When Jessy Rosales was a sophomore at the University of California, Riverside, she had a boyfriend and she was taking birth control pills. Then out of nowhere, she started feeling sick.

“I just thought it was the stomach flu,” she says. “It turns out I was pregnant.”

Rosales was clear that she was not ready to have a baby. She wanted a medication abortion, where she would take one pill at the clinic and a second one at home a day or two later to induce a miscarriage.

“I just wanted the intimacy of dealing with it on my own, in the privacy of my own home,” she says. “And being able to cry if I wanted to cry or just being able to curl up in my bed right away.”

Public university health centers in California do not perform abortions. But state lawmakers are expected to pass a bill in the coming weeks that would require student health centers at all 34 state campuses to provide medication abortions. If the measure becomes law, it will be the first of its kind in the U.S.

The bill’s supporters say they want to remove the obstacles women face accessing medical abortion off campus. For example, Rosales was given three off-campus referrals for abortion providers by her student health center. But the first clinic she called didn’t perform abortions after all. The second didn’t take her insurance.

By the time she could get an appointment at a third clinic, she was already into the second trimester of pregnancy — too late for a medication abortion, which can only be done up to 10 weeks. Rosales ended up having a surgical procedure.

“The doctor kept telling me to relax … and I couldn’t because it just hurt so bad,” she recalls. “I was just afraid and alone.”

Rosales graduated last year and is now advocating for the bill (SB 24) as a reproductive justice activist with the Women’s Foundation of California. She wants other students to have easier access to the abortion pill than she did.

Opponents of the bill have organized several rallies against it. In August, about 60 protesters in yellow T-shirts gathered outside a church in Sacramento, Calif., their heads bowed as a priest led them in prayer. Then they marched around the state’s Capitol, chanting, “Don’t kill babies! Don’t kill babies!”

While a consortium of women’s groups that support abortion rights has promised to pay for all the required ultrasound equipment and upfront training costs of providing the abortion pill on campus, eventually universities would likely need to dip into tax dollars or student fees for ongoing costs.

Abortion opponents such as Michele LaMonica object to that.

“Not on my dime, not on my dime,” LaMonica says. “Tax me to help the homeless. Tax me to help social services, but don’t tax me to pay for the disposal of human life.”

Insurers are already required to cover abortion under California law, and state tax dollars do go toward abortions provided through Medi-Cal, the state version of Medicaid for low-income patients. However, none of the UC campuses and only some of the CSU campuses get reimbursed for health services through Medi-Cal. University officials testified during legislative hearings on the bill last year that it could be an administrative or fiscal burden to establish billing systems to provide the abortion pill on campus. They predicted that some clinical costs, as well as security and liability costs, could fall directly to the universities and get passed on to students.

Up to 519 women at public universities seek a medication abortion every month in California, according to a study published last summer in the Journal of Adolescent Health.

The same research found that off-campus abortion providers were an average of 6 miles away from public university campuses in California.

Former Gov. Jerry Brown cited this stat when he vetoed a version of the same bill (SB 320) last year, saying the legislation was not necessary.

“Six miles away — that’s like a $5 Uber ride,” said abortion opponent Nick Reynosa, the Northern California regional coordinator for Students for Life of America.

He says the campaign is more about politics than need.

“Over the last decade, many pro-choice activists feel that in red states, there’s been a lot of momentum toward more abortion restrictions. This is a way to say, ‘No. Here, in blue California, we’re going to affirm or expand [the right to an abortion],’ ” Reynosa says.

The bill’s supporters don’t deny it. Phoebe Abramowitz was part of the student team that launched the campus campaign for medication abortions at UC Berkeley four years ago.

“Now that we’re doing statewide advocacy, we’re hoping to set a national precedent that we can, even in these really hostile times to women and queer people, move access to abortion forward,” she says. “It’s more important now than it even was a year ago.”

When Brown vetoed the bill last year, then-gubernatorial candidate Gavin Newsom said he would have supported it. He won the election about a month later, and advocates are optimistic that he will side with them this time around.

The state Legislature has until mid-September to pass the bill, and the governor has a month after that to sign or veto it.

This story is part of NPR’s reporting partnership with KQED and Kaiser Health News.

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While many Capitol Hill Republicans would like to avoid another public debate about whether to repeal the Affordable Care Act, President Donald Trump and his appointees keep bringing it up — promising their own health plan that would be “phenomenal” and make the GOP “the party of health care.”

“We’re actively engaged in conversations” on what to do, Medicare chief Seema Verma said last month. And Trump adviser Kellyanne Conway has indicated a health care announcement might come in September.

Behind the pronouncements lies a dilemma: whether or not to stray beyond efforts underway to improve the nation’s health care system — loosening insurance regulations, talking about drug prices and expanding tax-free health savings accounts — to develop an overarching plan.

For the White House, it’s a fraught decision.

A comprehensive plan could serve as a lightning rod for opponents. Conversely, not having a plan for replacing some of the most popular parts of Obamacare — such as its coverage protections for people with preexisting medical conditions — could leave the GOP flat-footed if an administration-supported lawsuit now before the 5th Circuit Court of Appeals were to invalidate the sweeping health law.

“This is a real conundrum,” says Dean Rosen, a Washington, D.C., health policy consultant who often advises Republicans. “There is a risk with action or inaction.”

