career in firefighting seem more like a career in health care.

Hooper drives the busiest ambulance in the city, based in a southside firehouse three miles east of the old Astrodome. Last year it answered more than 5,000 calls, and some of those were pretty frustrating, he says.

“We make a lot of runs to where it’s not an emergency situation,” he says.Ìý “And while we’re on that run, we hear another run in our territory, it could be a shooting, or a cardiac arrest, and now an ambulance is coming from further away and it’s extending the time for the true emergency to be taken care of.”

Hooper says the area his ambulance serves has many lower-income residents who don’t have insurance. But even those that do have coverage don’t always have a regular medical provider or a car to get to appointments.

“They don’t know they could walk into certain clinics without appointments or without insurance,” he says. Calling 911 is “just what they’ve always done or what they’ve been taught.”

City officials hope to break that cycle with a program designed to connect these residents in their homes with a doctor, via the emergency medical technicians and firefighters who answer the call.

On a recent morning, Hooper drove through the rain to answer a call at an apartment complex near Hobby airport. Susan Carrington, 56, sits on her couch in a red track suit, coughing and gasping.

“Have you seen your doctor?” Hooper asks. Carrington shakes her head.

“No? Okay,” Hooper says.

“I think a lot of people are very surprised that they can talk to a doctor directly and have been very happy with that,” saysÌýDr. Michael Gonzalez, the program’s director and an emergency medicine professor at Baylor College of Medicine.

Gonzalez says the idea is to direct patients such as Carrington to primary care clinics, instead of automatically bringing them to the emergency room, where ambulances can be tied up for precious minutes — even an hour — as EMTs do paperwork or wait for a nurse to admit the patient.

By diverting some patients to clinics, ambulances can stay in the neighborhoods and overloaded emergency rooms can focus on urgent cases.

Across the country, emergency medical services can’t keep up with the demand, saidÌýDr. Richard Bradley, chief of the Division of Emergency Medical Services and Disaster Medicine atÌýUT HealthÌýin Houston.

“I think that the Ethan approach is really a novel idea and really quite a good,” said Bradley, who is not involved in the project. “One of the advantages of having an emergency physician on the other end of the line is you’ve got someone who is best suited to be able to look for subtle indicators of what may be an emergency.”

Other cities have experimented with programs to relieve the burden on emergency responders. Some programs analyze 911 data to identify “super-utilizers,” and send teams into their homes to arrange needed services such as transportation and follow-up care after hospitalization. Those home-visit programs are often called “community paramedicine,” especially if they use paramedics to problem-solve the medical issues.

Other cities have tried to divert 911 callers by using nurse hotlines. Houston has also tried that approach, but firefighters complained it took too long, and patients never spoke directly with the nurse.

Gonzalez says a key component of the telemedicine program is that it doesn’t just turn patients away from the emergency room. It offers an alternative — a doctor’s appointment that day or the next, and transportation there and back. City health workers also follow up with Ethan patients to identify other issues that may be leading them to use 911 inappropriately.

The program costs more than $1 million a year, but the city has secured some grants and federal funding to help cover those expenses.

But Gonzalez predicts the program will eventually reap far more in savings for the region’s overburdened emergency system.

A 2011 of Houston-area emergency rooms showed 40 percent of visits were for primary-care related problems. Treating those problems in the ER cost, on average, $600 to $1,200 per visit, compared to $165 to $262 if the patients had been treated in an outpatient clinic. If all those ER visits could be diverted to a clinic, the savings would be more than $2 million.

Firefighter Alberto Vela recounted the experience of one woman who typically called 911 up to 40 times a month, often for very simple things, such as to get a prescription refilled. On one of those calls, he tried the video chat with her.

“I was so surprised by how long it took, it took maybe six to seven minutes, tops” to deal with her issue, Vela said. “It was awesome, and then we left the scene and were making more calls after that.”

Vela believes the program helped the woman find a regular clinic and transportation, because he hasn’t visited her home for months. “I would ask others shifts, ‘Hey, did you meet this lady?’ The other shifts said they hadn’t heard from her either. “And that’s very rare. So it’s working,” Vela said.

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

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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