The clinics had shut down Oct. 3 after a federal appeals court ruled that they had to comply with the state law’s mandate that they meet the standards of ambulatory surgery centers. That court will also hear arguments on a lawsuit brought by the clinics arguing the law is unconstitutional. But the U.S. Supreme Court this week said those clinics can continue to operate while the law is appealed.

“I was really surprised and really delighted in a way I hadn’t expected,” said Amy Hagstrom Miller, founder and chief executive of . Whole Woman’s is the lead plaintiff in the lawsuit for this case. The company once had six clinics in Texas, but the law forced all but one to close.

Miller said she will re-open her clinic in McAllen by Friday, which serves low-income women in the Rio Grande Valley. They had been forced to travel to the nearest clinic in San Antonio, but many couldn’t afford the trip or take time off from work, she said.

“There were only two clinic facilities in the Rio Grande Valley and both of us had to close, which meant that women had to travel upwards of 250 miles round-trip in order to get an abortion safely,” Hagstrom said.

Hagstrom is also working to re-open a second clinic in Fort Worth.

But even with this ruling, the ongoing fight in Texas has permanently changed the landscape for abortion providers, and not all the clinics will re-open.

Miller’s clinic in Austin no longer has a lease or a state license. One Houston doctor got frustrated, closed his clinic at the end of September, and retired. Miller once had a clinic in Beaumont, but she closed it in March when doctors there can’t obtain admitting privileges at nearby hospitals, another requirement in the state law.

In addition, any clinic that re-opens might have to close again if the Fifth Circuit Court of Appeals eventually rules the Texas law can stand.

in Houston was one of only eight places left in the state to get an abortion after the non-compliant clinics closed Oct. 3.

“Limiting abortion access to eight [clinics] in Texas – eight simply isn’t enough,” said Rochelle Tafolla, a Planned Parenthood spokeswoman. “We were overwhelmed with phone calls.”

Texas is the country’s second most populous state, with about 26 million people.

When the other clinics closed, Planned Parenthood received more than 500 calls in just one day, about six times the normal volume. Some women whose appointments were cancelled drove to the Houston clinic off the Gulf Freeway.

“Women were scared, they were nervous, they didn’t understand what was happening,” Tafolla said. “We’re just thrilled the court stepped in to stop this terrible law and we hope that it will eventually and ultimately be overturned.”

The Supreme Court’s intervention means that the cycle of emergency motions is over. The Fifth Circuit has agreed to expedite the full appeal, which could be heard as soon as December.

Houston-based supports the law and its strict new rules for providers. Emily Horne, a legislative associate, says the surgery center rule will make abortion safer for women.

Horne said it’s discouraging that some clinics can now re-open because she believes they don’t offer good medical care. But she remains optimistic the law will stand in the long term.

“The encouraging thing for us is that this case is still before the Fifth Circuit, and the Fifth Circuit has already said a lot of positive things about the state’s merit and likelihood of success,” Horne said.听 “And none of that actually changed with what the Supreme Court said.”

This is the second lawsuit over the Texas abortion law, known as HB2. The law’s tempestuous passage in the summer of 2013 propelled the political rise of State Sen. Wendy Davis, who waged an unsuccessful filibuster over the law. She is now the Democratic candidate for Texas governor.

The first lawsuit focused on the part of the law requiring that doctors performing abortions obtain admitting privileges at nearby hospitals. The U.S. Supreme Court declined to intervene in that case.

The second lawsuit focuses primarily on the surgery center rule, according to attorney David Brown. He’s part of the legal team at in New York, which helped some of the Texas clinics file the lawsuit.

Brown said no one can say for sure why the Supreme Court chose to intervene this time around. But he noted the reality on the ground has changed since last fall.

“Now we have hindsight and so the courts are looking at not what could happen but also what already has,” Brown said.

Since last fall, more Texas clinics have closed, which made the “evidence” presented in the second lawsuit more compelling, Brown explained.

“We were able to show that when clinics have to comply with onerous restrictions that are designed to close them under the pretext of health, that they will in fact close, that compliance is impossible,” Brown said, “And that when women have to drive hundreds of miles to get to the nearest health clinic for abortion services, many of them won’t be able to do that.”

Brown said although the Fifth Circuit appeal could be heard in December it’s more likely it will take place early in 2015.

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A three-judge panel heard arguments this morning for more than 90 minutes, first from the Texas solicitor general and then from a lawyer with the Center for Reproductive Rights, representing many of the Texas clinics. The questions from the judges centered mainly on what constitutes an “undue burden” when a woman is trying to get an abortion, and what fraction of Texas women would be affected.

Advocates say that about 20 abortion clinics in Texas in advance of the law; if the court rules in Texas’s favor, fewer than 10 clinics that provide abortion would remain in a state with a population of 26 million.

