Corley, a former Republican congressional staffer, filed not one, but six potential ballot measures in August to roll back her state’s near-total ban on abortion, triggered by the U.S. Supreme Court’s June 2022 decision to end federal protections for terminating pregnancies.

“I can’t emphasize enough how dangerous it is to be pregnant in Missouri right now,” Corley said at a restaurant near her home in this St. Louis suburb. “There is a real urgency to pass something to change the abortion law.”

Missouri is one of at least 11 states considering abortion-related ballot measures for next year, part of the wave of such actions since the Supreme Court’s decision on Dobbs v. Jackson Women’s Health Organization. And while November 2024 is still a year away, the groundwork for those campaigns has been in motion for months, sometimes years.

In Iowa, for example, efforts to pass a state constitutional amendment declaring no right to abortion began in 2021, although the legislature has yet to finish the process. In Colorado, competing initiatives — one to enshrine abortion protections and one to ban abortion — could potentially appear on the same ballot if supporters of both manage to garner enough signatures. And in Missouri, potential ballot measures to increase access to abortion have been bogged down in litigation for months, delaying the collection of signatures and highlighting internecine conflicts on both sides of the issue.

“In a way, I think this is what the Supreme Court wanted,” said John Matsusaka, executive director of the Initiative and Referendum Institute at the University of Southern California. “They said, ‘The people ought to figure this out.’”

The push for sending the contentious issue to voters comes on the heels of last year’s string of ballot measure wins for abortion rights in six states: California, Kansas, Kentucky, Michigan, Montana, and Vermont. And on Tuesday, Ohio voters broadly passed a measure to establish a state constitutional right to abortion.

Citizen-initiated ballot measures in the 26 states that allow them are often prompted by legislatures that stray far from public opinion, Matsusaka said. Fourteen states have banned abortion since the Dobbs decision, despite polling suggesting those bans are unpopular. Two-thirds of adults expressed concern in a May KFF poll, for example, that such bans could make it difficult for doctors to safely treat patients.

But in states where abortion is legal, a push is coming from the other direction.

“Colorado was actually the first state, or one of the first states, to provide abortion on demand,” said Faye Barnhart, one of the anti-abortion activists who filed petitions to restrict abortions there. “We were pioneers in doing the wrong thing, and so we’re hopeful that we’ll be pioneers in turning that around to do the right thing.”

A similar effort in Iowa, meanwhile, is up in the air. The legislature in 2021 approved a proposed amendment declaring the Iowa Constitution does not protect abortion rights. But the measure needs to pass the Republican-controlled legislature again to get on the ballot. Lawmakers declined to take up the matter during this year’s legislative session but could do so in 2024. A poll published by the Des Moines Register in March found that 61% of Iowans think abortion should be legal in all or most cases.

If Missouri’s abortion ban is indeed rolled back next year, it would mark the fourth time since 2018 that the state’s voters rebuked their Republican leaders, who have controlled the governorship and both legislative chambers since 2017. Recent initiative petitions have succeeded in raising the minimum wage, legalizing marijuana, and expanding Medicaid, the public insurance program for people with low incomes and disabilities.

The success of those campaigns doesn’t mean the petition process is easy, said Daniel Smith, a political science professor at the University of Florida who specializes in ballot initiatives. Collecting signatures is costly and often requires contracting with what he called the “initiative industrial complex.”

An analysis by Ballotpedia found that the cost per required signature collected for initiative campaigns in 2023 averaged $9.38. At that rate, it would cost more than $1.6 million to get an initiative on the ballot in Missouri — where around 172,000 signatures are needed. And that’s before adding in the cost of running campaigns to persuade voters to choose a side.

In the two months leading up to November’s vote in Ohio, the campaign to protect abortion rights raised about $29 million, and the opposing campaign raised nearly $10 million, according to The Associated Press. Much of the funding came from out-of-state groups, such as the progressive Sixteen Thirty Fund in Washington, D.C., and an Ohio organization associated with the national anti-abortion group Susan B. Anthony Pro-Life America.

And more money will pour into the next efforts: Last month, Illinois Gov. J.B. Pritzker, a billionaire Democrat whose family owns the Hyatt hotel chain, launched the Think Big America organization to help fund abortion-rights ballot measures across the country.

Still, the cost of launching a ballot campaign is a daunting obstacle, said Emily Wales, president and CEO of Planned Parenthood Great Plains, which has clinics in Missouri, Kansas, Oklahoma, and Arkansas. During last year’s vote in Kansas, for example, the competing campaigns raised over $11.2 million combined. That may be a factor in the absence of a ballot measure in Oklahoma despite momentum for one last year.

“It’s not just: Can you pull together a coalition, educate voters, and get them out? But: Can you also raise enough to combat what has been years of misinformation, miseducation, and really shaming and stigmatizing information about abortion?” Wales said.

Polling in Missouri indicates voters statewide, including many Republicans, might back abortion rights in certain circumstances.

That’s what led Corley to file her petitions in August despite a political action committee called Missourians for Constitutional Freedom having already filed 11 proposals to roll back the state’s abortion ban. Corley said her proposals are narrower to attract support from sympathetic Republicans like herself. They provide exemptions for rape, incest, fetal abnormalities, and the health of the mother. Three would prevent restrictions on abortions for the first 12 weeks of pregnancy.

The proposals from Missourians for Constitutional Freedom would allow abortion later in pregnancy. Some versions allow regulations on abortions only after 24 weeks, while others specify after “fetal viability” or don’t give any time frame.

One group withholding support from any effort so far is Planned Parenthood of the St. Louis Region and Southwest Missouri, the state’s other main Planned Parenthood affiliate and the final clinic to provide abortion services before Missouri’s ban.

“My concern is that we would potentially rebuild the same system that failed so many people,” said Colleen McNicholas, its chief medical officer for reproductive health services.

Missouri lawmakers long sought ways to limit abortion even while it was protected by the Supreme Court’s Roe v. Wade decision, including enacting a 72-hour waiting period in 2014. The number of recorded abortions in the state dropped from 5,772 in 2011 to 150 in 2021, the last full year before the current ban.

“We know what it’s like to live in a post-Roe reality, and we knew that reality well before the Dobbs decision,” said McNicholas.

Still, Corley said her group is ready to push ahead with at least one measure.

“People are looking for something like what we’re putting forward, which is something in the middle that provides protections against criminal prosecution,” Corley said. “I also don’t think people understand how much worse it can get in Missouri.”

