Shifting the Healthcare Debate

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Welcome to Wednesday’s Overnight Health Care, where Democrats have won back the House, opening the door to a shift in the health care debate.

Here’s what we’ll be watching for on health care when the new Democratic House majority takes over:

  1. Oversight. Democrats are sure to launch investigations and hearings into all sorts of actions Republicans have taken that they think undermined the Affordable Care Act, from expanding skimpier short-term health insurance plans to cutting outreach efforts. They could also bring up different industry executives to testify, for example those from drug companies. We’ve seen some of this happen already with Martin Shkreli and Heather Bresch, but Democrats may want to go even further to shame the industry for high prices.
  2. Drug pricing. Speaking of which, legislation to fight high drug prices is an early priority for House Democrats. They think it could be an area for bipartisan support, as President Trump has also focused on the issue. Democratic Leader Nancy Pelosi said Tuesday she thinks there could be “common ground” with Trump on the idea, and Trump listed the issue as a possible area of cooperation Wednesday as well. But any drug pricing action always faces an uphill climb.
  3. Pre-existing condition protections. If a federal judge rules in favor of Texas and the other Republican state attorneys general challenging the law, Congress is going to need to have a backstop in place. Republicans in the Senate already passed their versions of such legislation, but left the door open to insurers charging higher premiums for people with pre-existing conditions. If the law’s protections are truly at risk, Senate Republicans will need to back up their campaign rhetoric with action.
  4. Medicare for All. The most sweeping change Democrats have discussed does not have any real chance of being enacted into law with a Republican Senate and president. But it’s worth watching whether liberal Democrats start planning and agitating for some action on Medicare for all, with hearings, revised legislation, etc.

 

Medicaid wins big at the polls

It was a big night for Medicaid. Three red states voted to expand Medicaid, giving health coverage to potentially hundreds of thousands of newly eligible people.

Idaho voters approved expansion with more than 61 percent of the vote, Utah passed expansion with 54 percent and Nebraska passed it with 53 percent. In Nebraska and Utah, the approval came despite opposition from the states’ Republican governors.

Democrats also won close gubernatorial races in Kansas and Wisconsin, putting expansion on the table. In Kansas, expansion legislation passed in 2017 but former Gov. Sam Brownback (R) vetoed it. In Wisconsin, Gov. Scott Walker (R) lost to Democrat Tony Evers, who campaigned on a platform that included expansion.

 

The Trump administration finalized two rules today making it easier for some employers to avoid complying with the Affordable Care Act’s contraception mandate. Here’s what they do:

  • The first rule provides an exemption to the mandate for entities that object to contraception based on their “sincerely held religious beliefs.”
  • The second rule gives ax exemption to nonprofits, small businesses and individuals that have non-religious, moral objections to the mandate.

These rules are largely similar to two interim final rules released by the administration last year. But the second rule was amended to state that the moral exemptions don’t apply to publicly traded businesses and government entities.

The rules take effect 60 days after their publication in the Federal Register.

Context: These rules are already the subject of multiple lawsuits against the administration. From National Women’s Law Center President Fatima Goss Graves:

“The Trump Administration decided to finalize these outrageous rules, despite several pending lawsuits and two federal courts blocking them. It’s clear that this Administration will stop at nothing to attack women’s health care… if the Administration thinks it can move these rules forward without a fight, they’re wrong.”

 

On the topic of abortion, two states last night laid the groundwork to ban abortion if the Supreme Court makes changes to Roe v. Wade.

Voters in Alabama and West Virginia approved sweeping amendments to state constitutions that could put major limitations on access to abortions if Roe v. Wade is overturned by the Supreme Court.

Alabama’s amendment makes it state policy to protect “the rights of unborn children” and “support the sanctity of unborn life.” It also says there are no constitutional protections for a woman’s right to an abortion.

Fifty-nine percent of voters approved the measure.

West Virginia narrowly passed a similar amendment that states nothing in the state Constitution “secures or protects a right to abortion or requires the funding of abortion.” That vote was 52 percent to 48 percent.

Read more here.

