U.S. Rep. Frank Pallone, a Democrat from New Jersey, has been trying to get a look at the Republicans’ bill to repeal and replace the Affordable Care Act, also known as Obamacare.

He’s the top-ranking Democrat on the House Energy and Commerce Committee, which will have to approve the bill before the whole House can vote on it.

But as of Thursday afternoon, Pallone still couldn’t get his hands on a copy.

“We have no idea right now what they’re considering,” he said of his Republican colleagues.

Rep. Greg Walden, a Republican from Oregon and the Energy and Commerce Committee’s chairman, made draft legislation available to Republicans on the panel Thursday, but they had to read it in a private room and weren’t allowed to make copies.

When the location of that room leaked on Twitter late Thursday morning, reporters filled the hallway outside the room’s door on the first floor of the U.S. Capitol. Pallone, along with his Democratic House colleagues Jan Schakowsky, from Illinois, and Joseph Crowley, from New York, also stopped by.

But when they went in, the room was empty.

“We were looking for the bill but there’s no one there,” Pallone said.

That room was just down the hall from House Majority Leader Kevin McCarthy’s office, so Pallone went in to ask McCarthy where he could see the legislation. McCarthy directed him to Walden’s office.

Luckily, Walden had a Capitol “hideaway” office just down the hall.

Pallone led his colleagues, a string of reporters and even a couple of Capitol Police officers to the unmarked door, knocked and waited.

“It’s locked,” he said after trying the handle. “This is ridiculous.”

He paused and looked at the crowd. “Do you want to go to Rayburn?”

He was referring to the Rayburn House Office Building, across Independence Avenue from the Capitol. It’s where Walden’s personal office and the Energy and Commerce Committee offices are.

Everybody wanted to go.

As we strolled the halls of the Capitol, down elevators and through the underground tunnel that leads to the House office buildings, Pallone reflected on why his Republican colleagues were keeping the legislation under lock and key.

“I think they’re afraid,’ he said. “I think they’re afraid that it will show that it really doesn’t cover most of the people that receive coverage under the Affordable Care Act.”

Even many Republicans weren’t invited to view the latest draft; Sen. Rand Paul from Kentucky condemned the GOP leadership Thursday for not making it more widely available.

Last week, an earlier draft of the bill, dated Feb. 10, was leaked to Politico.Most analysts said that legislation would lead to millions of people losing coverage. And members of the House Freedom Caucus, considered the most conservative wing of the Republican Party, said they would oppose the bill because it includes refundable tax credits for people who are too poor to pay any federal income tax.

Pallone said he was pushing to get a copy of the most recent draft of the bill because he had heard Walden intends to have the committee vote on it next Wednesday — a timeline that wouldn’t give the Democrats and the public much time to analyze the legislation.

He compared what the Republicans are doing this week with what theDemocrats did with their draft of the Affordable Care Act several years ago; Democrats posted the text of the ACA online 30 days before it went to members for a vote.

“The reason why Republicans were able to comment on the ACA — and of course many of them commented negatively — was because the bill was out there,” Pallone said.

At Walden’s personal office in the Rayburn building, Andrew Malcolm, Walden’s deputy chief of staff, told Pallone he would be better off directing questions about the bill to the Energy and Commerce Committee office. It was an awkward conversation as Pallone asked repeatedly whether Walden would be there, and Malcolm refused to answer.

“That’s not helpful,” Pallone said. “He’s probably ducking us.” Still, Pallone headed to that committee office, as Malcolm suggested.

And just as Pallone walked in, Walden came down the hall walking very quickly, trailed by some of his staff. He scowled at Pallone and the crowd of reporters in his lobby, then headed out a back hallway toward the hearing room next door. He didn’t say a word.

“Well, obviously he doesn’t want to talk,” Pallone said. “I’m not going to keep chasing him. I’m tired of chasing him around. Obviously he doesn’t want us to see the bill.”

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Some conservative members of Congress and activists who bedeviled GOP leadership during the Obama administration are back again in opposition to the health care plan led by House Speaker Paul Ryan.

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President Trump’s declaration during his speech to Congress Tuesday night that Obamacare is “collapsing” and must be replaced was cheered by Republicans.

But Republican lawmakers remain unable to coalesce behind an approach to their oft-stated goal of repeal and replace, and Democrats believe they hold the upper hand to the fate of the Affordable Care Act.

In an interview with Morning Edition host Steve Inskeep that aired Thursday, Senate Minority Leader Chuck Schumer said the odds “are much greater than half” that the ACA will remain in place.

