The new anti-abortion tilt of the U.S. Supreme Court has inspired some states to further restrict the procedure during the first trimester of pregnancy and move to outlaw abortion entirely if Roe v. Wade ever falls. But the rush to regulate has exposed division among groups and lawmakers who consider themselves staunch abortion opponents.

On Thursday, Ohio became the latest state to ban abortions after a fetal heartbeat can be detected. For a long time, Ohio Right to Life supported a more gradual approach to restrict the procedure and deemed what’s come to be called a “heartbeat bill” too radical — until this year. Restricting abortions after a fetal heartbeat can be detected basically bans the procedure after six weeks’ gestation — before many women know they’re pregnant.

“We see the Court as being much more favorable to pro-life legislation than it has been in a generation,” spokeswoman Jamieson Gordon says. “So we figured this would be a good time to pursue the heartbeat bill as the next step in our incremental approach to end abortion-on-demand.”

The Ohio law contains no exception for pregnancies that are the result of rape or incest; it does have an exception for the life of the mother.

Some say the rush to pass these bills is about lawmakers competing to get their particular state’s law before the Supreme Court. The state that helps overturn Roe v. Wade would go down in history.

More than 250 bills restricting abortions have been filed in 41 states this year, according to the Guttmacher Institute, a reproductive rights research and advocacy group.

“After the appointment of Justice [Brett] Kavanaugh, there really is just an environment in state legislatures to roll back abortion rights. And so we’re seeing these bans just fly through,” says Elizabeth Nash, who monitors state laws at Guttmacher.

But the speed of passage of some of these laws masks divisions about strategy and commitment to the cause within the anti-abortion movement.

Tennessee infighting over ‘heartbeat bill’

In Tennessee, for instance, there’s a philosophical split between pragmatists and idealists.

A heartbeat bill in the state has had high-profile support, including from the Tennessee’s new governor. But the Republican attorney general warned such a law would be difficult to defend in court. And several Republicans, swayed by that logic, voted no for the heartbeat bill.

“This is an issue that is extremely important to me. It’s the reason I got into politics many years ago,” Republican state Rep. Bill Dunn said as the House approved the measure over his objection earlier this year. Dunn says he wants to stop abortion, but that will require strategy. He points out that no heartbeat bill has ever been enforced. And recent laws in Iowa and Kentucky have been immediately blocked in court. The same is expected for Ohio.

“Number one, it’ll probably never save a life if we go by what’s happened in the past,” Dunn argued on the Tennessee House floor.

But it’s money that ultimately stopped the heartbeat bill this year in Tennessee (It stalled in committee this week, though the state’s Senate Judiciary Committee agreed to review the bill this summer.)

Senate Speaker Randy McNally says he’s pro-life too, but has no interest in wasting tax dollars to make a point.

Even worse, in the view of Republicans who voted against the heartbeat bill, the state could end up paying the legal fees for groups that defend abortion.

“That is a big concern,” McNally says. “We don’t want to put money in their pockets.

The last time Tennessee had a case that went to the U.S. Supreme Court, it cost roughly $1.9 million. The experience was enough to give a few anti-abortion crusaders some pause. They voted this week with Democrats for a one-year delay on a heartbeat bill, vowing to study the issue over the summer.

Name-calling in Oklahoma

Even if it doesn’t result in a case that upends abortion law, heavily Republican legislatures like Oklahoma’s want to be ready.

“If Roe v. Wade ever gets overturned, we won’t be prepared,” Republican Senate Pro Tempore Greg Treat said while explaining his so-called “trigger bill” at a committee hearing in February.

Treat’s legislation, modeled after existing laws in a handful of states, would “trigger” a state ban on abortion and make it a felony if Roe were overturned. A handful of states, including Arkansas, Kentucky, Louisiana, Mississippi, North Dakota and South Dakota, already have trigger laws on the books.

Oklahoma has some of the strictest abortion laws in the nation, such as mandatory counseling and a 72-hour waiting period. But the most conservative anti-abortion activists in the state want more immediate action. So they targeted Treat and other self-described pro-life Republicans with protests, billboards and fliers, accusing them of not being anti-abortion enough.

“I’ve been called every name in the book these past few weeks,” Treat says. “I’ve had my Christianity questioned. I’ve had a member of my own caucus hold a press conference and call me a hypocrite.”