 

 

Healthcare Triage News: Women on Web Move to Increase Access to Abortion Pills in the US

https://theincidentaleconomist.com/wordpress/healthcare-triage-news-women-on-web-move-to-increase-access-to-abortion-pills-in-the-us/

Image result for Healthcare Triage News: Women on Web Move to Increase Access to Abortion Pills in the US

Women on Web is an organization that increases access to pharmaceutical abortion services in countries where those options are limited. The organization has now started a separate service that will fill prescriptions in the United States to replace access in states that have made access to abortion difficult. Healthcare Triage talks through the details.

I mention it in the video, and we link to it in the description, but you should also read Olga Khazan’s coverage of this at The Atlantic.

https://www.theatlantic.com/health/archive/2018/07/after-abortion-is-illegal/565430/

 

 

 

A Sense of Alarm as Rural Hospitals Keep Closing

The potential health and economic consequences of a trend associated with states that have turned down Medicaid expansion.

Hospitals are often thought of as the hubs of our health care system. But hospital closings are rising, particularly in some communities.

“Options are dwindling for many rural families, and remote communities are hardest hit,” said Katy Kozhimannil, an associate professor and health researcher at the University of Minnesota.

Beyond the potential health consequences for the people living nearby, hospital closings can exact an economic toll, and are associated with some states’ decisions not to expand Medicaid as part of the Affordable Care Act.

Since 2010, nearly 90 rural hospitals have shut their doors. By one estimate, hundreds of other rural hospitals are at risk of doing so.

In its June report to Congress, the Medicare Payment Advisory Commission found that of the 67 rural hospitals that closed since 2013, about one-third were more than 20 miles from the next closest hospital.

study published last year in Health Affairs by researchers from the University of Minnesota found that over half of rural counties now lack obstetric services. Another study, published in Health Services Research, showed that such closures increase the distance pregnant women must travel for delivery.

And another published earlier this year in JAMA found that higher-risk, preterm births are more likely in counties without obstetric units. (Some hospitals close obstetric units without closing the entire hospital.)

Ms. Kozhimannil, a co-author of all three studies, said, “What’s left are maternity care deserts in some of the most vulnerable communities, putting pregnant women and their babies at risk.

In July, after The New York Times wrote about the struggles of rural hospitals, some doctors responded by noting that rising malpractice premiums had made it, as one put it, “economically infeasible nowadays to practice obstetrics in rural areas.”

Many other types of specialists tend to cluster around hospitals. When a hospital leaves a community, so can many of those specialists. Care for mental health and substance use are among those most likely to be in short supply after rural hospital closures.

The closure of trauma centers has also accelerated since 2001, and disproportionately in rural areas, according to a study in Health Affairs. The resulting increased travel time for trauma cases heightens the risk of adverse outcomes, including death.

Another study found that greater travel time to hospitals is associated with higher mortality rates for coronary artery bypass graft patients.

In many communities, hospitals are among the largest employers. They also draw other businesses to an area, including those within health care and others that support it (like laundry and food services, or construction).

A study in Health Services Research found that when a community loses its only hospital, per capita income falls by about 4 percent, and the unemployment increases by 1.6 percentage points.

Not all closures are problematic. Some are in areas with sufficient hospital capacity. Moreover, in many cases hospitals that close offer relatively poorer quality care than nearby ones that remain open. This forces patients into higher-quality facilities and may offset negative effects associated with the additional distance they must travel.

Perhaps for these reasons, one study published in Health Affairs found no effect of hospital closures on mortality for Medicare patients. Because it focused on older patients, the study may have missed adverse effects on those younger than 65. Nevertheless, the study found that hospital closings were associated with reduced readmission rates, which is regarded as a sign of increased quality. So it seems consolidating services at larger hospitals can sometimes help, not harm, patients.

“There are real trade-offs between consolidating expertise at larger centers versus maintaining access in local communities,” said Karen Joynt Maddox, a cardiologist and health researcher with the Washington University School of Medicine in St. Louis and an author of the study. “The problem is that we don’t have a systematic approach to determine which services are critical to provide locally, and which are best kept at referral centers.”

Many factors can underlie the financial decision to close a hospital. Rural populations are shrinking, and the trend of hospital mergers and acquisitions can contribute to closures as services are consolidated.