Schumer cited the pledge by three Republican senators, Rand Paul of Kentucky, Mike Lee of Utah and Ted Cruz of Texas, in support of what they called #FullRepeal of Obamacare, which is further than other Republican senators have said they are willing to go.

Schumer said if they lose those votes, “that’s the margin” and Republicans don’t have enough votes to support any kind of replacement.

Schumer said Democrats are willing to sit down and negotiate with Republicans about “how to improve the ACA,” but he said Democratic senators are united in opposition “to any form of repeal.”

Key House Republican committee chairs held a closed-door meeting on Capitol Hill Wednesday in which they briefed GOP senators on the evolving ACA proposal. But House Republicans are also divided about how to approach the issue.

Two House conservative groups, the Republican Study Committee and the House Freedom Caucus, say they oppose a draft measure that was circulated by GOP leaders, which would provide tax credits for low-income Americans to help them purchase health insurance.

Those tax credits could be refundable, meaning they would be paid out even if the recipients pay very little or no income tax. Conservatives who find that unacceptable see it as replacing one subsidy with another.

Backers of the approach said they have Trump’s support, based on his mentioning of tax credits during his speech.

Meanwhile, Paul tweeted he was “heading to a secure location” in the Capitol where he alleges House leaders “are keeping the House Obamacare bill. I will demand a copy for the American people.”

Even if Republicans in Congress are unable to settle on a measure to replace Obamacare, there are still steps the Department of Health And Human Services could take on its own to alter the program.

Health and Human Services Secretary Tom Price has long been a chief opponent of the Affordable Care Act.

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If you’re failing less, then you’re succeeding more, right? That’s exactly what appears to be happening with birth control in the United States, according to a new study released by the Guttmacher Institute.

Contraceptive failure rates for all of the most common contraceptives (think: the pill, condoms, and IUDs) fell from 2006-2010, according to the most recent data collected for the Center for Disease Control and Prevention’s National Survey of Family Growth.

Overall, the one-year failure rate for forms of contraception dropped from 12 percent in 2002, the last time the data was collected, to about 10 percent. For some methods, the drop was much larger; others saw smaller declines. The decliner was more pronounced if you look back to 1995, when the overall failure rate for all methods was nearly 15 percent.

It’s not clear what’s causing the improvement, says Kathryn Kost, a co-author of the report. Kost says possible explanations include women moving from less effective birth control options to more effective ones; more consistent and correct use of available methods (check out this handy comparison chart here;) and what she describes as “major public health efforts” in recent years to improve public knowledge about contraception.

The option the study found least likely to fail was long-acting reversible contraceptives, or LARCS, like IUDs, which had about a 1 percent failure rate. But even less-reliable options, like condoms, saw their failure rates fall significantly over the long-term, from 18 percent in 1995 to 13 percent in the latest survey.

Kost says the improvement in the success rate of male condoms is important because unlike other forms of birth control, condoms also help prevent sexually transmitted diseases, and are one of the few contraceptive methods readily available to men.

“We should probably be exploring men’s role in these improvements,” she says.

Whatever the reason, Kost says, the bottom line is clear: “We’re seeing declines in abortion rates; we’re seeing declines in birth rates. So we know that American women are not getting pregnant unintentionally at the same levels that we had been observing.”

The analysis did find disparities in the effectiveness of contraceptives for some groups of women. African American and Latina women had higher contraceptive failure rates compared with white women, and low-income women had a higher rate of failure than those earning at least 200 percent above the federal poverty level. The study did not adjust for poverty when assessing racial and ethnic disparities, but noted that poverty is likely a factor.

Dr. Molly Findley is an obstetrician-gynecologist who practices in New York City, and a former LARC fellow with the American Congress of Obstetricians and Gynecologists.

She says low-income patients in particular may struggle to get consistent reproductive health care because of lack of insurance, access to healthcare providers, or other barriers.

“Their childcare falls through; they can’t come to the appointment. The bus is late. They missed their appointment because their mom got sick and they have to go to the hospital with their mom,” Findley says. “There’s so many different reasons why my patients have a hard time accessing the healthcare they need and deserve.”

Findley calls the overall decline in birth control failure rates “heartening.” She points to the growing use of long-lasting methods, which she says allow women to choose contraceptives that may better fit their needs.

“Women who know themselves, women who have a lifestyle that says, ‘Yeah, I can take a pill every day; I can remember that.’ Those are the women that are continuing to use birth control pills. So those are the women who are good at it,” she says.

“And the women who have a lifestyle that’s hectic, that doesn’t let them to remember to take a pill every day, they have more options that they can use now.”