Both sides agreed that if the 11 clinics close, women in the Rio Grande Valley would have to travel more than 200 miles to San Antonio to get an abortion under the new law. But Jonathan Mitchell, the Texas solicitor general, said there was no good evidence that women weren’t figuring out how to deal with that and no evidence that if the abortion rate in Texas had fallen, that it was related to the law.

“An abortion law cannot be enjoined based on conjecture,” Mitchell said. Judge Jennifer Elrod questioned him about a clinic’s survey of 20 patients . An expert testifying for the clinics said one patient surveyed said she did not get an abortion after the law, known as HB2, went into effect.

“He did not report she was unable to get it, he did not report she encountered an undue burden,” Mitchell answered. “She could simply have changed her mind.”

Furthermore, patients in El Paso, where another clinic might close because it is not an ambulatory surgical center, could just travel to New Mexico for an abortion, Mitchell added.

Stephanie Toti with the Center for Reproductive Rights argued on behalf of affected clinics such as . She says lots of evidence was presented at the trial last month that women were facing numerous burdens exercising their constitutional right to an abortion. For example, a San Antonio clinic had offered women in the Rio Grande Valley who were seeking abortions free bus passes to help them travel north. But the patients told the clinic it wasn’t just the distance and money, but the problems with child care, time off work, and explaining to family why they were going so far.

Toti said a听promontora, a health outreach worker, testified at the trial that women were experiencing obstacles due to the clinics closing in Rio Grande Valley. “She says she personally observed women turning to illegal means to get an abortion,” Toti told the judges.

In a rebuttal, Mitchell called that testimony “vague” and says the promontora couldn’t give specific numbers of women doing that and couldn’t provide evidence that those choices were related to the effects of HB2.

The three judges did not indicate when they would decide, but if the decision goes for state of Texas, the clinics would probably close immediately. The judges could also decide that some of the most isolated clinics could remain open, while others must close.

Federal district Judge Lee Yeakel ruled in August that the surgery center regulation had no health benefit and would place numerous burdens on women seeking care, especially if they lived in the Rio Grande Valley and west Texas. Yeakel allowed the non-complying clinics to remain open, but the state asked for an emergency motion to overrule that and close them. The three judges did not indicate when they would decide.

Mitchell told the panel the state of Texas has a compelling interest in closing clinics that it deems unsafe, and that’s why the state sought an emergency motion to stay Yeakel’s decision.

“If there is a Kermit Gosnell-type clinic in a state, and that’s the last clinic in the state, I think everyone could agree that clinic could be shut down,” Mitchell said, referring to convicted of murder in Philadelphia.

Outside the hearing, reproductive rights protesters carried signs.

Bethany Van Kampen, a recent law school graduate and a board member of the New Orleans Abortion Fund, attended the hearing. She said it seemed that the judges were asking very hard questions of Toti.

“It’s a bit discouraging,” she said. “It felt very targeted. I felt our line of questioning was harder and more difficult, and I think we tried to do our best.”

Sandy Jones, an activist with Stop Patriarchy, traveled from Houston to attend. She said it seemed the judges had too narrow of a focus.

“These are forces that are determined to criminalize every abortion, every woman and make it inaccessible to every woman,” Jones said. “And birth control as we know is not far behind. This is a war on women; this is a state of emergency.”

Abortion opponents had also traveled from Austin and Fort Worth to listen.

“It’s hard to say how this will go,” said Emily Horne, a legislative associate for Texas Right to Life.

She said there was a need for Texas to seek this emergency hearing to shut down the non-complying clinics right away. “It is a direct safety measure for the health and safety of Texas women, so we think that sooner is better to implement that,” Horne said.

Horne said it was exciting to be there, and important for all states, not just Texas.

“Texas is definitely setting some precedents as far as what states are being allowed to pass, so there is a lot that does hinge on this,” she added.

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In a听ruling,听a federal judge in Austin struck down part of a Texas law that would have required all abortion clinics in the state to meet the same standards as outpatient surgical centers. The regulation, which was set to go into effect Monday, would have shuttered about a dozen abortion clinics, leaving only eight places in Texas to get a legal abortion 鈥� all in major cities.

Judge Lee Yeakel ruled late Friday afternoon that the state’s regulation was unconstitutional and would have placed an undue burden on women, particularly on poor and rural women living in west Texas and the Rio Grande Valley.

, a Republican running for governor, immediately filed an appeal with the 5th U.S. Circuit Court of Appeals.

“We applaud today’s ruling from Judge Yeakel,” says Rochelle Tafolla, a spokeswoman for in Houston. “But we also understand that the fight to protect women’s access to medical care, including safe and legal abortion, is not over.”

Supporters of the law argued that the surgical center requirement would make abortion safer, but the judge found no health benefit. He ruled that the effect might actually be the opposite, writing: “Higher health risks associated with increased delays in seeking early abortion care, risks associated with longer distance automotive travel on traffic-laden highways, and the act’s possible connection to observed increases in self-induced abortions almost certainly cancel out any potential health benefit associated with the requirement.”