Rural editor and correspondent Tony Leys in Des Moines, Iowa, contributed to this report.

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The vote comes on the heels of last year’s string of ballot measure wins for abortion rights in six states: California, Kansas, Kentucky, Michigan, Montana and Vermont. But this is just the start.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

Next year, 11 more states could see abortion-related ballot measures, part of a wave of such actions since the Supreme Court’s 2022 Dobbs decision, which overturned Roe v. Wade. The groundwork for these next campaigns has been in motion for months, sometimes years. 

In Iowa, for example, efforts to pass a state constitutional amendment declaring no right to abortion began in 2021, although the GOP-led legislature has yet to finish the process. In Colorado, competing initiatives — one to enshrine abortion protections and one to ban abortion — could appear on the same ballot if supporters of both garner enough signatures. 

And in Missouri, where I’m based, two groups filed a combined 17 initiative petitions to increase access to abortion. The proposals range from exemptions for rape, incest, fetal abnormalities and the health of the mother to preventing any restrictions on abortion without a “compelling governmental interest.” 

It’s unclear which, if any, of those will make it to the ballot since months of litigation has delayed signature collection and highlighted internecine conflicts on both sides of the issue.

• “In a way, I think this is what the Supreme Court wanted,” said John Matsusaka, executive director of the Initiative and Referendum Institute at the University of Southern California. “They said, ‘The people ought to figure this out.’”

Money has been pouring into the initiatives. In the two months leading up to the vote in Ohio, the campaign to protect abortion rights raised about $29 million, and the opposing campaign raised nearly $10 million, according to the Associated Press.

There’s much more to come. Last month, Illinois Gov. J.B. Pritzker, a billionaire Democrat whose family owns the Hyatt hotel chain, announced his Think Big America organization to help fund abortion rights ballot measures across the country. 

The cost of launching a ballot campaign can be a daunting obstacle, said Emily Wales, president and CEO of Planned Parenthood Great Plains, which has clinics in Kansas, Oklahoma, Arkansas and Missouri. During last year’s vote in Kansas, for example, the competing campaigns raised more than $11.2 million combined. That may be a factor in the absence of a ballot measure in Oklahoma, despite momentum for one last year.  

• “It’s not just: Can you pull together a coalition, educate voters and get them out? But: Can you also raise enough to combat what has been years of misinformation, miseducation, and really shaming and stigmatizing information about abortion?” Wales said.

Six of the 17 proposals in Missouri were filed by Jamie Corley, a former Republican congressional staffer who helms the new 501(c)(4) nonprofit Missouri Women and Family Research Fund. An abortion rights supporter, she’s trying to land on language that appeals to sympathetic Republicans like herself and thus has a chance of prevailing in her largely red state, one of 14 to ban abortion since the Dobbs decision. 

“I can’t emphasize enough how dangerous it is to be pregnant in Missouri right now,” Corley said. “There is a real urgency to pass something to change the abortion law.”

That’s for next year. In the meantime, we’ll find out today whether abortion rights supporters can go 7-0 for ballot measures and add Ohio to the states with constitutional protections. A recent poll from Baldwin Wallace University found that 58 percent of likely voters favored passing State Issue 1.

Turnout is expected to be high because the measure is under much debate locally, with competing pro and anti signs dotting yards and road medians. Last week, for example, at a small restaurant on the east side of Cincinnati, my KFF Health News colleague Stephanie Stapleton was on hand when a table of four women heatedly discussed Issue 1, criticizing men in the state legislature who they said were trying to control their bodies. 

The restaurant got quiet, and people at the table next to them stared. Some of the women who had been loudly talking apologized in case they had caused offense. 

But at the table that had been staring, laughter broke out. One of the young women stood up, took off her jacket and revealed that she was wearing a vintage 1973 T-shirt celebrating Roe v. Wade.

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As CEO of the Urgent Care Association, Horwitz knows the industry is booming. Its market size has doubled in 10 years, as patients, particularly younger ones, are drawn to the convenience of the same-day appointments and extended hours offered by the walk-in clinics.

“Urgent care is harder than it looks,” Horwitz recalled thinking when the Tulsa-based gas station and convenience store company QuikTrip announced an urgent care venture called MedWise in late 2020. “And that’s a whole different ballgame than selling Funyuns.”

But Horwitz said the more she thought about it, the more she saw an overlap between the business models of QuikTrip and of successful urgent care clinics: setting up in easy-to-find locations, catering to walk-ins, and accepting multiple payment methods, for example. QuikTrip opening health clinics might just make sense, she thought, provided they could deliver quality medical care.

In fact, QuikTrip had been providing primary care services to its own employees for years, through third parties and eventually at its own clinics. Five years ago, longtime “QuikTripper” Brice Habeck was tasked with leading a team to figure out how the company could offer such medical services to the general public, too. His team quickly realized that urgent care had a lot in common with their retail spaces.

“It’s about access. It’s about convenience,” said Habeck, who started his career as a clerk at a QT, as the stores are often branded, and is now the executive director of MedWise.

MedWise has opened 12 clinics so far, all in the Tulsa area, and now belongs to Horwitz’s trade group. The company is owned by QuikTrip, but the two businesses don’t share buildings or a name. As much as people love the gas station, Habeck said, company leaders didn’t want patients to think the person checking their vitals had just wiped down a gas pump.

QuikTrip is not the first company to see potential in the urgent care industry. Private equity firms have been investing in urgent care’s consumer-friendly niche for over a decade. And nearly half of urgent cares are affiliated with hospital systems — which often see urgent care as a front door for bringing in new patients while also taking some burden off their busy emergency rooms.

Other retailers have also seen opportunities in expanding into patient care. Walmart, Target, CVS, and Walgreens have all opened what are called “retail clinics” in recent years, often in their existing stores and often partnering with local health systems to provide the actual medical care. Generally, the scope of services available at urgent care centers, such as MedWise clinics, is more robust than what’s offered at those retail clinics, according to Horwitz.

But urgent care and retail clinics may not be a panacea for rising health care costs. A study co-authored by Harvard Medical School health policy professor Ateev Mehrotra shows urgent care clinics reduce less serious visits to the emergency room, yet 37 urgent care visits are needed to prevent a single trip to the ER, increasing total health care spending with all those trips.