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Since President Trump took office, there’s been an upswing in rallies and protests outside clinics that perform abortions.

During the campaign, Trump vowed to try to overturn Roe v. Wade, which has emboldened activists on both sides of the abortion debate. At one abortion clinic in Texas, along the border with Mexico, two young women in opposing camps recently changed their minds about the way they feel and think about the issue of abortion.

It’s midday on a Tuesday, and 32-year-old Mercedes Soto is standing outside the Whole Woman’s Health clinic in McAllen, Texas. The name is counterintuitive. It’s the last remaining abortion clinic in the entire 1,800-square-mile region known as the Rio Grande Valley.

Soto is demonstrating with fellow anti-abortion protesters who call themselves prayer warriors. She doesn’t look like the other women praying. She’s a lot younger.

The word “misunderstood” is tattooed in cursive on the outside of her arm. Soto says she had a rough childhood. She says she always felt isolated and unloved, so when she turned 18 she left home.

“If you would have looked at me in my old life, you wouldn’t have expected anything good,” Soto says. “I was in very very bad steps. I turned to drugs as a coping mechanism. I started hanging out with the wrong crew. I joined a gang. I just wanted to belong. I wanted to belong. And I wanted somebody to be there for me.”

Then, two years ago she got pregnant. That’s when she came to this clinic for the first time, except not as an anti-abortion protester but as a patient.

“I was on the other side,” Soto says. “I was contemplating abortion, and I was very headstrong about my abortion.”

On her way into the clinic that day, Soto was stopped by a woman, an anti-abortion activist praying outside the clinic.

“She starts telling me I’m beautiful, and I wasn’t trying to hear this woman,” she says. “I wasn’t.”

Soto decided not to have an abortion. Now, she is carrying a sign with what looks like a gory fetus and the words “Abortion Is Murder.” In her other hand, she is holding an even more persuasive tool — her 1-year-old son, Samson, whom she often brings with her to protest shutting down the McAllen clinic.

In January, hundreds of protesters rallied outside the Whole Woman’s Health Clinic. One group was marching against the abortion clinic, and another, smaller group was standing to protect it.

“Seeing all of these women here has just ignited the fire,” said 25-year-old Laura Molinar, who traveled more than 230 miles from San Antonio.

She held a hand-drawn sign on yellow poster board with the words “Don’t Tread On Me” on top. The flag is one you see all over the place in Texas. Only this time, the snake is wrapping around a giant uterus.

“It took me a while to draw this uterus,” Molinar joked. “It’s not the best.”

There used to be another abortion clinic about 35 miles from the one in McAllen, but it closed because of a Texas law known as House Bill 2. HB2 was eventually overturned by the Supreme Court, but many clinics affected by the law never reopened.

For Molinar, these closures would have been celebrated in the church she grew up in.

“As a teenager I was so involved with the Catholic Church, you know, doing praise and worship,” Molinar said.

Friends from her church youth group used to pray outside abortion clinics. But last year, the issue became personal when Molinar chose to have an abortion.

“I was faced with making that choice for myself,” Molinar said. “And I never thought that that would happen to me until it actually did. I remember feeling so alone, and so scared and unworthy, and I remember telling myself that I will do everything in my power from this point on to help women so that they will never feel like that.”

In the Rio Grande Valley, the local Catholic diocese is a major organizer of anti-abortion efforts.The clinic in McAllen has protesters outside its main entrance almost every day. And anti-abortion activists even travel from across the border in Mexico to demonstrate at the clinic.

But for Molinar, her religion remains a guide. For her, it’s not just about maintaining abortion access in this part of Texas, but also fighting for all the other services the clinic provides to low-income women and unauthorized immigrant women, like birth control, prenatal care and Pap smears.

“I still identify as Catholic, and I still feel that God loves me,” she said. “I don’t think I’ve confronted that yet. And I feel that a lot of members of the church shame these women, and they make them feel unloved and unsupported and that God doesn’t love them, which is not true.”

With abortion, it so often seems like the national divides are entrenched and that nothing will change a person’s point of view. But in this Texas town and across the U.S., there are women like Soto and Molinar, who defy what you might think, and sometimes even switch sides.

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Kentucky was one of the states that embraced the Affordable Care Act. Residents talk about their experiences with the law and how a potential repeal might affect them.

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In his first address to a joint session of Congress, President Trump outlined his plan to repeal and replace the Affordable Care Act, which has long been a rallying cry for the Republican Party. But how realistic is it? NPR takes a closer look at the president’s proposal to overhaul the health care system.