Yeakel also noted that the intent of the Texas rule was to close existing abortion clinics, given that the state left no provision for “grandfathering” existing clinics that could not afford millions of dollars in upgrades to comply with the regulations that govern surgery centers.

A local Houston obstetrician-gynecologist who performs abortions calls Yeakel’s ruling “beautiful.” (The physician asked not to be identified because he fears retribution from abortion protesters.)

The doctor says that if the Texas law had been upheld, he would have had to stop performing abortions in his two office locations because they do not meet the surgery center requirements, which include particular hallway dimensions and certain equipment. He says he cannot afford to construct or purchase an outpatient surgery center, and leasing space in an existing center is difficult because other tenants don’t want protesters around.

“This was a good case,” he says “There is no medical anything, anywhere, to show that having this done in a hospital or ambulatory surgical center is safer. It’s nonsense; it’s not. Complications are the same, risks are the same.”

With the day the law was supposed to go into effect fast approaching, the doctor says he told some patients who called this week seeking abortions to make appointments, but to keep in contact with his office.

“鈥榊ou call me, listen to the news, keep your fingers crossed and pray for the women of Texas to have their constitutional rights restored.’ That’s what I told patients today,” he says.

Texas Right to Life, a Houston-based group, said in a statement that “Pro-Life Texans are disappointed in the dangerous ruling and disconcerted by the prospect that the financial interests of big business abortionists are placed in higher regard than the safety and health of women. The women of Texas have been subjected to shoddy, sub-par and potentially dangerous abortion facilities for too long.”

In the decision, Yeakel, who was appointed to the court in 2003 by President George W. Bush, focused on poor, rural and disadvantaged women. He says the burden did not just involve the hundreds of miles some women would have had to travel. He says that distance had to be assessed along with other factors, such as the need for child care, the unreliability of transportation, the inability to take time off work, and even immigration status and the inability to pass immigration checkpoints.

He writes in the decision, “When viewed in the context of the other state-imposed obstacles a woman faces when seeking an abortion in Texas 鈥� including a sonogram requirement, a waiting period, and the reduced number of abortion performing physicians resulting from the admitting-privilege requirement 鈥� the court is firmly convinced that the State has placed unreasonable obstacles in the path of a woman’s ability to obtain a pre-viability abortion.”

The Houston doctor who says he’s relieved by Yeakel’s decision,also says he realizes he may have to cancel abortion appointments next week 鈥� depending on how the Fifth Circuit responds. He says his patients have to become more proactive.

“I’m there to support them in their right to choose,” he says. “But you know, I’m not going to take the whole thing on my head. If they want it, they should be out there, actually protesting and voting too.”

听

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A federal judge in Austin, Texas, will issue a decision in the next few days about whether clinics that perform abortion in the state must become outpatient surgery centers.

The Texas law is part of a national trend, in which state legislatures seek to regulate doctors and their offices instead of women seeking abortions.

The laws are collectively known as TRAP laws for “Targeted Regulation of Abortion Providers.”

“They do just that,” said Rochelle Tafolla, a spokeswoman for Planned Parenthood Gulf Coast听in Houston. “They 鈥榯rap’ providers into very tight, medically unnecessary restrictions.”

The Texas law that passed in 2013 requires doctors who perform abortions to first obtain admitting privileges at a hospital within 30 miles. Many clinics, especially rural ones, found it difficult to comply with that rule by the November deadline. The number of Texas clinics that perform abortions has dropped from 41 to 20.

Now the law’s final rule requires doctors’ offices to meet the standards of ambulatory surgical centers, including an array of rules that govern hallway widths, the presence of showers and lockers, heating and cooling specifications. The rules also require conformance with other construction codes that can cost millions of dollars.

The rule goes into effect on Labor Day, unless federal Judge Lee Yeakel of the Western district in Austin issues an injunction to stop it. He is expected to issue a decision by Friday. If he stops the surgery center rule, Texas Attorney General Greg Abbott could quickly appeal to reinstate it.

One Houston doctor, who asked not to be identified because he fears being targeted by abortion protestors, says he will have to stop providing abortions if the final rule goes into effect.

Abortions are a small but important part of his practice: he delivers babies, gives well-women exams, performs gynecological surgery, and even offers tummy tucks.

“Abortion is part of what we’re trained to do as obstetricians-gynecologists. That’s the medical point of it,” he said. “When the politicians get into the mix, it becomes a completely different story.”

Planned Parenthood’s Tafolla said only eight clinics in Texas would meet the newest requirement, and they’re all in the major cities: two are in Houston (including Planned Parenthood Gulf Cost), two in San Antonio, two in Dallas, and one each in Fort Worth and Austin.

Women in East Texas, the Rio Grande Valley, and west of San Antonio would have to drive hundreds of miles for multiple visits, because a 2011 law put in place a 24-hour waiting period following a mandatory ultrasound, plus follow-up visits for women using the abortion pill.