And ongoing research by Vanderbilt University assistant professor Kevin Griffith suggests that newly constructed urgent care or retail clinics can decrease wait times at nearby private and public sector health centers initially. Eventually, however, the increased access provided by the new clinics increases demand as well, he is finding, and wait times creep back up.

“It’s kind of like the ‘build it and they will come’ of health care,” said Griffith, adding that even though the clinics may not decrease wait times long-term or reduce costs, they are getting patients seen. “There is a huge problem with unmet care in the United States. And so ostensibly, these clinics are making a dent into that problem as well.”

The experience of some retail clinics is a cautionary tale for companies like MedWise, according to Mehrotra: Disrupting the health care industry is easier said than done, even for businesses with a successful track record of good customer service in a low-margin business such as gas stations.

“Generally people have been happy with the convenience,” Mehrotra said, but the clinics have not been very profitable, prompting many closures over the years.

Gas stations are accustomed to competing over customers by offering something special. QuikTrip, for example, was recently ranked ninth on a list of best gas station brands in America that noted QT’s “beloved” made-to-order food, such as breakfast tacos. Habeck said he thinks patients today are open to a more transactional approach in health care as well.

That doesn’t mean offering roller-grill hot dogs and taquitos in urgent care waiting rooms, although Habeck joked that MedWise might have tried that if it hadn’t launched during the pandemic. Rather, he said, the chain is banking on winning customer loyalty by offering patients consistent service without necessarily offering a consistent clinician.

And, Habeck said, even though MedWise and QTs are not in the same buildings, the parent company’s experience finding prominent locations for gas stations is useful for placing urgent cares as well.

On a recent Friday afternoon, Billy Rohling and Amy Shaver stood waiting for their ride home in the mostly empty parking lot of a MedWise at the same exit as a QT off Interstate Highway 244 in Tulsa. Rohling, 56, remembers when this corner of Admiral Place and Sheridan Road was a shopping center with tenants like J.C. Penney Co. and a five-and-dime called TG&Y.

Those stores are long gone now, though. The couple came to MedWise because Shaver, 37, was having breathing problems. It was her second time visiting the clinic.

“They aren’t busy at all,” Rohling said. “It took 15 minutes to get an EKG.”

Indeed, MedWise’s patient visits have slowed since the unexpected “windfall volume” that came as a result of opening during the pandemic, Habeck said. At one point, MedWise clinics administered curbside covid-19 tests to hundreds of patients a day, many of whom paid cash. The momentum from all those visits helped propel the clinics through abnormally low flu seasons in 2020 and 2021 — typically urgent care’s bread and butter.

But Habeck said MedWise is still on track to expand. Four more locations are slated to open in northeastern Oklahoma this year, and the future should bring even more MedWise locations in QuikTrip’s 17-state, 1,000-location footprint, in places such as Kansas City, Missouri, and Wichita, Kansas.

State health care rules, public insurance payment rates, and existing health system locations will all factor into where the new clinics are located, Habeck said, although expansion out of state is probably a couple of years away.

Horwitz said scaling up in the industry requires a degree of standardization — everything from clinic layouts to staffing levels, and even where various supplies are stored — that can be hard to attain. But she said it’s a trend, with more urgent care chains having a triple-digit number of locations than ever before.

“Nobody’s at 1,000, but some are closing in on it,” Horwitz said.

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She knew it was triggered by food, so she said she tried taking an antacid. That helped a little, but, eventually, she avoided eating altogether. She estimated she lost 25 pounds in that time.

One night that September, the pain would not go away for hours. It was so severe she went to the emergency room at Indian Path Community Hospital in Kingsport, Tennessee, where she lives. An ultrasound revealed she needed her gallbladder removed right away. She was able to get into surgery quickly because she hadn’t eaten in over 12 hours due to her food avoidance.

At the time, Birch was 23 and uninsured. Once she was released from the hospital, however, she lost her housing and spent months without a permanent mailing address while crashing with family.

“It was a pretty rough situation because, at the time, I didn’t have a job, I didn’t have a driver’s license or anything,” Birch said.

For fear of bills she couldn’t afford, she said, she had often avoided seeking care for emergencies, including a broken finger, asthma attacks, and a sprained ankle. She didn’t expect her gallbladder surgery — which cured her pain — to be free.

But she said she never received a bill. She got engaged and moved in with her husband after they married at the end of 2017. Then, in 2018, there was a knock on her door, and she was served a lawsuit.

The Patient: Bethany Birch — née Bethany Allison — now 30, a stay-at-home mom. She lacked health coverage at the time of her surgery.

Medical Services: Emergency gallbladder removal in 2016, plus a previous visit to the emergency room at the same hospital the same year. A bill later obtained for that visit showed she received treatments consistent with an asthma attack, and while Birch said she could not recall that specific visit, she added that she has gone to the ER so many times for asthma attacks she finds it hard to keep track.

Service Provider: Indian Path Community Hospital, which in 2018 became part of Ballad Health, a health system in Tennessee and Virginia.

Total Bill: $11,749.60 plus interest, for two hospital visits and additional court costs associated with the lawsuit Ballad Health pursued against Birch. According to an affidavit of debt, she owed the hospital $9,986.40 for gallbladder removal surgery and $1,603.70 for the previous visit. The court judgment ultimately tacked on $159.50 in court costs and an interest rate of 7%. As of May 2023, she had accumulated $2,715.97 in interest.

What Gives: In October 2018, Birch was served papers at her home in Kingsport informing her that Ballad Health was suing her for $11,590.10 for two unpaid hospital bills from 2016 — including $9,986.40 for her gallbladder removal.

An executive with the health system later said the hospital attempted to contact her for payment and to discuss charity care. But Birch — who had neither a permanent mailing address nor reliable phone service at the time and could not recall whether she provided the hospital with her email address — said she never received their communications.

Under the Affordable Care Act, hospitals must take certain measures to notify patients of an outstanding bill before pursuing “extraordinary collection actions,” like filing a lawsuit. But experts said the law does not account for individual circumstances that can complicate a patient’s receipt of a bill.

And when interest is added to a repayment plan, medical debt can balloon even more. Ballad Health sued more than 6,700 patients over medical debt in 2018, according to an analysis by The New York Times.

Birch brought her father along for support when she showed up to her court date that November, but she did not have an attorney representing her.

“I would never be able to afford one,” Birch said.