No matter how the 5th Circuit rules, its decision, which could come soon, is likely to be stayed while the issue heads to the Supreme Court. Such a delay would give the Trump administration time to flesh out a proposal if the appeals judges throw out the ACA. But it would also ensure that a health care debate is front and center during the presidential campaign.

Right now, polls show the public is focused on health costs, says professor Robert Blendon, who directs the Harvard Opinion Research Program, which studies public knowledge of health care and policy issues. Consumers are concerned about what they pay at the pharmacy counter, or about the sum of their insurance premiums and deductibles.

“Most voters are not interested in another debate on a new health plan,” Blendon says.

But if the 5th Circuit upholds a Texas ruling overturning the entire ACA, “that changes the entire framework,” he adds. “The administration could not just say, ‘Oh, we’ll have something great.’ They would have to have something outlined.”

Supporters and critics say likely elements are already in plain sight, both in executive actions and proposals in the president’s budget as well as in a little-noticed interagency white paper released late last year, called Reforming American’s Health Care System Through Choice And Competition.

The president has won praise from both conservatives and liberals for initiatives such as his proposal to require hospitals to post their actual, negotiated prices, and some strategies to lower drug prices. But legal battles from industry could thwart such initiatives.

On these topics, “a lot of what they’ve proposed has been pretty smart,” says Shawn Gremminger, senior director of federal relations at the liberal Families USA advocacy group.

Still, Gremminger points to other administration actions — such as loosening rules on health insurers to allow sales of what critics call “junk” insurance, because they don’t have all the consumer protections of ACA policies, or promoting work requirements for Medicaid recipients — as strong hints to what might be in any eventual election-related plan.

“I think what we’ll see is a lot of that same sort of stuff, warmed-over and put into a new package,” Gremminger says. “We fully expect it will include a lot of really terrible ideas.”

For other policy clues, some Trump advisers, like Brian Blase, a former special assistant to the president at the National Economic Council, who is now with the Texas Public Policy Foundation, say look no further than that 2018 interagency report.

The 114-page document, a joint publication of the U.S. Departments of Labor, Treasury and Health and Human Services, includes more than two dozen recommendations that broadly focus on loosening federal and state regulations, limiting hospital and insurer market power and prompting patients to be more price-conscious shoppers.

Many are long-standing, free-market favorites of Republicans, such as increasing the use of health savings accounts — which allow consumers to set aside money, tax-free, to cover medical expenses. Other ideas are not typically associated with the GOP, such as increased federal scrutiny of mergers of hospitals and insurers; such mergers have driven up prices.

The white paper also calls for easing restrictions on Medicare Advantage plans, which offer an alternative to the traditional fee-for-service Medicare. The Trump proposal would allow the advantage program to have smaller networks of doctors and hospitals — presumably ones that agreed to charge less.

“The administration knows where it is going on health care,” Blase says.

If the court strikes down the ACA, he expects the administration to release a plan supporting “generously funded, state-based high-risk pools.”

Such pools existed in most states before the ACA. They helped provide coverage for people with preexisting conditions who were denied policies by insurers. But the pools were expensive, so they often were underfunded — capping members’ benefits and producing long waiting lists.

Not everyone thinks the white paper is a plan, but more of a “combination of policy ideas and political statements,” says Joe Antos at the conservative-leaning American Enterprise Institute.

Still, he doubts the GOP needs a comprehensive health proposal. Republicans are more likely to gain politically by merely attacking the Democrats’ ideas, Antos says, especially if the Democratic nominee backs proposals for a fully government-funded health care system, such as the Medicare for All plans some candidates support.

Republicans will “have their own one-liners, saying they are dedicated to protecting people with preexisting conditions. That might be enough for a lot of people,” Antos says.

Politically, taking on the Affordable Care Act — or not taking it on — are both risky. While many voters don’t understand all that the federal health law does, some of its rules enjoy broad support. That’s particularly true of the protections for people with medical problems — under the current law, insurers are barred from rejecting them for coverage or charging them more than people without such conditions.

The Republican effort to repeal the ACA galvanized activists during the 2018 midterm elections and is credited with boosting Democrats to victory in many House districts.

Analysts on both sides expect concerns about health costs and health law to play a large role again in 2020.

For Republicans, “the risk of doing nothing potentially leaves no port in a storm if the ACA is overturned legally,” Rosen says. “But a more limited version, which is what most Republicans are for, is likely to be met with the same concerns. No matter what the president says, it won’t be enough for the Democrats.”

Opinion poll analyst Blendon says there is an additional unknown: Which Democrat will win the nomination — and what type of coverage will she or he back?

Even as the GOP is split on how to address health care concerns, so too are the Democrats.

“If they are reading the same polling data as I am, they would have serious proposals for lowering drug and hospital costs, but not offer a national health plan,” Blendon says.

The Democrats’ most progressive wing, led by Sens. Bernie Sanders of Vermont and Elizabeth Warren of Massachusetts, wants Medicare for All, which would essentially eliminate private and job-based coverage. Recent polls have shown voters are not keen to lose private insurance.

The party’s center, led by former Vice President Joe Biden, wants to keep the ACA but apply “fixes” to make insurance purchased by individuals more affordable.

“If the Democratic nominee is running on keeping the ACA, the Republican will have to have an alternative,” Blendon says. But, if the nominee supports Medicare for All, Blendon predicts simply a GOP “anti-campaign” targeting the Democrat’s idea as unworkable, socialist or a danger to Medicare.

Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.

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