“So it isn’t as simple as saying 鈥極h, there’s that one place in Houston, there’s that one place in Austin or Dallas.’ There simply isn’t enough capacity, there aren’t enough physicians,” Tafolla said.

The Guttmacher Institute, a research organization that studies reproductive rights, says TRAP laws really took off听in 2010. Twenty-six states now have them.

Groups that oppose abortions say the new laws make the practice safer and therefore protect women.

Melissa Conway, spokeswoman for Houston-based Texas Right to Life, said if the number of abortions and the number of clinics drops in Texas, that’s something she’s glad about, but it wasn’t the intent of the law. She said the regulations are about making abortion safer, so abortion providers should invest in the required upgrades.

“The choice to have fewer clinics comes down to the abortion providers,” Conway said. “If they choose to have disregard for the health of women, and the safety standards, which are practical, common-sense and best standards, that’s their choice. But that points highly to the fact that they care more about their bottom line than they do their patient care.”

The American College of Obstetricians and Gynecologists’ position is that “what those laws do is they limit women’s access and expose women to increased risk by not enabling them to have a procedure near where they live,” said ACOG CEO Dr. Hal Lawrence.

Lawrence said low-income women can’t afford to travel, and may try to self-induce an abortion or carry an unwanted pregnancy to term. He added that other outpatient procedures, such as colonoscopy, carry a fatality risk that is 40 times greater than first-trimester abortion, yet colonoscopy does not receive the same unwarranted scrutiny from lawmakers.

Tafolla said legislatures are passing TRAP laws because laws targeting demand for abortion were ineffectual. Other “demand-focused” laws include mandatory ultrasounds, a requirement that the patient listen to the fetal heartbeat and waiting periods before abortions.

Legislators who oppose abortions “thought they could reduce abortion by focusing on women and shaming them,” she said. “Now they’re focusing on the providers and doing everything they can to shut them down.”

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Many of those closed because of the requirement that doctors at those clinics obtain hospital admitting privileges within a certain radius of the clinic, and many doctors couldn’t comply. That requirement began November 1. This week marks the one-year anniversary of .

Bitter fighting over the law last summer propelled state senator Wendy Davis听into the national spotlight, and she is now running for Texas governor on the Democratic ticket.

“We’re seeing delays,” said , executive director of听 NARAL Pro-Choice Texas.听“We’re seeing people being pushed further into pregnancy, having to leave the state, having to drive and sleep in their cars in parking lots because of these barriers to access.”

The last restriction under the law goes into effect Sept. 1. All abortion clinics at that point must have upgraded their facilities to ambulatory surgery centers. Busby says many can’t afford it and more will close.

“This would basically force all the clinics to become mini-hospitals,” Busby said. “They have to have hallway widths a certain length, and a janitor’s closet, male and female locker rooms, which is completely unnecessary – and a bunch of other regulations that are really not appropriate or do anything to increase the safety of one of the safest procedures in the country.”

Pro-life groups supported the law, saying it would protect women by making abortion safer. At the time of the passage of the law, 听Republican state Sen. Donna Campbell saying: “There’s nothing in this legislation that will close a clinic. 鈥μ齌hat’s up to the clinic. If they want to put profit over a person, that’s up to them.”

Busby said abortion is already one of the safest office-based medical procedures, with a complication rate of less than .05 percent.

Busby predicted that after September only six or eight places will be left in Texas to get an abortion, unless stops the new requirement from going into effect. is part of that lawsuit. The group previously had six reproductive health clinics in Texas, but had to close two clinics听over the past year, Busby said. It may have to close an additional three clinics that don’t meet the new surgical center specifications, in Fort Worth, Austin and San Antonio. It would be left with just one other clinic in San Antonio that meets the new requirements.

Busby noted there are now no abortion clinics in all of East Texas or in the Rio Grande Valley. She said the one clinic left in El Paso could close soon.

In Houston, the newly-built headquarters of does fulfill the ambulatory surgical center requirements, so it will remain open. But the status of smaller clinics remains unclear.

A call and email to for comment was not returned.

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At lunchtime on the North Harris campus of Community College, students stream through the lobby of the student services center, plugged into their headphones or rushing to class. Many walk right past a small information table about the Affordable Care Act.

The table is the brainchild of , a health and fitness professor. Franks says getting overworked students to stop and learn about the law is tough.

“If you say 鈥極bamacare,’ they know what you’re saying. If you say 鈥楢ffordable Care Act,’ they walk by without any 鈥榙ing, ding, ding’ (of recognition),” she says. “So then we throw out the word 鈥榩enalty’: Zoom! They’ve before. Penalty? That really tends to be a hook more than 鈥楪ee you really need health care.'”

Franks says many students at Lone Star are low-income. They often work. Some have families to support. Others struggle to find gas money to even get to class.