At the courthouse, she said, she met with a representative from Wakefield & Associates — now known simply as Wakefield — the debt collection and revenue firm representing the health system. Birch signed an agreement to pay the full $11,590.10, plus $159.50 in court costs, in monthly installments of $100 beginning in January 2019.

The court tacked on a 7% interest rate, the default interest rate under Tennessee law at the time of the judgment.

Karen Scheibe Eliason, general counsel at Wakefield, declined interview requests despite Birch’s offer to give permission for a representative of the company to speak with KFF Health News about her case.

Anthony Keck, an executive vice president at Ballad Health, reviewed Birch’s case with KFF Health News after Birch signed a release waiving federal privacy protections. The health system’s timeline indicates a screening of Birch found she was single, uninsured, and unemployed at the time of the visit.

Given those circumstances, Birch might have qualified for free or reduced-cost care under the hospital’s financial assistance policy for low-income patients if she had applied.

Information about the financial assistance option was included in the bills the hospital mailed in September, October, and December 2016, Keck said.

But Birch said she never received the bills, likely because they were sent to an address where she no longer lived. She said she filed a change of address form with the post office in 2017 listing her grandmother’s house, where she was staying, but that change would have occurred after the hospital said it sent her bills. She didn’t initially update her address, she said, because she didn’t have a permanent place to live.

Ballad Health’s timeline also indicates a financial counselor left a voicemail for Birch soon after she left the hospital, which Birch said she also did not receive, likely because her pay-as-you-go phone plan was not paid at the time.

Keck said Ballad Health has since changed its financial assistance program to screen and help people like Birch who have barriers in life that could prevent them from applying for financial assistance, such as financial, housing, and food insecurity.

“If we had had that system in place” when Birch was being treated, Keck said, “this wouldn’t have happened.”

The hospital where Birch was treated became part of Ballad Health in 2018, when two competing hospital systems in eastern Tennessee merged, creating one of the largest health systems in the country. According to recent public filings, Ballad Health had an operating revenue of $2.3 billion in 2022 and paid its CEO $2.8 million in 2021.

The Resolution: Birch was originally sued for $11,590.10. Since her court-ordered payment plan began, Birch had paid $5,270.20 as of May.

But her balance was still $9,299.82 — $6,583.85 on the principal amount, for her hospital debt and court costs, plus $2,715.97 of accrued interest. After more than four years of payments, she had barely made a dent in her debt.

A KFF Health News-NPR investigation showed many hospitals now commonly use aggressive collection tactics, including selling unpaid medical debt to third-party companies that handle collections, like Wakefield, and pursuing lawsuits against patients.

Keck said Ballad Health does not receive the interest payments. “Interest is mandated by the courts and is directed towards legal fees incurred by the agency collecting on the unpaid patient debt,” he said.

In February, Birch started receiving assistance from Ashley Beasley, a patient advocate her grandmother knew from church. Beasley agreed to help Birch as a favor and suggested she reach out to NPR and KFF Health News.

Birch and Beasley said they asked Ballad Health twice that month to settle her debt, but representatives told them Birch needed to work with Wakefield, the debt collector. When they called Wakefield, they said they were told Birch had to work with Ballad Health.

In May, on a phone call with Wakefield representative Anna Elrick, Birch and Beasley again asked to settle the debt, offering to pay an additional $500 on top of what Birch had already paid. Elrick said she would take the offer to Ballad Health. Three days later, Elrick called Beasley to say their offer had been accepted, Beasley said. Birch has since paid the $500 and received a letter from Wakefield acknowledging her account has been paid in full.

Birch called her settlement “bittersweet.” On one hand, she said, she feels relief.

“But it’s bitter because I know I’m not the only person who’s fallen prey to this,” she said. “I’m not going to forget that there are other people in my situation, too.”

The Takeaway: The ACA requires hospitals to make “reasonable efforts” to determine if a patient qualifies for financial assistance before taking them to court. Those efforts specifically include notifying a patient about a financial assistance policy and waiting at least 120 days after providing the first billing statement before initiating a legal process, for instance. Ballad Health’s timeline of Birch’s case indicates the health system followed those steps.

Zack Buck, a University of Tennessee associate professor who specializes in health law, said the ACA standards leave gaps that patients living in unstable circumstances can fall through.

“What does it mean to provide someone with a bill if it’s someone who is not easily reachable and does not have a home?” he said. “It’s almost as if the regulations don’t even ponder that possibility.”

Berneta Haynes, a senior attorney with the National Consumer Law Center, said some states have moved to cap or even ban certain interest charges on medical debt. In Arizona, for example, voters approved a 3% cap on medical debt last year. A Maryland law passed in 2021 prohibits hospitals from charging interest payments for patients who qualify for free or discounted care.

But Haynes said policy initiatives should also focus on how to prevent medical debt in the first place.

“Because once it happens, it seems like the situations get more and more complicated and people get left in these gaps,” Haynes said.

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Son parte de una nueva migración de estadounidenses que se están desarraigando debido a una oleada de leyes que restringen la prestación de servicios de salud para personas transgénero.

Missouri, Florida y Texas se encuentran entre al menos 20 estados que han limitado la atención de afirmación de género para jóvenes trans. Los tres estados también están entre aquellos que impiden que Medicaid, el seguro de salud público para personas de bajos ingresos, cubra aspectos clave de estos servicios para pacientes de todas las edades.

Más de una cuarta parte de los adultos trans encuestados por KFF y The Washington Post a fines del año pasado dijeron que se mudaron a otro vecindario, ciudad o estado en busca de un ambiente más tolerante. Ahora se sienten impulsados por las nuevas restricciones en la atención de la salud y la posibilidad de que estas se sigan multiplicando.

Muchos de ellos optan por estados que están aprobando leyes para proteger y apoyar estos servicios, lugares que se han convertido en santuarios. En California, por ejemplo, se aprobó una ley el otoño pasado que protege de demandas a las personas que reciben o brindan servicios de afirmación de género. Y ahora, los proveedores en California están recibiendo cada vez más llamadas de personas que quieren mudarse al estado para evitar interrupciones en sus servicios, dijo Scott Nass, médico local de familia y experto en atención de personas transgénero.

Pero esta afluencia de pacientes presenta un desafío, dijo Nass, “ya que el sistema actual no puede recibir a todos los refugiados que pudiera haber”.