Another factor: Over the long term, we are using less hospital care as more services are shifted to outpatient settings and as inpatient care is performed more rapidly. In 1960, an average appendectomy required over six days in the hospital; today one to two days is the norm.

Part of the story is political: the decision by many red states not to take advantage of federal funding to expand Medicaid as part of the Affordable Care Act. Some states cited fiscal concerns for their decisions, but ideological opposition to Obamacare was another factor.

In rural areas, lower incomes and higher rates of uninsured people contribute to higher levels of uncompensated hospital care — meaning many people are unable to pay their hospital bills. Uncompensated care became less of a problem in hospitals in states that expanded Medicaid.

In a Commonwealth Fund Issue Brief, researchers from Northwestern Kellogg School of Management found that hospitals in Medicaid expansion states saved $6.2 billion in uncompensated care, with the largest reductions in states with the highest proportion of low-income and uninsured patients. Consistent with these findings, the vast majority of recent hospital closings have been in states that have not expanded Medicaid.

In every year since 2011, more hospitals have closed than opened. In 2016, for example, 21 hospitals closed, 15 of them in rural communities. This month, another rural hospital in Kansas announced it was closing, and next week people in Kansas, and in some other states, will vote in elections that could decide whether Medicaid is expanded.

Richard Lindrooth, a professor at the University of Colorado School of Public Health, led a study in Health Affairs on the relationship between Medicaid expansion and hospitals’ financial health. Hospitals in nonexpansion states took a financial hit and were far more likely to close. In the continuing battle within some states about whether or not to expand Medicaid, “hospitals’ futures hang in the balance,” he said.

 

 

State and Federal Contraceptive Coverage Requirements: Implications for Women and Employers

https://www.kff.org/womens-health-policy/issue-brief/state-and-federal-contraceptive-coverage-requirements-implications-for-women-and-employers/?utm_campaign=KFF-2018-March-Womens-Health-Contraceptive-Coverage-State-Federal-Law&utm_medium=email&_hsenc=p2ANqtz–UJl9zNocQ0KN8sNboiXq-Is7ri7ERgc5AOrlcI9Jkun0vMLWO2c6OEdVCaT924Zm8lRAguOVrZaG75KYWciO0BPWRUg&_hsmi=61727079&utm_content=61727079&utm_source=hs_email&hsCtaTracking=081209d1-aacb-4d2b-85b8-d9d3d1101ef0%7C765b6ce1-10b8-48ec-b7e8-ca92cce70fb1

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Contraceptive Coverage under the Affordable Care Act (ACA) has made access to the full range of contraceptive methods affordable to millions of women. Since it was first issued in 2012, this provision has been controversial and has been the focus of two major cases that have reached the Supreme Court. Following the Hobby Lobby ruling, the Obama Administration took the stand that almost all women had an entitlement to the contraceptive benefit and developed an “accommodation” to assure they would still get coverage, even if their employer had religious objections to contraception. The Trump Administration, in contrast, has prioritized the rights of employers, and in October 2017, issued regulations that significantly broadened the exemption to nearly any employer with a religious or moral objection. The new regulations have been challenged by 8 states and have been blocked from being implemented pending the outcome of the litigation.

Before the ACA was passed, many states had enacted contraceptive equity laws that required plans to treat contraceptives in the same way they covered other services. In addition, since the ACA was passed, a number of states have enacted laws that basically codify in state legislation the ACA benefit rules (requiring all plans to cover, without cost-sharing each of the 18 FDA approved contraceptive methods). This issue brief provides an update on the status of the continuing litigation on the federal contraceptive requirement and explains the interplay between the federal and state contraceptive coverage laws and the implications for employers and women.