“I still think so many of them are at survival mode. 鈥楬ealth insurance? Really? You know, I’ve got to get to work,'” she says.

She could be talking about Adan Castillo. He’s 19 and hoping for a career in law enforcement, or maybe the Marines. In addition to his classes, he also works. Castillo actually used to be insured. He paid his parents $55 a month to stay on their health plan. But he says it just felt like throwing money away.

“I just stopped giving it to them,” he says. “There are other important things I have to do, like paying for my college books, classes, gas. Gas is expensive nowadays.”

But Castillio’s girlfriend, Leslie Gonzalez, an accounting student, says insurance is important: “He needs it. Because what if 鈥� let’s say he doesn’t have it right now and he gets in an accident. He’s going to have to pay everything out of pocket and what if he doesn’t have it?”

Gonzalez works part time as a bank teller. She says she will sign up for insurance at work as soon as she is eligible.

The stereotype about young people is that they think they’re “invincible,” that they don’t need insurance because they’re young and nothing bad will happen to them for years. But most young adults don’t actually think that way.

Two recent surveys, and , reveal that cost is the real issue. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

Young people often , and they assume they can’t afford it. And they simply don’t know about the subsidized plans offered under the law, or how to get them.

Taylor Castille is a nursing student in her second year at Lone Star. She has logged on to , but her first visit didn’t go very well.

“I finally got on the website the other day and it was kind of confusing to me because I didn’t understand if I would have to pay, what would I pay, what I’m not paying,” she explains. “I got stressed out all over again just looking at that. So I just left the site and didn’t even bother to go back.”

Castille still wants coverage. Last fall she suffered a series of fainting spells and seizures. After a few visits to the ER, she now has $30,000 in medical debt. And she still doesn’t have a diagnosis.

“I have all this debt and I’m 21. I haven’t bought a car, I haven’t done anything,” Castille says. “I don’t have the debt because I was being irresponsible, I have the debt because I was sick and I couldn’t control that, so now I’m stuck with that.”

Castille later visited the information table and got a flier on how to sign up for a health plan.

So far, only about 25 percent of adults who have signed up are younger than 34. The federal government is that proportion closer to 40 percent.

The deadline to enroll 鈥� for all ages 鈥� is March 31.

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

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Boudreaux, 43, lives just outside of Houston and works as a psychiatric social worker on a freelance basis, with no benefits.

This year Boudreaux estimates she spent about $1,500 on medical care, including a trip to the ER for a cut finger. She also takes a few prescription medications and occasionally sees a psychiatrist and a nutritionist.

She can’t get insurance through her partner, because her partner’s employer doesn’t offer benefits to same-sex couples.

And, Boudreaux has been skipping mammograms and other check-ups for a few years. “It’s worrisome,” she says. “It’s like gambling. Gambling with my health, and it is very frustrating.”

Boudreaux was hoping to find a better deal on healthcare.gov. Boudreaux has logged on, looked at the plans, and so far, remains largely unimpressed.

She likes the monthly premiums that she sees but balks at the annual deductibles.

“Let’s say if I paid the $178 a month, my deductible would be $5,000,” she says. “I would have to pay up to $5,000 before I received any kind of payment from my insurance company.”

As a comparison, the average deductible for single coverage in employer sponsored insurance is about $1,135, according to the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)

Boudreaux could get a lower deductible if she paid a higher premium, but about $200 a month is all she feels she can afford. She doesn’t qualify for subsidies to help pay for a policy, either.

“I don’t smoke, I’m relatively healthy, so I was pretty insulted when I saw this [price],” she says. “I was extremely angry actually. I felt hoodwinked by the insurance companies: 鈥極h here’s this wonderful insurance plan but by the way you need to come up with $6,000 out-of-pocket first before we pay for anything.'”

That reaction is typical, says ,听an analyst and expert on the new health insurance marketplaces for the consulting firm Avalere Health.

“A lot of people aren’t ever going to get out of that deductible,” says Pearson. “Only if you have a catastrophic health event or you’re really chronically ill will you ever hit your out-of-pocket cap. People are left, I think, feeling like 鈥業 spent a lot of money this year on premium and I didn’t get any meaningful coverage from my insurance.'”

But Pearson says people forget two things if they just focus on the high deductible. One is that the new plans , like mammograms and yearly physicals. The other is that having a plan protects you from medical bankruptcy if you get in an accident or face something like a cancer diagnosis.

That’s because Affordable Care Act requires that health plans have a yearly limit on out-of-pocket expenses.听 If something did happen to Boudreaux, she wouldn’t pay more than $6,350 in the year.

Not As Generous As Workplace Coverage

Nevertheless, Pearson points out that the plans sold on the exchange are not as generous as employer-sponsored insurance. The plans have a range of deductibles, depending on which level 鈥� bronze, silver, gold or platinum – the consumer picks.