En Florida, la persecución legislativa de las personas trans y su atención médica convenció a Arlo Dennis, de 35 años, de que es hora de irse. Hace más de una década que vive con los cinco miembros de su familia en Orlando. Ahora, tienen planes de mudarse a Maryland.

Dennis ya no tiene acceso a su terapia de reemplazo hormonal. Esto se debe a que desde fines de agosto, el seguro de Medicaid de Florida ya no cubre la atención médica relacionada con la transición. El estado considera que estos tratamientos son experimentales y que su eficacia no está suficientemente probada. Dennis dijo que su medicación se acabó en enero.

“Sin duda esto me ha causado problemas de salud mental y física”, explicó Dennis.

Agregó que mudarse a Maryland requiere recursos que su familia no tiene. Lanzaron una campaña de GoFundMe en abril y ya recaudaron más de $5,600, la mayoría donada por desconocidos, contó Dennis. Ahora la familia de tres adultos y dos niños piensa irse de Florida en julio. La decisión no fue fácil, pero sintieron que no había otra opción.

“No me importa si a mi vecino no le gusta mi forma de vivir”, dijo Dennis. “Pero esto era una prohibición literal de mi ser y me impedía el acceso a la atención médica”.

Mitch y Tiffany Tillison decidieron irse de Texas después de que los republicanos del estado enfocaron su agenda legislativa en las políticas anti-trans para los jóvenes. Su hija de 12 años se declaró trans hace unos dos años. Los padres pidieron que se publicara solo su segundo nombre, Rebecca: temen por su seguridad debido a las amenazas de violencia contra las personas trans.

Este año, la Legislatura de Texas aprobó una ley que limita la atención médica de afirmación de género para jóvenes menores de 18 años. La ley prohíbe específicamento aquellos servicios de salud física. Sin embargo, defensores de los derechos LGBTQ+ en el estado dicen que las medidas recientes también han tenido un escalofriante efecto sobre la prestación de servicios de salud mental para personas trans.

Los Tillison se negaron a precisar si su hija está recibiendo tratamiento y cuál. Pero afirmaron que reservan el derecho, como padres, de poder brindarle a su hija la atención que necesita, y que el estado de Texas les ha quitado ese derecho.

A esto se suman las amenazas cada vez más serias de violencia en su comunidad, sobre todo después del tiroteo masivo del 6 de mayo por parte de un supuesto neonazi. La masacre, que ocurrió en el centro comercial Allen Premium Outlets, en los suburbios de Dallas, a 20 millas de su casa, hizo que la familia decidiera mudarse al estado de Washington. 

“La he mantenido a salvo”, dijo Tiffany Tillison, agregando que suele recordar el momento en que su hija le dijo que era trans durante un largo viaje a casa después de un torneo de fútbol. “Es mi responsabilidad seguir protegiéndola. Mi amor es interminable, incondicional”.

Por su parte, Rebecca tiene una actitud pragmática sobre la mudanza, que está planeada para julio. “Es triste pero tenemos que hacerlo”, dijo.

En Missouri, donde casi se aprueba una medida que limitaba la atención de la salud trans, algunas personas empezaron a repensar si deberían vivir ahí.

En abril, el fiscal general de Missouri, Andrew Bailey, presentó una norma de emergencia para limitar el acceso a la cirugía relacionada con la transición y el tratamiento hormonal cruzado para personas de todas las edades, además de restringir los bloqueadores de la pubertad, medicamentos que detienen la pubertad pero no alteran las características de género.

Al día siguiente, Dempsey, de 24 años, lanzó una campaña de GoFundMe para recaudar fondos para irse con sus parejas de Springfield, Missouri.

“Somos tres personas trans que dependen de la terapia de reemplazo hormonal y de la atención de afirmación de género que pronto será casi prohibida”, escribió Dempsey en su campaña de GoFundMe, agregando que querían “escapar de Missouri cuando se termine nuestro contrato de alquiler a fines de mayo.”

Dempsey dijo que su médico en Springfield les recetó un suministro de tres meses de terapia hormonal para cubrirlos hasta la mudanza.

Bailey retiró la norma en mayo, cuando la legislatura estatal restringió el acceso a estos tratamientos para menores pero no para adultos como Dempsey y sus parejas. Aún así, Dempsey dijo que no tenía muchas esperanzas para su futuro en Missouri.

El estado vecino de Illinois era una opción obvia para mudarse; la legislatura allí aprobó una ley en enero que exige que los seguros médicos regulados por el estado cubran la atención médica de afirmación de género sin ningún costo adicional. Dónde en Illinois exactamente era una pregunta más importante. Chicago y sus suburbios parecían demasiado caros. Sus parejas querían una comunidad progresista similar en tamaño y costo de vida a la ciudad que estaban dejando. Buscaban “un Springfield”, en Illinois.

“Pero no Springfield, Illinois”, bromeó Dempsey.

Gwendolyn Schwarz, de 23 años, también esperaba quedarse en Springfield, Missouri, su ciudad natal, donde recientemente se graduó de Missouri State University con un título en estudios de cine y medios de comunicación. Pensaba seguir su carrera académica en un programa de posgrado de la universidad y, en el siguiente año, someterse a una cirugía de transición, que puede requerir varios meses de recuperación.Pero sus planes cambiaron cuando la norma propuesta por Bailey generó miedo y confusión.“No quiero quedarme atrapada y temporalmente discapacitada en un estado que no reconoce mi humanidad”, dijo Schwarz.

Ella y un grupo de amigos tienen planeado mudarse al oeste, al estado de Nevada, cuyos legisladores aprobaron una medida que requiere que Medicaid cubra el tratamiento de afirmación de género para pacientes trans.

Schwarz espera que mudarse de Missouri a Carson City, la capital de Nevada, le permita seguir viviendo su vida sin miedo y eventualmente someterse a la cirugía que desea.

Dempsey y sus parejas finalmente decidieron mudarse a Moline, Illinois. Los tres tuvieron que renunciar a sus trabajos, pero han recaudado $3,000 en GoFundMe, más que suficiente para cubrir el depósito de un nuevo departamento.

El 31 de mayo, empacaron las pertenencias que no habían vendido e hicieron el viaje de 400 millas hasta su nuevo hogar.

Dempsey ya tuvo una cita con un proveedor médico en una clínica en Moline que atiende a la comunidad LGBTQ+, y consiguió que le recetaran los medicamentos que necesita para su terapia hormonal.