Background on State and Federal Contraceptive Coverage Requirements

Before the ACA, coverage for prescription contraceptives was generally widespread in the private and public sectors, but not universal, and certainly not free of cost-sharing. In 2000, a ruling by the Employment Equal Opportunity Commission found that employers that covered preventive prescription drugs and services but did not cover prescription contraceptives were in violation of the Civil Rights Act.1 Currently, 29 states and DC2 require insurance plans to cover contraceptives, with a wide range of coverage and cost-sharing requirements, and exemptions among these mandates (Appendix A). State laws, however, do not have authority over all plans; they only apply to state regulated (fully-insured) plans, but not self-funded plans under ERISA where 60% of covered workers are insured.3

The ACA is the first law to set preventive coverage requirements for health insurance across all markets – individual, small group, large group and self-insured plans. Starting in 2012, all new private plans were required to cover, without cost-sharing, the full range of contraceptive services and supplies approved by the Food and Drug Administration (FDA) as prescribed for women. Only employers that were classified as a “house of worship” were exempted from this requirement. While a number of states had contraceptive equity laws that required plans to cover some or all methods, cost-sharing typically applied. Fully-insured plans must comply with both state and federal laws. For some health services, the federal law may require a higher level of benefits, and for other services the state law may require a higher level of benefits.

Conclusion

The outcome of the litigation challenging the Trump Administration’s new regulations is not clear. Currently, the federal government is blocked from enforcing the new regulations. The new regulations would substantially expand the exemption to nonprofit and for-profit employers, as well as to private colleges or universities with religious or moral objections to contraceptive coverage. If the new regulations become effective, for women enrolled in fully-insured employer plans, the scope of their contraceptive benefits would depend on the coverage policies and exemptions established by state laws. Employers who qualify for the exemption under federal law would still need to comply with the state contraceptive requirement. Depending on the state law, employers may still have to provide no-cost coverage for some or all methods of contraception or a narrower set of contraceptive benefits. For women covered by fully-insured plans issued for employers with religious or moral exemptions, their choice of contraceptive methods would be determined by the scope of benefits and exemptions allowed by state law where they live.

 

 

California’s anti-abortion pregnancy centers want the Supreme Court to overturn state notice law

http://www.latimes.com/local/lanow/la-me-ln-pregnancy-court-20180318-story.html

California's anti-abortion pregnancy centers want the Supreme Court to overturn state notice law

At a faith-based pregnancy center here, rooms are crammed with baby supplies, both new and used, for expectant mothers, and a medical office contains equipment to allow pregnant women to view their fetuses.

“Life is not about waiting for the storm to pass,” reads a saying on a wall, “but learning to dance in the rain.”

The Alpha Pregnancy Center, located in a storefront on a busy street in the Mission District, is one of about 200 centers in California and thousands across the country pushing the U.S. Supreme Court to spare them from government regulation.

The California centers are challenging a state law that requires them to inform clients that contraception, prenatal care and abortion may be obtained free or at low cost from the state, along with a state phone number for information about Medi-Cal. The law also requires clinics to disclose if they are not licensed.

The case, which will be argued on Tuesday, pits the free speech rights of the anti-abortion centers against government consumer regulations. The decision is likely to affect abortion laws in other states.

The U.S. 9th Circuit Court of Appeals upheld California’s law, but similar requirements passed by cities and counties elsewhere in the nation have fared poorly in the courts.

Mark L. Rienzi, a religious liberties lawyer who represents pregnancy clinics, frames the debate as a question of whether the government can force anti-abortion activists to give clients phone numbers of abortion providers.

“Can the government make you say something you don’t want to say?” Rienzi asked. “They are pro-lifers. They exist to tell people you shouldn’t get an abortion.”

Rienzi said 11 states and local governments have passed laws to regulate what the pregnancy centers must tell clients — rules he argues amount to discrimination against abortion opponents.

Other analysts view California’s law as mere consumer protection. It was passed in response to reports that the centers were luring pregnant women without clearly identifying themselves as anti-abortion.

“The law is so clearly constitutional,” said UC Berkeley Law School Dean Erwin Chemerinsky. “It is one thing to compel somebody to speak. It is another thing to say you have to post on your wall information that is completely accurate.”

Rienzi, though, said California has plenty of resources to let low-income women know that they may be eligible for government-assisted contraception and abortion.

“I don’t think the government gets to turn private speakers into government billboards,” he said.

At the Alpha Pregnancy Center, nothing on the outside of the storefront indicates the group opposes abortion, but it states on its website that it does not provide abortion referrals.

The government-required notice is posted not on a wall, but is included near the end of three pages of a handout that deals primarily with privacy rights. Clients are required to sign that they have been given the form.