“We think most people are going to be enrolled either in silver or bronze plans, which will cover 60 to 70 percent of a person’s health care costs, and a typical employer plan covers 80,” Peason says. “So when the law was passed, by definition we knew these plans would be less generous than employer coverage. And that has definitely played out.”

Boudreaux has been managing her health needs without insurance for several years. For her depression, her doctor prescribes her double doses of her psychiatric medicines, which she then cuts in half, and because the meds are generic they only cost her about $40 per year.

But Boudreaux has considered the possibility that something catastrophic can happen.

“That is a huge fear. What if 鈥�” she says.

If nothing unexpected happens, she thinks she’d pay less just continuing to go along on her own. And she could put the $200 that would go to the monthly premium into a savings account.

In any case, Boudreaux doesn’t feel any urgency to sign up right away. She’s been uninsured for a few years, so what’s a month or two more?

With the holidays coming up, this is one difficult and confusing decision she’d rather just avoid for now.

“Whoa, shut the computer. Find something else to do. There’s something much better I could be doing with my time than trying to figure out this rigmarole of insurance policies and deductibles and what’s covered and what’s preventative and what’s included and blah blah blah,” she says. “It’s not very well explained.”

If Boudreaux does not enroll in a plan by the end of March, 听would probably be a few hundred dollars – for the first year. The penalty starts out at $95 or 1 percent of income in 2014 and rises in later years.

This story is part of a collaboration that includes , and Kaiser Health News.

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The spokeswoman for Oregon Health Authority says that while the state’s is that “people haven’t enrolled in the new coverage available in Oregon,” in fact “that’s not accurate. We have 70,000 people.”

She’s talking about some of the state’s poorest uninsured folks. A work-around helped 70,000 of them secure coverage in its version of Medicaid. Oregon is one of the to adults who haven’t previously qualified.

One of them is Kyle Thompson, who lives in the farming community of Jefferson, Oregon.听Since his work as a tile cutter ended during the recession, he hasn’t been able to afford health care. But because his two children qualified for Medicaid (the Oregon Health Plan), the state had all the family’s income details.听

So when Oregon sent out about 260,000 applications to families like the Thompsons 鈥� with incomes less than 138 percent of the federal poverty level 鈥� to enroll them in Medicaid, they jumped on the opportunity.

“I filled it out. I sent it off. Me and my wife are really excited in having the health care coming up because it’s not something that’s been an option for us,” he said.

Wentz says the letters were so successful that another batch will go out any day now. There’s already been a big impact, she says: “People will call and ask if it’s real. Can I really get health care coverage? When they hear that they can, they’re so grateful.听 One call center staff told me that, the person she was talking to said, please tell everyone there, thank you, thank you.”

The work-around is necessary because Cover Oregon’s website isn’t functioning. But the reason Oregon’s website is having more problems than most states is because it included many different kinds of insurance: private policies (with or without subsidies); children qualifying for the Oregon Health Kids Plan; as well as the Oregon Health Plan (Medicaid).

“I guess one could argue in retrospect we bit off more than other states,” Gov. John Kitzhaber recently said. But, he added “it was an intentional decision. We’ve got a single portal for Medicaid and for the people who are coming in that are not Medicaid eligible. And once we work out these difficulties I think the people in Oregon will be ahead of the pack.”

Marketplace officials say they’re cautiously optimistic insurance agents and navigators will be able to help customers determine their eligibility for a tax subsidy and choose a health plan by Dec. 1.听

But the public in general won’t have access for a while, due to the ongoing problems with the website. Instead, a series of “application fairs” have been arranged so that everyone can use old-fashioned paper to apply in time to get covered starting in 2014.

Meanwhile, in Texas, the get-out-to-the-people approach hasn’t gotten much momentum. Only have signed up for private insurance and the state isn’t expanding its Medicaid program.

“Navigator” Alysia Greer has been trying to encourage sign-ups from a folding table in the lobby of a medical building in northwest Houston. As people walk by she offers them brochures and asks “Does everyone in your household have health insurance?”听

Most walk right by, but Dorothy Green, who already has Medicaid, grabs a packet for a neighbor, “because she doesn’t drive. And she’s asking me about it and I have no idea, as well as the other folks, (I’m) confused, you know?”

Outreach organizations in Texas received more than $10 million in federal funds to hire and train navigators. But along with 16 other states, Texas has also passed a law to regulate how the navigators operate. It’s expected to go into effect in a few months, after insurance regulators write the specific rules.

Texas Attorney General Greg Abbott says he’s and wants regulations that are tougher than those already in the Affordable Care Act. He’s told the that he wants the rules to include criminal background checks so that felons can’t work as navigators. He thinks navigators might misuse confidential information they gather while helping people sign up for health plans. “We need to have better training for these people who are 鈥� may be completely unversed in how to deal with someone’s private information,” he says.