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They are part of a new migration of Americans who are uprooting their lives in response to a raft of legislation across the country restricting health care for transgender people.

Missouri, Florida, and Texas are among at least 20 states that have limited components of gender-affirming health care for trans youth. Those three states are also among the states that prevent Medicaid — the public health insurance for people with low incomes — from paying for key aspects of such care for patients of all ages.

More than a quarter of trans adults surveyed by KFF and The Washington Post late last year said they had moved to a different neighborhood, city, or state to find more acceptance. Now, new restrictions on health care and the possibility of more in the future provide additional motivation.

Many are heading to places that are passing laws to support care for trans people, making those states appealing sanctuaries. California, for example, passed a law last fall to protect those receiving or providing gender-affirming care from prosecution. And now, California providers are getting more calls from people seeking to relocate there to prevent disruptions to their care, said Scott Nass, a family physician and expert on transgender care based in the state.

But the influx of patients presents a challenge, Nass said, “because the system that exists, it can’t handle all the refugees that potentially are out there.”

In Florida, the legislative targeting of trans people and their health care has persuaded Arlo Dennis, 35, that it is time to uproot their family of five from the Orlando area, where they’ve lived for more than a decade. They plan to move to Maryland.

Dennis, who uses they/them pronouns, no longer has access to hormone replacement therapy after Florida’s Medicaid program stopped covering transition-related care in late August under the claim that the treatments are experimental and lack evidence of being effective. Dennis said they ran out of their medication in January.

“It’s definitely led to my mental health having struggles and my physical health having struggles,” Dennis said.

Moving to Maryland will take resources Dennis said their family does not have. They launched a GoFundMe campaign in April and have raised more than $5,600, most of it from strangers, Dennis said. Now the family, which includes three adults and two children, plans to leave Florida in July. The decision wasn’t easy, Dennis said, but they felt like they had no choice.

“I’m OK if my neighbor doesn’t agree with how I’m living my life,” Dennis said. “But this was literally outlawing my existence and making my access to health care impossible.”

Mitch and Tiffany Tillison decided they needed to leave Texas after the state’s Republicans made anti-trans policies for youth central to their legislative agenda. Their 12-year-old came out as trans about two years ago. They asked for only her middle name, Rebecca, to be published because they fear for her safety due to threats of violence against trans people.

This year, the Texas Legislature passed a law limiting gender-affirming health care for youth under 18. It specifically bans physical care, but local LGBTQ+ advocates say recent crackdowns also have had a chilling effect on the availability of mental health therapy for trans people.

While the Tillisons declined to specify what treatment, if any, their daughter is getting, they said they reserve the right, as her parents, to provide the care their daughter needs — and that Texas has taken away that right. That, plus increasing threats of violence in their community, particularly in the wake of the May 6 mass shooting by a professed neo-Nazi at Allen Premium Outlets, about 20 miles from their home in the Dallas suburbs, caused the family to decide to move to Washington state.

“I’ve kept her safe,” said Tiffany Tillison, adding that she often thinks back to the moment her daughter came out to her during a long, late drive home from a daylong soccer tournament. “It’s my job to continue to keep her safe. My love is unending, unconditional.”

For her part, Rebecca is pragmatic about the move planned for July: “It’s sad, but it is what we have to do,” she said.

A close call on losing key medical care in Missouri also pushed some trans people to rethink living there. In April, Missouri Attorney General Andrew Bailey issued an emergency rule seeking to limit access to transition-related surgery and cross-sex hormones for all ages, and restrict puberty-blocking drugs, which pause puberty but don’t alter gender characteristics. The next day, Dempsey, 24, who uses they/them pronouns, launched a GoFundMe fundraiser for themself and their two partners to leave Springfield, Missouri.

“We are three trans individuals who all depend on the Hormone Replacement Therapy and gender affirming care that is soon to be prohibitively limited,” Dempsey wrote in the fundraising appeal, adding they wanted to “escape Missouri when our lease is up at the end of May.”

Dempsey said they also got a prescription for a three-month supply of hormone therapy from their doctor in Springfield to tide them over until the move.

Bailey withdrew his rule after the state legislature in May restricted new access to such treatments for minors, but not adults like Dempsey and their partners. Still, Dempsey said their futures in Missouri didn’t look promising.

Neighboring Illinois was an obvious place to move; the legislature there passed a law in January that requires state-regulated insurance plans to cover gender-affirming health care at no extra cost. Where exactly was a bigger question. Chicago and its suburbs seemed too expensive. The partners wanted a progressive community similar in size and cost of living to the city they were leaving. They were looking for a Springfield in Illinois.

“But not Springfield, Illinois,” Dempsey quipped.

Gwendolyn Schwarz, 23, had also hoped to stay in Springfield, Missouri, her hometown, where she had recently graduated from Missouri State University with a degree in film and media studies. She had planned to continue her education in a graduate program at the university and, within the next year, get transition-related surgery, which can take a few months of recovery.

But her plans changed as Bailey’s rule stirred fear and confusion.

“I don’t want to be stuck and temporarily disabled in a state that doesn’t see my humanity,” Schwarz said.

She and a group of friends are planning to move west to Nevada, where state lawmakers have approved a measure that requires Medicaid to cover gender-affirming treatment for trans patients.

Schwarz said she hopes moving from Missouri to Nevada’s capital, Carson City, will allow her to continue living her life without fear and eventually get the surgery she wants.

Dempsey and their partners settled on Moline, Illinois, as the place to move. All three had to quit their jobs to relocate, but they have raised $3,000 on GoFundMe, more than enough to put a deposit down on an apartment.

On May 31, the partners packed the belongings they hadn’t sold and made the 400-mile drive to their new home.

Since then, Dempsey has already been able to see a medical provider at a clinic in Moline that caters to the LGBTQ+ community — and has gotten a new prescription for hormone therapy.

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CLAYTON, Mo. — Kaitlyn Anderson was six months pregnant when a driver killed her and a Missouri Department of Transportation colleague in 2021 while they were doing roadwork near St. Louis. Her fetus also died.

Although Anderson’s family tried to sue the department on her behalf, workers’ compensation laws in Missouri and elsewhere shield employers from wrongful death lawsuits when an employee dies on the job. So the case was also filed on behalf of the 25-year-old woman’s unborn child, a son named Jaxx. This was possible because Missouri law defines life — and legal rights — as beginning at conception.