During a recent visit, only the executive director and a receptionist were working. A woman walked out pushing a baby carriage.

Most of the center’s clients are unmarried and about 80% decide to give birth, said the executive director, who declined to give her name. The center tries to help the women financially with donated goods and offers classes in money management, life skills, time management, child behavior and potty training, she said.

Brochures in the center are designed to steer women away from abortion.

One contains information on fetal development. At eight weeks, “the elbows and fingers can be seen,” it reads. There are photographs of fetuses at various stages.

Another pamphlet describes all that could go wrong with an abortion and links the procedure to breast cancer, mental illness and relationship problems, claims that those on the other side of the debate say are either false or misleading.

Elizabeth Nash, a policy analyst for the Guttmacher Institute, a research organization that favors abortions rights, said some pregnancy centers use deception to lure pregnant women who may be seeking abortions, while others are straightforward and even help women obtain government-funded healthcare.

The Supreme Court’s decision to review California’s 2015 law delighted crisis pregnancy centers, but it doesn’t mean they will win the case. Votes of only four of the nine justices are needed to take a case, and the court does not disclose those votes.

Justice Anthony M. Kennedy, often a swing vote, is likely to be the decisive vote in the case, National Institute of Family and Life Advocates v. Becerra, analysts said.

“It’s really hard to know what the Supreme Court is going to do here, ” said Stanford University Law School professor Pamela S. Karlan. “They have two competing impulses.

“On one hand the Supreme Court is extraordinarily receptive to a wide variety of 1st Amendment claims. On the other hand, this is a consumer protection statute, and the Supreme Court has at least so far not shown much interest in telling government they can’t regulate the information” that must be given to medical patients, Karlan said.

Some legal analysts said a ruling against California could hurt the anti-abortion movement by imperiling dozens of state laws that require providers to counsel patients that abortion may harm them.

The Supreme Court’s 1992 decision in Planned Parenthood v. Casey said that “counseling requirements are OK in the sense that the state is allowed to prefer childbirth over abortion,” Nash said.

Of 29 states with abortion counseling requirements, 20 require providers to give patients “misleading or inaccurate information” on such topics as fetal pain, fetal personhood, and links between abortion and breast cancer, future fertility and mental illness, she said.

The National Academy of Sciences released a major study Friday that found abortion was safe and debunked claims it increased the risk of infertility, breast cancer and mental illness.

Many of the state laws that require providers to make such claims have not been challenged because of the high costs of litigation, Nash said. But if the Supreme Court rules that California’s law violates free speech, these laws might become stronger targets, she and other analysts said.

“If the state can’t require that pregnant women be able to read a sign that gives them accurate information,” Chemerinsky said, “it seems an even stronger argument that healthcare professionals cannot be forced to utter falsehoods.”

 

Often Missing From The Current Health Care Debate: Women’s Voices

http://www.npr.org/sections/health-shots/2017/08/16/543723927/often-missing-from-the-current-health-care-debate-womens-voices?utm_campaign=KFF%3A%20The%20Latest&utm_source=hs_email&utm_medium=email&utm_content=55441015&_hsenc=p2ANqtz-9nhXUhC_zqpJNwIaw0vOuF3PfAn3PBrmE3HVyeYM_l7-5vAx-FPWjwuS3F0Ac1H67HXbfu9Hfyvmuf37WeEGpqXqf-Sw&_hsmi=55441015

Women have a lot at stake in the fight over the future of health care.

Not only do many depend on insurance coverage for maternity care and contraception, they are struck more often by autoimmune conditions, osteoporosis, breast cancer and depression. They are more likely to be poor and depend on Medicaid, and to live longer and depend on Medicare. And it commonly falls to them to plan health care and coverage for the whole family.

Yet in recent months, as leaders in Washington discussed the future of American health care, women were not always invited. To hammer out the Senate’s initial version of a bill to replace Obamacare, Majority Leader Mitch McConnell appointed 12 colleagues, all male, to closed-door sessions – a fact that was not lost on female Senators. Some members of Congress say they don’t see issues like childbirth as a male concern. Why, two GOP representatives wondered aloud during the House debate this spring, should men pay for maternity or prenatal coverage?