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Back in the day, people paid for routine, primary medical care on their own and only used insurance when something serious came up. Some primary care doctors are betting that model can thrive again through a monthly subscription for routine care and a high-deductible insurance policy to take care of the big stuff.

But the changes raise questions about whether that approach really leads to more effective and efficient health care.

It’s easy to understand the appeal of direct primary care, as it’s called, for doctors and patients. Doctors charge a monthly fee, generally from $50 to $150, to provide routine clinical care and consultation, sometimes including basic lab work and tests. Patients who need other care, an MRI or surgery, for example, would be covered by their insurance policy, if they have one.

Freed from having to devote time and money to managing insurance claims, doctors say they can accept fewer patients and spend more time with them without focusing on the question of which services are paid for.

Patients, meanwhile, may get more personalized care. They also may save money on insurance if they can pair their primary care plan with a cheaper, high-deductible policy.

Although only a fraction of primary care doctors practice this way, the proportion has grown from 2 percent to 3 percent in the past year, according to data from the American Academy of Family Physicians, which supports this type of practice.

Advocates of direct primary care believe their prospects are bright because the new Republican administration favors market-driven approaches to health care. The plan introduced by Health and Human Services Secretary Tom Price when he was in Congress would allow people to pay monthly fees for direct primary care with funds from health savings accounts. A bipartisan bill introduced in January for consideration by the current Congress would amend Internal Revenue Service rules to permit that.

William Bayne, a commercial real estate developer in Las Vegas, joined MedLion, a direct primary care company, last October. For $300 a month, Bayne gets routine primary care for himself, his wife and their five children. “It’s great for the little stuff that comes up with five kids,” says Bayne, 41. They also have a comprehensive family insurance plan.

When Bayne’s 8-year-old son woke up with what looked like a big pimple on the side of his eye one morning, they called MedLion and made an appointment for 12:30 that afternoon. But their family physician, Dr. Samir Qamar, called before that, having seen their names on the schedule, and asked for a photo of the boy’s eye. Qamar said it looked like an oil gland in an eyelid was clogged and suggested they wait a day before coming in, because it would probably clear up on its own. It did.

Qamar used to have a high-end concierge practice in Pebble Beach, Calif., where he provided on-call primary care services. When the Great Recession hit in 2007, he says, he and his wife, who was a physician with a traditional primary care practice, decided to offer concierge-style primary care at a lower price point. They moved to Las Vegas and opened MedLion, which is now available in seven locations in the Las Vegas area and works with 429 affiliated physicians in 25 states.

Like many direct primary care practices, MedLion has shifted its focus from individuals to the employers who offer the service as a benefit. Workers typically pick one of their company’s regular insurance plans and add the direct primary care service if they wish to. The company pays the monthly fee for those who choose the option and may or may not pass that cost along to workers.

In perhaps the largest effort of its kind, the state of New Jersey recently kicked off a pilot program with Philadelphia-based direct primary care provider R-Health that aims to enroll at least 60,000 state employees in the first three years.

Not surprisingly, the program is particularly appealing to people with chronic conditions, says Mason Reiner, CEO of R-Health.

“Those are the folks who really need and can benefit from relationship-based primary care,” he says. “It can make a big difference for them and for the state, since so much of the cost of care is driven by these folks.”

Improving access to primary care is important, says Dr. A. Mark Fendrick, an internist who directs the Center for Value-Based Insurance Design at the University of Michigan. But he cautions that while direct primary care doctors who get a flat monthly fee aren’t motivated to provide unnecessary, low-value care, patients don’t have the same incentive. For patients, an “all you can eat model” may encourage them to get care they don’t need.

“By removing fee-for-service [payments], this model is positive on the provider side,” Fendrick says. “But it isn’t nuanced enough on the patient side to get the system where we need it to be.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Follow Michelle Andrews on Twitter: @mandrews110.

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President Trump doubled down on his pledge to quickly repeal and replace Obamacare. He talked about the longtime Republican idea of having health insurers sell insurance across state lines.

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Many Republican leaders have promoted the idea that consumers should have a “health care backpack,” which would make it possible to take insurance from job to job or when moving, starting a business or retiring.

The concept — often referred to as “portability” — is appealing. Why should a health plan be tied to where you work or live? The answer, of course, is “it’s complicated.” As Republicans debate ideas for repealing and replacing the Affordable Care Act, portability might play a central role in their plan. So how would that work?