In response, Treat abandoned the trigger bill.

Now he’s trying something else — an amendment to the state constitution that would reinforce that nothing in Oklahoma law “secures or protects” the right to abortion. But that’s still not anti-abortion enough for some.

“It’s going to add on to that legacy that we have of death and just status quo pro-life policy that does nothing,” says Republican state Sen. Justin Silk.

Not far enough in Georgia

In Georgia, a heartbeat bill passed the legislature, but has paused at Gov. Brian Kemp’s desk. Supporters of abortion rights don’t want him to sign it, of course, but some anti-abortion activists aren’t happy either.

“It really just does not go far enough in the protection of innocent human life,” says Georgia Right to Life executive director Zemmie Fleck. Fleck argues that certain exceptions in his state’s bill — for abortions after rape or incest if the woman makes a police report — make it weak.

Gov. Kemp has until May 12 to sign or veto the measure.

Cost as no object in Kentucky

The American Civil Liberties Union in Kentucky sued the day after a heartbeat bill was signed into law by Gov. Matt Bevin. But even during his annual speech to the Kentucky legislature in February, Bevin acknowledged his intent to challenge Roe v. Wade.

“Some of these will go all the way to the U.S. Supreme Court. But at the end of the day, we will prevail because we stand on the side of right and we stand on the side of life,” Bevin said.

Kentucky has become accustomed to defending abortion restrictions in court. Currently, one law that makes it a felony for a doctor to perform a common abortion in the second trimester has been suspended indefinitely.

It is unclear how much it costs Kentucky to defend abortion laws that are immediately challenged. In an emailed statement, Bevin administration spokesman Woody Maglinger writes that the state is using in-house lawyers, and hasn’t hired outside counsel. He declines to provide a cost estimate on hours spent on these cases.

“It is impossible to place a price tag on human lives,” Maglinger writes.

This story is part of a reporting partnership that includes NPR, Kaiser Health News and member stations. Blake Farmer is Nashville Public Radio’s senior health care reporter, and Jackie Fortier is senior health care reporter for StateImpact Oklahoma. Marlene Harris-Taylor at WCPN in Cleveland, Lisa Gillespie at WFPL in Louisville and Alex Olgin at WFAE in Charlotte, N.C., also contributed reporting.

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It’s Saturday morning and the women of the Contreras family are busy in Montclair, Calif., making pupusas, tamales and tacos. They’re working to replace the income of José Contreras, who has been held since last June at Southern California’s Adelanto ICE Processing Center, a privately run immigration detention center.

José’s daughter, Giselle, drives around in an aging minivan collecting food orders. First a hospital, then a car wash, then a local bank.

Giselle’s father crossed from Guatemala more than two decades ago, without authorization to enter the U.S. He worked in construction until agents picked him up and brought him to Adelanto.

Giselle says her father languished there for three months without his diabetes medication. Now, she says, the guards give it to him at odd times during the day and night. And, she says, ICE agents took his eyeglasses so he can’t read legal documents or write letters.

“My aunt tried to take in glasses for him but they don’t allow for us to give them anything,” Giselle tells me as she steers the minivan. “They tell us that they give them everything they need.” When I ask if her father has glasses now, she says, “No, he doesn’t. He doesn’t have glasses.”

Giselle says her father, who is 60 years old, is terrified of being deported, and she says the regimented world inside Adelanto is driving him into a deep depression. “His conversations now have become shorter,” she says. “He doesn’t talk to us and ask, ‘How’s your day? How you been?’ He’s always looking down at the ground; he doesn’t want to make eye contact for the same reason that he’s so depressed.”

José’s sister, Maria Contreras, visits her brother every Saturday. She has urged him to see a psychologist at Adelanto, but he tells her that even though he filled out a medical request, he doesn’t get any help. “No response, or anything,” Maria says.

Adelanto sits on a desolate stretch of road in the high desert about an hour north of the city of Riverside. Nearly 2,000 men and women are held here. Some arrived recently during the surge in border crossings. Others lived in the U.S. — undocumented and undetected — for years. In the visiting room, where detainees are brought in wearing blue, orange or red baggy pants and tops, a sign on the wall reads, “Don’t give up hope.”