In turn, the lawyers representing the state argued that, since Jaxx was considered a person, his case should be dismissed because under workers’ compensation laws he met the definition of an employee.

“That’s just disgusting,” said Tonya Musskopf, Anderson’s mother. “Who would have known what he would have grown into? His whole life was ahead of him.”

What wasn’t in question from either side was the idea that the 6-month-old fetus had legal rights under Missouri law. Every state has at least some statute or case law that considers a fetus a person, according to a report from Pregnancy Justice, a nonprofit that advocates for the rights of pregnant people. The report lists Missouri among at least 10 states with personhood language that is so broad it could be interpreted to apply to all civil and criminal laws.

Around the country, state personhood definitions have often been restrained by laws protecting the right to abortions, according to Pregnancy Justice acting executive director Dana Sussman, because together they create an inherent inconsistency: How could a fetus be a person if abortion is legal? But now that abortion rights are no longer federally protected, personhood definitions could expand throughout state law.

“States have more leverage and leeway to tread in these waters,” said John Seago, president of Texas Right to Life, a group that opposes abortion.

The U.S. Supreme Court’s 1973 decision in Roe v. Wade, which protected abortion rights, stated that the word “person” did not include the unborn for the purposes of individual rights such as equal protection under the law. The ruling prompted a nationwide push to grant more rights to fetuses, according to Laura Hermer, a visiting professor at St. Louis University School of Law.

Among states, Missouri’s recognition of personhood for fetuses was early and consequential.

Here, a 1986 law to regulate abortion included a preamble that defined life as beginning at conception. Three years later, the U.S. Supreme Court ruled Missouri’s definition could stand since it was merely a “value judgment.” A Missouri Supreme Court ruling in 1995 opened the door for the definition to apply to all Missouri statutes.

Still, Sussman noted, Missouri courts have not applied personhood to every state statute.

In 2018, a Missouri man unsuccessfully attempted to appeal his conviction for child molestation by arguing the state’s personhood language required the court to calculate the age of the victim from conception, not birth, which would have made her above the statutory age limit. Sussman said it’s an example of how the limits of broad personhood language are tested.

“People will start to utilize that and figure out ways to have it benefit their particular circumstances,” Sussman said.

That type of boundary-pushing, Sussman said, is invited by inconsistencies in the law, like those created by the U.S. Supreme Court’s Dobbs decision last summer, which overturned Roe v. Wade without addressing the question of when personhood rights begin.

The Dobbs ruling gives states the power to regulate abortion, and in Texas it triggered an abortion law that defines an unborn child as an “individual living member of the homo sapiens species from fertilization until birth.” Just days later, a Texas woman was given a ticket for driving in the carpool lane despite arguing that her unborn daughter counted as a second person in the vehicle.

“One law is saying that this is a baby and now he’s telling me this baby that’s jabbing my ribs is not a baby,” she said of the officer who gave her the ticket. That ticket and a second one she got for a similar incident the next month were ultimately dismissed.

Another legal boundary was pushed in early April when a U.S. District Judge in Texas ruled that the FDA had improperly approved the common abortion drug mifepristone. The judge noted that part of the ruling’s analysis “arguably applies to the unborn humans extinguished by mifepristone — especially in the post-Dobbs era.” The Supreme Court has blocked the ruling, for now.

Seago said these kinds of legal tests are important.

“That’s the phase that we’re at after undoing a court precedent that had been there for almost 50 years,” Seago said. “We’re encouraged that it’s forcing these important questions, like, ‘What do we owe our unborn neighbors?’”

But Sussman worries about an increase in criminal charges filed against pregnant people. Pregnancy Justice filed a brief in a 2021 court case challenging an Arizona law that granted personhood rights to unborn children “at every stage of development.”

Citing Missouri as a cautionary tale, the brief asserts not a single woman was arrested in the state in relation to her pregnancy before the Supreme Court allowed Missouri’s personhood language to stand. The years that followed, however, brought at least 39 arrests of women “for being pregnant and subjecting ‘unborn children’ to perceived risks of harm including drinking alcohol, smoking marijuana, or drinking tea made with mint and marijuana leaves to treat morning sickness.”

The Arizona law was blocked, at least temporarily.

Texas’ new abortion case law has yet to play out, but Seago anticipated it would follow the pattern established for child abuse, in which the accused can defend themselves by establishing they didn’t intend to cause harm.

“There’s no accidental abortion in Texas,” Seago said.

In Missouri, wrongful death claims for unborn children have been allowed since the 1995 state Supreme Court ruling.

Anderson’s family filed a wrongful death lawsuit in St. Louis County in 2022 against the driver, the Missouri Highways and Transportation Commission — which governs the Department of Transportation — and several of Anderson’s supervisors.

The state’s attorneys argued that Jaxx, like his mother, met the definition of an “employee” under Missouri workers’ compensation law, which includes an employee’s dependents in the event the employee is dead. Because Jaxx’s rights under Missouri law began at his conception, the filing read, he should be considered Anderson’s dependent. That would prevent a wrongful death suit brought against the Department of Transportation on Jaxx’s behalf.

“Who the hell would argue that someone who hasn’t been born works for them and is a dependent?” said Andrew Mundwiller, the attorney representing Anderson’s family. “I would say it stretches the bounds of the law.”

Theresa Otto, an attorney representing the Department of Transportation, declined to comment about the case, saying the department does not comment on active litigation.

St. Louis University School of Law professor Michael Duff, who has written a book on workers’ compensation law, said this type of case was, “thankfully,” rare. But he did find nine cases nationwide since 1985 that examined whether workers’ compensation laws barred suits against companies for injuries sustained in utero. In each case, the answer was no and the lawsuit continued.

On March 29, Judge Joseph Dueker, who was assigned the case in St. Louis County Circuit Court in Clayton, issued a similar ruling in Jaxx’s case, writing that barring Jaxx’s claims would lead to an “extremely absurd result.” A trial is set for March 2024.

Sussman, of Pregnancy Justice, said broad personhood language would allow legal boundaries to be pushed until state legislatures act to clarify the laws.

The case in Missouri prompted the introduction of a bill in the state legislature, dubbed “Jaxx’s Law,” that would bar unborn children from being considered employees in any civil actions, including wrongful death lawsuits.

But they would still be considered people with legal rights.

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A New York bill includes a cap on the amount staffing agencies can charge health care facilities. And a Texas measure would allow civil penalties against such agencies.

