With Democrats now in control of the U.S. House of Representatives, it might appear that the fight over abortion rights has become a standoff.

After all, abortion-rights supporters within the Democratic caucus will be in a position to block the kind of curbs that Republicans advanced over the past two years when they had control of Congress.

But those on both sides of the debate insist that won’t be the case.

Despite the Republicans’ loss of the House, anti-abortion forces gained one of their most sought-after victories in decades with the confirmation of Justice Brett Kavanaugh to the Supreme Court. Now, with a stronger possibility of a 5-4 majority in favor of more restrictions on abortion, anti-abortion groups are eager to get test cases to the high court.

And that is just the beginning.

“Our agenda is very focused on the executive branch, the coming election and the courts,” says Marjorie Dannenfelser, president of the anti-abortion organization Susan B. Anthony List. She says the new judges nominated to lower federal courts by President Trump and confirmed by the Senate, reflect “a legacy win.”

The Republican majority in the U.S. Senate is expected to continue to fill the lower federal courts with judges who have been vetted by anti-abortion groups.

Meanwhile, abortion-rights supporters believe they, too, can make strides in 2019.

“We expect 25 states to push policies that will expand or protect abortion access,” said Dr. Leana Wen, who took over as president of the Planned Parenthood Federation of America in November. If the landmark 1973 Supreme Court decision Roe v. Wade is eventually overturned, states will decide whether abortion will be legal, and under what circumstances.

Here are four venues where the debate over reproductive health services for women will play out in 2019:

Congress

The Republican-controlled Congress proved unable in 2017 or 2018 to realize one of the anti-abortion movement’s biggest goals: evicting Planned Parenthood from Medicaid, the federal-state health insurance program for people who have low incomes. Abortion opponents don’t want Planned Parenthood to get federal funds because, in many states, it functions as an abortion provider (albeit with non-federal resources).

Though Republicans have a slightly larger majority in the new Senate, that majority will still be well short of the 60 votes needed to block any Democratic filibuster.

Because Democrats generally support Planned Parenthood, the power shift in the House makes the chances for defunding the organization even slimmer, much to the dismay of abortion opponents.

“We’re pretty disappointed that, despite having a Republican Congress for two years, Planned Parenthood wasn’t defunded,” says Kristan Hawkins of the anti-abortion group Students for Life of America. “This was one of President Trump’s promises to the pro-life community, and he should have demanded it,” she says.

Another likely area of dispute will be the future of various anti-abortion restrictions that are routinely part of annual spending bills. These include the so-called Hyde Amendment, which bans most federal abortion funding in Medicaid and other health programs in the Department of Health and Human Services. Also disputed: restrictions on grants to international groups that support abortion rights, and limits on abortion in federal prisons and in the military.

However, now that they have a substantial majority in the House, “Democrats are on stronger grounds to demand and expect clean appropriations bills,” without many of those riders, says Wen of Planned Parenthood. While Senate Republicans are likely to eventually add those restrictions back, “they will have to go through the amendment process,” Wen says. And that could bring added attention to the issues.

With control of House committees, Democrats can also set agendas, hold hearings and call witnesses to talk about issues they want to promote.

“Even if the bills don’t come to fruition, putting these bills in the spotlight, forcing lawmakers to go on the record — that has value,” Wen says.

The Trump administration

While Congress is unlikely to agree on reproductive health legislation in the coming two years, the Trump administration is still pursuing an aggressive anti-abortion agenda — using its power of regulation.

A final rule is expected any day that would cut off a significant part of Planned Parenthood’s federal funding — not from Medicaid but from the Title X Family Planning Program. Planned Parenthood annually provides family planning and other health services that don’t involve abortion to about 40 percent of the program’s 4 million patients.

The administration proposal, unveiled last May, would effectively require Planned Parenthood to physically separate facilities that perform abortions from those that provide federally funded services, and would bar abortion referrals for women who have unintended pregnancies. Planned Parenthood has said it is likely to sue over the new rules when they are finalized. The Supreme Court upheld in 1991 a similar set of restrictions that were never implemented.

Abortion opponents are also pressing to end federal funding for any research that uses tissue from aborted fetuses — a type of research that was authorized by Congress in the early 1990s.

“It’s very important we get to a point of banning [fetal tissue research] and pursuing aggressively ethical alternatives,” says Dannenfelser.

State capitols

Abortion opponents having pushed through more than 400 separate abortion restrictions on the state level since 2010, according to the Guttmacher Institute, an abortion-rights think tank. In 2018 alone, according to Guttmacher, 15 states adopted 27 new limits on abortion and family planning.