Alysia Greer takes issue with Abbott calling her unprepared. She says patient privacy and security were a big part of her navigator training, which lasted more than 20 hours and involved several tests. She adds that Abbott may be unnecessarily frightening uninsured people and his comments could damage the enrollment effort.

“I do think it will scare some people away. Because there are a lot of people who are very influenced, of course, by what the attorney general and other people of political status say,” she says.

Greer says when she assists people while using a computer, she turns the screen towards them and away from herself, and never even sees Social Security numbers or income information.

Justin Giovannelli of Georgetown University’s Health Policy Institute is tracking efforts by states to regulate navigators.

“It’s听interesting to note that many of the states that have been relatively reluctant to act and implement the federal health law in many other respects have been fairly quick to adopt these laws and regulations on consumer assisters,” Giovannelli says.

He says some of the regulations may have a chilling effect, making it hard for navigators to do their jobs.

In any case, the Affordable Care Act itself prohibits disclosure of personal information, and imposes a $25,000 fine for doing so. And navigators who did steal information would also face 15 years in prison under federal identity theft law.

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

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On the other side you have Rosy Mota and her clipboard, standing at the door of a CVS pharmacy in one of Houston’s Latino neighborhoods, stopping shoppers.

“Hello, would you like a brochure about the new health care coverage that’s coming into effect? We’ll be here if you have any questions,” she tells a customer.

Mota works for , a national organization that has from the Obama re-election campaign. Using data-mining and digital maps, the group is figuring out where the uninsured in Houston live, down to the block and house level.

Enroll America has just seven workers for Houston’s 800,000 uninsured residents. But it is part of a coalition of organizations that include the city health department, the county’s public clinics and groups like the Urban League, which are trying to get the word out about health insurance marketplaces, which will open Oct. 1, providing resources to help the uninsured buy new coverage created under the health law.

“Regardless of whether you are for the Affordable Care Act or you’re against the Affordable Care Act, we’re not looking at it that way,” says Houston health official . “We’re saying that, from a public health perspective, getting people insured and getting them into the system is a good thing to do.”

The state of Texas is not providing any money or staff to help people sign up. So the city is using federal money funneled through the United Way and also tapping its own resources.

In fact, it considers the project so important that it’s using the same command-and-control structure that it uses during hurricanes. Instead of shelters and relief centers, the city is compiling a list of block parties, church events and festivals where people can learn about Obamacare and how to sign up.

“Otherwise you would have鈥rganizations going to the same territory, knocking on the same doors, talking to the same number of people, and when you look at Harris County, we’ve got close to about a million uninsured people, so there’s a lot to go around,” said Hernandez. “So that’s why we want to organize, so we make sure we get to all the different pockets in the county that need to hear about this.”

In addition, the Harris Health System is getting involved on a large scale. The publicly-funded safety-net system runs two hospitals and 16 community clinics. It has a lot to gain from Obamacare: It sees 250,000 uninsured patients every year. An estimated 75,000 of those make between 100-400 percent of the federal poverty level, and could therefore be eligible for subsidized coverage on the marketplace.

Although the hospital district did not receive any federal money, it’s requiring 300 of its own workers to become certified application counselors under Obamacare, a five-hour on-line training process.

“I think we had to be active and proactive to take steps to make the community aware that the law did pass and that it is starting Oct. 1,” said Deborah Boswell, director of community outreach services for Harris Health System. “Many people think because they live in Texas it doesn’t count for then, but it does. So we want the uninsured population to know that they have options.”

In addition to uninsured whites, black and Latinos, Houston has large populations of immigrants from Vietnam, China and South Asia. Last week Asian American health advocates met to discuss the problem and hear from the city health director and a Medicare official. They shared concerns about people’s lack of information and trouble finding interpreters.

Yani Rose Keo works with Cambodian farmers from rural areas southwest of Houston. Many of them are refugees and fearful of what the law means for them as small business owners, and individuals.

“We are scared to death,” Keo told the officials. 听“All the farmers, they have the small backyard – one acre, two acres of land and no insurance.”

“Please help us!” she pleaded. “What should I do, to help them?”

Denise Truong, program director at the Chinese Community Center, described problems she had with the government’s 800 number, which is supposed to offer interpreters in 150 languages. “First, either we can’t reach an interpreter and the phone is hung up, or we reach an interpreter and鈥he interpreter isn’t qualified to answer questions about the marketplace,” she said.

Michael Coulter, the Medicare official, said there have been problems with the interpreters, but they’re getting fixed and urged the groups to keep trying.

With almost 2.6 million Texans eligible to enroll in the marketplaces, the scope of the enrollment will be historic, Coulter says. “It’s a huge program. This makes our Medicare rollout that we did eight years ago for Part D look like a small Sunday school picnic.” Part D was the plan under which Medicare began to cover the cost of outpatient prescription drugs.

Mota is working with those Texans one at a time. She catches Maribel Hernandez’s attention by telling her that everything will be explained to her clearly. “There’s like no more fine print. It’s, like, plain.”