As the debate over health care continues, one of the challenges in addressing women’s health concerns is that they have different priorities, depending on their stage in life. A 20-year-old may care more about how to get free contraception, while a 30-year-old may be more concerned about maternity coverage. Women in their 50s might be worried about access to mammograms, and those in their 60s may fear not being able to afford insurance before Medicare kicks in at 65.

To get a richer sense of women’s varied viewpoints on health care, we asked several women around the country of different ages, backgrounds, and political views to share their thoughts and personal experiences.

Patricia Loftman, 68, New York City

Loftman spent 30 years as a certified nurse-midwife at Harlem Hospital Center and remembers treating women coming in after having botched abortions.

Some didn’t survive.

“It was a really bad time,” Loftman says. “Women should not have to die just because they don’t want to have a child.”

When the Supreme Court ruled that women had a constitutional right to an abortion in 1973, Loftman remembers feeling relieved. Now she’s angry and scared about the prospect of stricter controls. “Those of us who lived through it just cannot imagine going back,” she says.

A mother and grandmother, Loftman also recalls clearly when the birth control pill became legal in the 1960s. She was in nursing school in upstate New York and glad to have another, more convenient option for contraception. Already, women were gaining more independence, and the Pill “just added to that sense of increased freedom and choice.”

To her, conservatives’ attack on Planned Parenthood, which has already closed many clinics in several states, is frustrating because the organization also provides primary and reproductive health care to many poor women who wouldn’t be able to get it otherwise.

Now retired, Loftman sits on the board of the American College of Nurse-Midwivesand advocates for better care for minority women. “There continues to be a dramatic racial and ethnic disparity in the outcome of pregnancy and health for African-American women and women of color,” she says.

Terrisa Bukovinac, 36, San Francisco

Bukovinac calls herself a passionate pro-lifer. As president of Pro-Life Future of San Francisco, she participates in marches and protests to demonstrate her opposition to abortion.

“Our preliminary goal is defunding Planned Parenthood,” she says. “That is crucial to our mission.”

As much as the organization touts itself as being a place where people get primary care and contraception, “abortion is their primary business model,” Bukovinac says.

She said the vast majority of abortions are not justifiable and that she supports a woman’s right to an abortion only in cases that threaten her life. “We are opposed to what we consider elective abortions,” she says.

Bukovinac says she also tries to help women in crisis get financial assistance so they don’t end their pregnancies just because they can’t afford to have a baby. She supports women’s access to health insurance and health care, both of which are costly for many. “Certainly, the more people who are covered, the better it is” for both the mother and baby.

Bukovinac herself is uninsured because she says the premiums cost more than she would typically pay for care. Self-employed, Bukovinac has a disorder that causes vertigo and ringing in the ear and spends about $300 per month on medication for that and for anxiety.

She doesn’t know if the Affordable Care Act is to blame, but she said that before the law “I was able to afford health insurance and now I’m not.”

Irma Castaneda, 49, Huntington Beach, Calif.

Castaneda is a breast cancer survivor. She’s been in remission for several years but still sees her oncologist annually and undergoes mammograms, ultrasounds, and blood tests.

The married mom of three, a teacher’s aide to special education students, is worried that Republicans may make insurance more expensive for people like her with pre-existing conditions. “They could make our premiums go sky high,” she says.

Her family previously purchased a plan on Covered California, the state’s Obamacare exchange. But there was a high deductible, so she had to come up with a lot out-of-pocket money before insurance kicked in. “I was paying medical bills up the yin yang,” she says. “I felt like I was paying so much for this crappy plan.”

Then, about a year ago, Castaneda’s husband got injured at work and the family’s income dropped by half. Now they rely on Medicaid. At least now they have fewer out-of-pocket expenses for health care.

Whatever the coverage, Castaneda says, she needs high-quality health care. “God forbid I get sick again,” she says. And she worries about her daughter, who is transgender and receives specialized physical and mental health care.

“Right now she is pretty lucky because there is coverage for her,” Castaneda says. “With the Trump stuff, what’s going to happen then?”