The facility — run by a federal contractor, GEO Group, a for-profit company based in Boca Raton, Fla., that runs private prisons — has a troubled past. During an unannounced visit last year, federal inspectors from the Department of Homeland Security’s Office of the Inspector General found “nooses” made out of bedsheets in 15 out of 20 cells. The inspectors found that guards overlooked the nooses even though a detainee had died by suicide using a bedsheet in 2017 and several others had attempted suicide using a similar method. The government audit concluded GEO Group guards improperly handcuffed and shackled detainees, unnecessarily placed detainees in solitary confinement and failed to provide adequate medical care.

A separate investigation of Adelanto and other immigration detention facilities in California released in February by state Attorney General Xavier Becerra found similar health and safety problems and concluded that detainees were treated like prisoners, some kept in their cells for 22 hours a day, even though they have not been charged with a crime. A state law passed in 2017 directs the state to inspect and report on the treatment of immigrant detainees held in California.

The alleged cases documented in the most recent report by Disability Rights California, a watchdog group with legal oversight to protect people with disabilities in the Golden State, are grim: detainees slitting their wrists; discontinued medication for depression; and ignored requests for wheelchairs and walkers. At least one detainee said that guards pepper-sprayed him when he did not stand up and a second time while he tried to hang himself.

In a written statement, GEO Group says it “strongly disputes the claims” in the report and that the remedies recommended by Disability Rights California “were already in place.”

“We are deeply committed,” the company says, “to delivering high-quality, culturally responsive services in safe and humane environments.” An ICE spokesperson says, in an emailed statement, that GEO Group’s Adelanto facility is in “full compliance with the Americans with Disabilities Act.”

But Mario, who was inside Adelanto for six months in 2018, says the report describes his own experiences there. “What’s happening is all those claims that have been made against GEO and the staff in the medical department are finally being backed up by reports,” Mario says.

He asked us not to use his last name since he is out on bond and still fighting deportation. Mario is now 32; he crossed the border with his parents without documentation when he was 5.

In 2017, he was convicted of a misdemeanor and ICE agents picked him up at his home in Ontario, Calif. At the time, Mario was seeing a therapist for depression and taking medication. It took three weeks to get back on antidepressants, he says, and the sessions with the psychologists at Adelanto were only cursory.

“They keep their actual sessions to five to 10 minutes,” he says. “It’s basically like a quick check-in. They just ask you, ‘How are you? Do you have any suicidal thoughts? When is your next court date?’ It’s one of those things that I feel is basically done just to say, ‘All right, we did it.’ “

Mario is gay and lived in a room with three other men, including a gay man from Mexico who was seeking asylum. The two men became close friends.

“He was persecuted in Mexico because of being gay,” Mario says. Months of detention “and not getting any mental health care really took a toll on him. And that’s when he cut himself. He cut his wrist with a razor blade that we get to shave. And after that he was placed in solitary confinement for about a week.”

Mario says when his friend came back to their room, he was taking some sort of medication. “After that, all he did was sleep,” Mario says. “When the food was ready I’d go call him: ‘OK, it’s time to eat.’ “

Other detainees and immigration lawyers described a similar pattern, of GEO psychiatrists prescribing antipsychotic medications that make people sleep much of the time. It’s one of the reasons people were reluctant to seek help, Mario says. But also, like other detainees, he was worried about being labeled as depressed.

“I couldn’t express whenever I was extremely feeling sad or depressed or anxious because I was afraid that would be used against me in court,” he explains.

Judges cannot use mental health conditions to deny legal status to a detainee, according to immigration attorneys.

Last month, long after GEO Group says the company addressed any problems detailed in the Disability Rights California report, detainees in Adelanto staged a hunger strike. The detainees gave an attorney a handwritten note, which was released by the Inland Coalition for Immigrant Justice, an advocacy group.

Chief among their demands was speedier access to good medical care.

Sarah Varney is a senior national correspondent at Kaiser Health News, a nonprofit health newsroom that is an editorially independent part of the Kaiser Family Foundation.

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As Democratic candidates for president try to walk a political tightrope between the party’s progressive wing and its center-left, they are facing increasing pressure to outline the details of their health care overhaul proposals.

On Wednesday, Sen. Bernie Sanders, I-Vt., who is running in Democratic primaries, reaffirmed his stance on health care by reintroducing a “Medicare-for-all” bill, the idea that fueled his 2016 presidential run.