Portability Is Hard To Define

The notion of “portability” in the purest sense means that consumers can stick with the same insurer, the same benefits and the same coverage limits, even if they move or change jobs. In the current policy discussion, though, portability is more likely to be viewed as a means for consumers to get access — possibly with the help of a tax credit — to a variety of health plans.

If keeping the same plan is the goal, that would be very tricky. The health care system is just not built that way.

Among the health plans 156 million of us get from our jobs, only a few insurers offer national networks of participating doctors and hospitals. And most of the plans available to people who buy their own insurance through the individual or small group market are local and limited by specific geographic areas. Policyholders who move away generally must change carriers. And insurers sometimes pull out of markets, meaning stranded consumers would also have to pick new plans.

Such factors could create a predicament for Republicans similar to the “if-you-like-your-health-plan-you-can-keep-it” problem that bedeviled President Barack Obama when tens of thousands of consumers had to change their coverage after the ACA took effect.

Take A Tax Credit Instead

Because of these hurdles, some advocates suggest a portable tax credit. The proposals vary, but here’s how it could work: If a consumer moves or quits a job to start a business or go back to school or take an early retirement, they would get a tax credit they could apply to pay for their new insurance.

“To get to true portability, you have to be able to choose a plan and have the same subsidy … and take [the subsidy] it with you when you leave,” says Stuart Butler, a senior fellow at the Brookings Institution, a D.C.-based think tank. That’s how the ACA subsidy works. It uses an advance tax credit calculated by income.

In contrast, several of the GOP proposals would link the subsidy to age instead of income, with older consumers who likely have higher health costs and premiums getting a bigger credit, although the amounts debated are generally less than what consumers now receive under the health law. Also, the proposals generally do not link the credits to the cost of insurance, potentially creating unhappy consumers in high-premium regions.

Current Portable Coverage Poses Political Problems

Portable coverage already existed before Obamacare. The Federal Employees Health Benefit Program, the military’s TriCare and Medicare all offer such coverage. But enrollment in those programs is limited to specific groups: federal workers, military members and their families, certain qualifying people with disabilities and those older than 65.

When running for president, Sen. Bernie Sanders, I-Vermont, suggested a Medicare-for-All plan, an idea popular among the left. But the current GOP-controlled Congress is unlikely to adopt this approach or to call for opening the federal employee program or the military plan to the general public.

Covering everyone through a single-payer system — common in Europe — where the government pays the bills but private providers or government agencies offer the medical care, also would fall into this category but is currently a political nonstarter in the U.S.

A Risk To Job-Based Insurance

Employers who provide work-based coverage fear that if Congress makes health plans too portable, meaning everyone has access to the tax credits, the youngest and healthiest might peel away from their employer plans’ risk pools to buy insurance. This would drive up premiums for those who remain. To prevent that, several GOP plans — including House Speaker Paul Ryan’s — would bar people with job-based coverage from getting a credit. But others, including the plan put forward last year by now-Health and Human Services Secretary Tom Price, don’t include that prohibition.

Pre-Existing Conditions? Separate Rules

To be truly portable, consumers must be offered plans regardless of their health status, age or other considerations. Before the health law was enacted, insurers could reject people with medical conditions. But the ACA prohibits insurers from redlining sick people or charging them higher premiums. Although popular in opinion polls, those Obamacare provisions may face some changes under the GOP plans.

Ryan’s plan would allow a one-time open enrollment during which uninsured people could sign up no matter their health status. Waiting would result in higher premiums.

Price’s plan would require insurers to accept all comers during enrollment periods every two years. His plan would also require consumers to maintain continuous coverage, or risk having preexisting conditions excluded from future coverage.

Kentucky Sen. Rand Paul’s plan would do away with the “guarantee issue” requirement altogether and allow insurers to exclude medical conditions from coverage.

Cheaper Plans, Less Coverage

Cost is essential to portability because if consumers can’t afford insurance, it doesn’t matter that it can move with them. To bring premiums down, some Republicans suggest easing the health law’s essential benefits requirements. More flexibility for these rules could spark competition and open the market to added options, from low-cost, “bare-bones” plans to high-premium comprehensive coverage, proponents say.

“From a consumer perspective, it’s important to have wide choice,” says Butler.

But the less expensive plans would likely be more restrictive and exclude coverage for some services, such as prescription drugs.

Some experts warn that without some benefit rules, plans could end up in a “race to the bottom,” with few insurers wanting to offer broad benefits at the risk of attracting the sickest enrollees.

“If their answer is to make it affordable by stripping down the benefits, then you leave families exposed to a lot of financial risk if something happens to them,” says Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

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