Celene Wong, 39, Boston

The choice was agonizing for Wong. A few months into her pregnancy, she and her husband learned that her fetus had chromosomal abnormalities. The baby would have had severe special needs, she said.

“We always said we couldn’t handle that,” Wong recalls. “We had to make a tough decision, and it is not a decision that most people ever have to face.”

The couple terminated the pregnancy in January 2016, when she was about 18 weeks pregnant. “At the end of the day, everybody is going to go away except for your husband and you and this little baby,” she says. “We did our research. We knew what we would’ve been getting into.”

Wong, who works to improve the experience for patients at a local hospital, says she is fortunate to have been able to make the choice that was right for her family.

“If the [abortion] law changes, what is going to happen with that next generation?” she wonders.

Lorin Ditzler, 33, Des Moines, Iowa

Ditzler is frustrated that her insurance coverage may be a deciding factor in her family planning. She quit her job last year to take care of her 2-year-old son and was able to get on her husband’s plan, which doesn’t cover maternity care.

“To me it seems very obvious that our system isn’t set up in a way to support giving birth and raising very small children,” she says.

While maternity benefits are required under the Affordable Care Act, her husband’s plan is grandfathered under the old rules, which is not uncommon among employers that offer coverage. Skirting maternity coverage might become more common if Republicans in Congress pass legislation allowing states to drop maternity coverage an “essential benefit.”

Ditzler looked into switching to an Obamacare plan that they could buy through the exchange, but the rates were much higher than what she pays now.

If she goes back to work, she could get on a better insurance plan that covers maternity care. But that makes little sense to her. “I would go back to a full-time job so I could have a second child, but if I do that, it will be less appealing and less feasible to have a second child because I’d be working full time.”

Ashley Bennett, 34, Spartanburg, S.C.

Bennett describes herself as devoutly Christian. She is grateful that she was able to plan her family the way she wanted, with the help of birth control. She had her daughter at 22 and her son two years later.

“I felt free to make that choice, which I think is an awesome thing,” she says. She’s advised her 12-year-old daughter to wait for sex until marriage but has also been open with her about birth control within the context of marriage.

But she draws the line at abortion. “I just feel like we’re playing God. If that conception happens, then I feel like it was meant to be.”

Bennett had apprehensions about Trump but voted for him because he was the anti-abortion candidate. “That was the deciding factor for me, [more than] him yelling about how he’s going to build a wall.”

For her, opposition to abortion must be coupled with support for babies once they are born. She supports adoption and is planning to become a foster parent.

She also is concerned about the mental and physical well-being of young women. Bennett teaches seventh-grade math and coaches the school’s cheerleading and dance teams.

She watches the girls take dozens of photos of themselves to get the perfect shot, then add filters to add makeup or slim them down.

“There’s going to be an aftermath that we haven’t even thought about,” she says. “I worry we’re going to have more and more kids suffering from depression, eating disorders and even suicide because of the effects of the social media.”

Maya Guillén, 24, El Paso, Texas

When Guillén was growing up, her family spent years without health insurance. They crossed the border into Juárez, Mexico, for dental care, doctor appointments, and optometry visits.

Guillén is now on her parents’ insurance plan under a provision of the Affordable Care Act that allows children to stay on until they turn 26. She’s been disheartened by Republicans’ proposed changes to contraception and abortion coverage, she says.

In high school, Guillén received abstinence-only sex education. She watched her friends get pregnant before they graduated.

When it came time to consider sex, she thought she’d be able to count on Planned Parenthood, but the clinic in El Paso closed, as have 20 other women’s health clinics in Texas. She worries that if Republicans defund Planned Parenthood, more young girls, especially those in predominantly Hispanic communities like hers, will not be able to get contraceptives.

Jaimie Kelton, 39, New York City

When Jaimie Kelton’s wife gave birth to their baby 3½ years ago, she thought the country was finally becoming more open-minded toward gays and lesbians.

“Now I am coming to realize that we are the bubble and they are the majority and that’s really scary,” says Kelton, now pregnant with her second child.

Kelton says it seems as though Republicans have launched a war against women in general, with reproductive rights and maternity care at risk.

“It is crazy to think that most of the people making these laws are men,” she said. “Why do they feel the need to take away health care rights from women?”