Hernandez is 38. Her family has insurance, but she’s unhappy with the coverage. Mota tells her she might find a better deal in the marketplace.

Another of Hernandez’s concerns is her diabetes. “It is pre-existing, so will they deny you because of that?” she asked.

“No, ma’am,” Mota answers. “They are prohibited by law now鈥nd they cannot charge you more either.”

“Good,” Hernandez responds, “because that’s one of my main things.”

This story is part of a collaboration that includes听,听听and Kaiser Health News.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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The “” are what health policy wonks call healthy young adults (18-30) who don’t see being uninsured as a problem. But it is a problem, at least for the success of the Affordable Care Act.

That’s why the Department of Health and Human Services is spending $30,000 on prizes for a national video contest, in a frank appeal to the YouTube generation.

The digital demographic may not know co-pays from co-insurance, but creating and uploading free “content” practically defines that generation. HHS hopes to tap that creativity and essentially get young adults to market Obamacare to themselves.

HHS Secretary Kathleen Sebelius announced during a visit to , a federally qualified health clinic in Houston.

“We’re encouraging folks to create a song, or a graphic, or a video about the law’s benefits,” Sebelius said. “Like staying on their parent’s plan until they’re 26, not being denied coverage because of a pre-existing health condition.”

If those topics don’t sound super sexy, Sebelius nevertheless seemed confident that the young folks would figure out creative ways to sell it. The contest will also allow people to vote online for their favorites in various categories, and then a grand prize winner will be selected after “a final round of voting and judging” -– presumably by HHS, although the website doesn’t specify.

If the prize amounts don’t听seem Hollywood-level听(the most anyone can win is $6,500), HHS also noted that the first 100 entrants get a “Stay Healthy” kit, which “includes a t-shirt, first aid kit, sun protection kit and water bottle.”

In Houston, Sebelius made the announcement before community health workers who had gathered for a training session on how to explain Obamacare to people under 34. The training session was run by , an advocacy group that represents the interests of young people in the fight for health reform.

Sebelius acknowledged that when twentysomethings wake up in the morning, “health insurance is not the first thing on their minds.” But, she says, friends, family members, health care providers and trained organizers can educate young adults about the dangers of an accident or sudden diagnosis.

She talked about her own two sons. The older son is a lawyer and has insurance; the younger one, John, is 29 and a self-employed “entrepreneurial artist.” John attended the Rhode Island School of Design and at one point made the news for .

“He now has a master’s in fine arts,” Sebelius says. “He’s trying to knit together a way to pay his bills while he pursues his art. So, I’ve seen sort of up close and personal how complicated that can be and how difficult that is.”

Although John does have an insurance policy, Sebelius said “it’s always a worry, it’s always a problem. He isn’t in a plan that he’s sure of from moment to moment or day to day. So I know how complicated this can be.”

Texas Governor Rick Perry released a short听听dismissing the video contest as a gimmick. “If Obamacare were sound health care policy, Secretary Sebelius wouldn’t have to resort to video contests and prizes to tempt people to sign up. Texans are already subject to too much costly and burdensome federal regulation, and Obamacare only makes the problem worse.”

Sebelius also spent part of her visit meeting privately with a select group of Houston politicians and health care stakeholders. She said local leaders in major Texas cities understand what the state leaders do not, that Obamacare will bring relief to overburdened local hospitals and property taxpayers, who foot the bill for the uninsured.

,听a Republican and the county executive for Harris County where Houston is located,听stood by Sebelius during a press conference. They were听joined by Houston’s mayor, Annise Parker, a Democrat.

“The law is in place,” Emmett said. “People are still arguing about whether it should be repealed or shouldn’t be repealed, but it is in place. And in the meantime, here in Harris County we have an inordinate number of underinsured and uninsured people -– who right now the taxpayers of Harris County are paying for [their] health care.”

Emmett said Texas made a mistake in rejecting the health law’s provisions to 听to allow childless adults and听those听earning听below 133 percent of the federal poverty level听to sign up. The federal government would pick up the tab for the newly eligible for the first 3 years, and gradually decrease to 90 percent by 2020.

“Personally I think leaving that money on the table, those are our taxpayer dollars that are already in Washington. And if we don’t reimburse through Medicaid then the local taxpayer has to pick up that tab. So, yes, I think it was a mistake. Costs us twice.”

Sebelius said it’s 听for Texas to decide to expand Medicaid to cover low-income adults.

“We’re open to a program that looks uniquely Texan,” she said. But the impetus will have to come from hospital leaders, business leaders, and faith leaders fashioning a solution with state legislators. “We’re eager to have those conversations but I think they need to start with a Texas group coming together and talking to us,” she said. “This is really not a Washington-to-Texas conversation.”

This story is part of a collaboration that includes , and Kaiser Health News.

麻豆女优 Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at 麻豆女优鈥攁n independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).