These proposed regulations — and others in at least 11 more states, according to the American Staffing Association industry trade group — come after demand for travel nurses, who work temporary assignments at different facilities, surged to unprecedented levels during the worst of the covid-19 pandemic.

Hospitals have long used temporary workers, who are often employed by third-party agencies, to help fill their staffing needs. But by December 2021, the average weekly travel nurse pay in the country had soared to $3,782, up from $1,896 in January 2020, according to a Becker’s Hospital Review analysis of data from hiring platform Vivian Health. That platform alone listed over 645,000 active travel nurse jobs in the final three months of 2022.

Some traveling intensive care unit nurses commanded $10,000 a week during the worst of the pandemic, prompting burned-out nurses across the country to leave their hospital staff jobs for more lucrative temporary assignments. Desperate hospitals that could afford it offered signing bonuses as high as $40,000 for nurses willing to make multiyear commitments to join their staff instead.

The escalating costs led hospitals and their allies around the country to rally against what they saw as price gouging by staffing agencies. In February 2021, the American Hospital Association urged the Federal Trade Commission to investigate “anticompetitive pricing” by agencies, and, a year later, hundreds of lawmakers urged the White House to do the same.

No substantial federal action has occurred, so states are trying to take the next step. But the resulting regulatory patchwork could pose a different challenge to hospitals in states with rate caps or other restrictive measures, according to Hannah Neprash, a University of Minnesota health care economics professor. Such facilities could find it difficult to hire travel nurses or could face a lower-quality hiring pool during a national crisis than those in neighboring states without such measures, she said.

For example, Massachusetts and Minnesota already had rate caps for temporary nurses before the pandemic but raised and even waived their caps for some staffing agencies during the crisis.

And any new restrictions may meet stiff resistance, as proposed rate caps did in Missouri last year.

As the covid omicron variant wave began to subside, Missouri legislators considered a proposal that would have set the maximum rate staffing agencies could charge at 150% of the average wage rate of the prior three years plus necessary taxes.

The Missouri Hospital Association, a trade group that represents 140 hospitals across the state, supported the bill as a crackdown on underhanded staffing firms, not on nurses being able to command higher wages, spokesperson Dave Dillon said.

“During the pandemic there were staffing companies who were making a lot of promises and not necessarily delivering,” Dillon said. “It created an opportunity for both profiteering and for bad actors to be able to play in that space.”

Nurses, though, decried what they called government overreach and argued the bill could make the state’s existing nursing shortage worse.

Theresa Newbanks, a nurse practitioner, asked legislators to imagine the government attempting to dictate how much a lawyer, electrician, or plumber could make in Missouri. “This would never be allowed,” she testified to the committee considering the bill. “Yet, this is exactly what is happening, right now, to nurses.”

Another of the nearly 30 people who testified against the bill was Michelle Hall, a longtime nurse and hospital nursing leader who started her own staffing agency in 2021, in part, she said, because she was tired of seeing her peers leave the industry over concerns about unsafe staffing ratios and low pay.

“I felt like I had to defend my nurses,” Hall later told KHN. Her nurses usually receive about 80% of the amount she charges, she said.

Typically about 75% of the price charged by a staffing agency to a health care facility goes to costs such as salary, payroll taxes, workers’ compensation programs, unemployment insurance, recruiting, training, certification, and credential verification, said Toby Malara, a vice president at the American Staffing Association trade group.

He said hospital executives have, “without understanding how a staffing firm works,” wrongly assumed price gouging has been occurring. In fact, he said many of his trade group’s members reported decreased profits during the pandemic because of the high compensation nurses were able to command.

While Missouri lawmakers did not pass the rate cap, they did make changes to the regulations governing staffing agencies, including requiring them to report the average amounts charged per health care worker for each personnel category and the average amount paid to those workers. Those reports will not be public, although the state will use them to prepare its own aggregate reports that don’t identify individual agencies. The public comment period on the proposed regulations was scheduled to begin March 15.

Hall was not concerned about the reporting requirements but said another of the changes might prompt her to close shop or move her business out of state: Agencies will be barred from collecting compensation when their employees get recruited to work for the facility where they temp.

“It doesn’t matter all the money that I have put out prior, to onboard and train that person,” Hall said.

Dillon called that complaint “pretty rich,” noting that agencies routinely recruit hospital staff members by offering higher pay. “Considering the premium agencies charge for staff, I find it hard to believe that this risk isn’t built into their business model,” he said.

Of course, as the pandemic has waned, the demand for travel nursing has subsided. But pay has yet to drop back to pre-pandemic levels. Average weekly travel nurse pay was $3,077 in January, down 20% year over year but still 62% higher in January 2020, according to reporting on Vivian Health data by Becker’s.

With the acute challenges of the pandemic behind hospitals, Dillon said, health system leaders are eyeing proactive solutions to meet their ongoing workforce challenges, such as raising pay and investing in the nursing workforce pipeline.

A hospital in South Carolina, for example, is offering day care for staffers’ children to help retain them. California lawmakers are considering a $25-per-hour minimum wage for health care workers. And some hospitals have even created their own staffing agencies to reduce their reliance on third-party agencies.

But the momentum to directly address high travel nurse rates hasn’t gone away, as evidenced by the legislative push in Missouri this year.

The latest proposal would apply to certain agencies if a “gross disparity” exists between the prices they charge during an emergency and what they charged prior to it or what other agencies are currently charging for similar services and if their earnings are at least 15% higher than before the emergency.

Malara said he doesn’t have much of a problem with this year’s bill because it gives agencies the ability to defend their practices and pricing.

Kentucky last year applied its existing price gouging rules to health care staffing agencies. The rules, which set criteria for acceptable prices, allow increases driven by higher labor costs. Malara said if the Missouri bill gains momentum he will point its sponsor to that language and ask her to clarify what constitutes a “gross disparity” in prices.

The sponsor of the bill, Missouri state Sen. Karla Eslinger, a Republican, did not respond to requests for comment on the legislation.

Hall said she is opposed to any rate caps but is ambivalent about Missouri’s new proposal. She said she saw agencies raising their prices from $70 an hour to over $300 while she worked as a hospital nursing leader at the height of the pandemic.

“All these agencies that were price gouging,” Hall said, “all they were doing was putting that money in their own pockets. They weren’t doing anything different or special for their nurses.”

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