As with its previous iterations, Sanders’ latest bill would establish a national, single-payer Medicare system with vastly expanded benefits. Sanders’ plan would also prohibit private plans from competing with Medicare and would eliminate cost-sharing. New in this version is a universal provision for long-term care in home and community settings (though Medicaid would continue to cover institutional care, and states would determine the standard of eligibility).

Already, it has an impressive list of Senate co-sponsors — including some of Sanders’ rivals for the Democratic presidential nomination: Cory Booker of New Jersey, Kirsten Gillibrand of New York, Kamala Harris of California and Elizabeth Warren of Massachusetts.

But many of the candidates — even official “Medicare-for-all” co-sponsors — are at the same time edging toward a more incremental approach, called “Medicare for America.” Proponents argue it could deliver better health care to all Americans while avoiding political, budgetary and legal objections.

This movement to embrace a more incremental policy comes as politicians tread carefully over the political land mines a “Medicare-for-all” endorsement could unleash, while seeking to capitalize on voters’ growing appetite for health overhaul.

During the 2018 midterm election campaigns, some congressional candidates talked about allowing younger people — anyone older than 55 — to join Medicare or allowing people younger than 65 to buy into it if they choose (what’s come to be called the public option). Many candidates aren’t eager to face the industry opposition a full-on Medicare expansion would surely trigger.

From the consumer perspective, a sweeping overhaul poses a risk. Despite Medicare’s popularity with its beneficiaries, the majority of Americans express satisfaction with their health care, and many are nervous about giving up private options. Also, many analysts are worried that a generous “Medicare-for-all” plan that promises everything would break the bank if it didn’t include copayments from patients.

That tension is pushing a number of candidates toward an option that has come to be called Medicare for America. The bill was introduced last December with little fanfare by two Democrats — Rep. Rosa DeLauro of Connecticut and Rep. Jan Schakowsky of Illinois. It hasn’t been reintroduced in the new Congress.

This proposed system would guarantee universal coverage, but leave job-based insurance available for those who want it. Unlike “Medicare-for-all,” though, it would preserve premiums and deductibles, so beneficiaries would still have to pay some costs out-of-pocket. The bill would allow private insurers to operate Medicare plans as well — a system called Medicare Advantage, which covers about a third of the program’s beneficiaries currently and which would be outlawed under “Medicare-for-all.”

“Before policies get defined, what you see is people endorsing a plan that is a little, perhaps, less subject to early attack,” says Celinda Lake, a Democratic pollster with Lake Research Partners. “A lot of candidates feel if they endorse a plan that leaves some private insurance, they get more time to say what their ideas are about.”

“Medicare for America” got its first high-profile endorsement from former Texas Rep. Beto O’Rourke, who launched his own 2020 bid for president in mid-March. Other candidates — including Warren, Gillibrand and Pete Buttigieg, the mayor of South Bend, Ind. — have tiptoed toward that policy without making any endorsements, suggesting they back “Medicare-for-all” in theory but also support a system that retains private insurance, at least temporarily.

Such an approach is perhaps unsurprising. Recent polling indicates voters want strong health care improvement. And candidates need something powerful to deliver, election analysts say.

Simply improving the Affordable Care Act — an idea backed by Sen. Amy Klobuchar, a Minnesota Democrat running in the primary’s moderate lane — may not suffice.

“The ACA is popular at the 50 percent level, but it’s not energetic,” says Robert Blendon, a political analyst at the Harvard T.H. Chan School of Public Health. “It doesn’t get people who really like it. What they’re looking for is something that is exciting but isn’t threatening.”

Both “Medicare-for-all” and “Medicare for America,” pollsters note, offer something that presidential candidates can campaign on — a health care alternative that, at first blush, sounds appealing to many. But the latter proposal might more easily skirt some potential obstacles.

In polls, approval for the concept of “Medicare-for-all” drops when people learn that under such a program, they would very likely lose their current health plan (even if the government-offered plan could theoretically provide more generous coverage).

And, meanwhile, the cost-sharing element of “Medicare for America” would ostensibly quiet some concerns that have been raised about paying for Medicare’s expansion. (Still, critics on the left worry it would mean some people would remain unable to afford care.)

This also tracks with recent polling suggesting that while “Medicare-for-all” support can be swayed, voters of all political stripes favor some way to extend optional Medicare coverage, without necessarily eliminating the private industry altogether.

Employers would either have to offer plans that were at least as generous as the government program or send their employees to Medicare. And employers who stop offering health benefits would have to pay a Medicare payroll tax.

For now, most candidates are still avoiding a concrete stance on the “Medicare for America” plan. Despite signs of interest, the Buttigieg, Gillibrand and Warren campaigns have all declined to directly answer questions about whether they endorse “Medicare for America.” The campaigns of other candidates in the race — Harris, Klobuchar, Booker, former Housing and Urban Development Secretary Julián Castro and Washington Gov. Jay Inslee — similarly declined to comment.

Reading between the lines, though, their promises to achieve universal health care by expanding Medicare — while retaining private insurance — leave them few options aside from something like “Medicare for America,” argues Jacob Hacker, a political scientist at Yale University and one the proposal’s main architects.

“There are variations besides this particular plan, but once you start to actually dig into this, if you want universal coverage you’re going to have to do the kinds of things” spelled out in “Medicare for America,” Hacker says.

Still, though, the plan Hacker helped design has prompted objections from both the left and the right.

On the far left, the cost-sharing component is a dominant concern. (Under “Medicare for America,” an individual would have a $3,500 out-of-pocket annual limit; a family would have a $5,000 limit. Premiums would be capped at almost 1 percent of a household’s income.) Critics on the left also say the plan’s accommodations to private insurance limit the government’s ability to negotiate lower prices.

Meanwhile, conservatives repeat many of the arguments levied against “Medicare-for-all” — that the plan is too expensive, too disruptive.

Political analysts predict that contributors to the health care industry who have already mobilized against “Medicare-for-all” — including hospitals, insurers, drugmakers and many doctors — also can be expected to make a strong showing against “Medicare for America.” More Medicare means less revenue for the medical industry.

“The fact of expanded Medicare will be the focus of attacks,” says the Commonweath Fund’s David Blumenthal.

The nonprofit newsroom Kaiser Health News is an editorially independent part of the Kaiser Family Foundation. Shefali Luthra covers health care for KHN. She’s on Twitter @shefalil.

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Federal prosecutors on Tuesday said they dismantled one of the largest health care fraud schemes ever investigated by the FBI, charging 24 people in a $1.2 billion alleged scam involving telemedicine and durable medical equipment companies.

As part of the complex operation, doctors got kickbacks for prescribing unneeded back, shoulder, wrist and knee braces to elderly and disabled patients and charging the government’s Medicare program, the Department of Justice said.

The accused “concocted an elaborate scheme to exploit the U.S. health care system by targeting Medicare beneficiaries, paying doctors for prescriptions, paying kickbacks and bribes, and in turn selling these prescriptions to DME companies to ensure that they could line their pockets,” IRS special agent Matthew Line said, according to Tut Underwood of South Carolina Public Radio.

Prosecutors allege a multilayered scheme to defraud Medicare. Call centers in the Philippines and Latin America advertised to Medicare beneficiaries and “up-sold” them on unnecessary medical braces, they say.

The call centers then paid bribes to telemedicine companies, who in turn paid doctors to write orders for the equipment. Then the call centers sold the orders to the durable medical equipment companies and billed Medicare.

Equipment companies would ship the braces to beneficiaries. They would receive about $500 to $900 per brace from Medicare and paid kickbacks of almost $300 per brace, according to the Associated Press.

Doctors wrote prescriptions for medical equipment without any interaction with patients or after only a brief phone conversation, the DOJ said.

People participating in the alleged scheme laundered money through shell companies and used proceeds to buy “exotic automobiles, yachts and luxury real estate in the United States and abroad.”

CEOs, COOs and associates with five telemedicine companies; owners of durable medical equipment companies; and three licensed medical professionals were among the 24 people charged.

Prosecutors charged residents of several states, including Florida, New Jersey, Texas, North Carolina, South Carolina, California and New York.

The government Center for Medicare Services’ anti-fraud branch said it took “adverse administrative action” against 130 medical equipment companies that had billed Medicare more than $1.7 billion in claims and were paid more than $900 million.

The IRS chief of criminal investigation, Don Fort, said in a statement that the organized scheme “details broad corruption, massive amounts of greed, and systemic flaws in our healthcare system that were exploited by the defendants.”

The FBI, IRS and 17 U.S. attorneys’ offices took part in the operation, according to AP.

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