“Absolutely some [of these are] an exercise in what they can get to go up to the Supreme Court,” says Destiny Lopez of the abortion-rights group National Latina Institute for Reproductive Health. “Sort of ‘Let’s throw spaghetti against the wall and see what sticks.’ “

But 2018 also marked a turning point. It was the first time in years that the number of state actions supporting abortion rights outnumbered the restrictions. For example, Massachusetts approved a measure to repeal a pre-Roe ban on abortion that would take effect if Roe were overturned. Washington state passed a law to require abortion coverage in insurance plans that offer maternity coverage.

Federal courts

The fate of all these policies will be decided eventually by the courts.

In fact, several state-level restrictions are already in the pipeline to the Supreme Court and could serve as a vehicle to curtail or overturn Roe v. Wade.

Among the state laws closest to triggering such a review is an Indiana law banning abortion for gender selection or genetic flaws, among other things. Also awaiting final legal say is an Alabama law banning the most common second-trimester abortion method — dilation and evacuation.

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

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The skyrocketing cost of many prescription drugs in the U.S. can be blamed primarily on price increases, not expensive new therapies or improvements in existing medications as drug companies frequently claim, a new study shows.

The report, published Monday in the journal Health Affairs, found that the cost of brand-name oral prescription drugs rose more than 9 percent a year from 2008 and 2016, while the annual cost of injectable drugs rose more than 15 percent.

“The main takeaway of our study should be that increases in prices of brand-name drugs were largely driven by year-over-year price increases of drugs that were already in the market,” says Immaculata Hernandez, an assistant professor of pharmacy at the University of Pittsburgh, and the lead author of the study.

The price of insulin, for example, doubled between 2012 and 2016, according to the Health Care Cost Institute. And the price of Lantus, an insulin made by Sanofi, rose 49 percent in 2014 alone, according to the University of Pittsburgh.

The researchers used the wholesale acquisition cost data for more than 27,000 prescription drugs from First Databank, a company that collects prescription drug sales data. It then compared that data to claims data from the University of Pittsburgh Medical Center’s health plan, which the researchers say is a sample that mirrors the population as a whole.

They then compared new and existing drugs and separated the data into brand-name, generic and specialty categories to come up with cost increase estimates.

Brand-name drugs like Lantus and others account for an average 44 percent of total prescription drug spending, Hernandez says. That share is declining as drugmakers focus more on developing high-priced specialty medications, she says.

Gerard Anderson, professor of health policy and management at Johns Hopkins University, says price increases on existing drugs not only benefit drug makers, but also insurers, who can make more money through rebates on higher priced drugs.

“Research and development is only about 17 percent of total spending in most large drug companies,” he says. “Once a drug has been approved by the FDA, there are minimal additional research and development costs so drug companies cannot justify price increases by claiming research and development costs.”

The study did find that innovation was behind price increases for certain types of drugs. Hernandez and her team found that from 2008 to 2016, the price of so-called specialty drugs rose 21 percent for oral medications and 13 percent for injectable drugs. These increases were driven by new, innovative drugs like Sovaldi and Harvoni, two medications made by Gilead Sciences, Inc. that can cure Hepatitis C. Both drugs were initially priced at over $80,000 for a course of treatment.

Total spending by the government, consumers and insurers on prescription drugs was $333 billion in 2017, according to National Health Expenditure data. That was an increase of just 0.4 percent from the previous year. But that spending rose more than 41 percent over the previous decade, from $236 billion in 2007.

The researchers say their study is based on the list prices of medications and doesn’t take into account the discounts most insurance companies get for prescription drugs because those discounts are kept secret.

The study also showed big cost increases in generic drugs, with oral generics rising 4 percent a year and injectables increasing 7 percent annually. But Hernandez says that spike can be attributed to what she calls a “patent cliff” that hit the drug market during the study period in which several blockbuster drugs, including several anti-depressants and anti-psychotics, lost their patent protection and became generics.

“We’re talking here about highly used drugs,” Hernandez says. “And it takes some time to file generic applications and therefore in the first years after a patent expiration there’s less competition in the market.” So at first, prices are set very close to the brand name price.

So those high-volume, expensive generics drove up prices in the generic market overall. But, as more generic competitors hit the market, the prices begin to fall more, she says.

Since rising costs aren’t paying for improved treatments, policy makers may want to take action, says Dr. William Shrank, chief medical officer of the UPMC Health Plan, who is also an author on the study.

“This observation supports policy efforts designed to control health care spending by capping price inflation to some reasonable level,” he says.

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Doctors told Steve Dillman the throat cancer he was diagnosed with in 2008 came from smoking. He knew it didn’t.

“I thought it had to be job-related because I’ve never smoked a day in my life. I don’t chew. I don’t drink excessively … and that’s the three main criterias,” he says.

But Dillman did spend 38 years as an Indianapolis firefighter — and that included running into burning buildings.

Dillman, who’s now retired, recalls one fire on Aug. 1, 1985. That day, his fire station responded to a call at the American Fletcher National Bank warehouse in downtown Indianapolis.

Firefighters noticed something strange and painful after they put out the flames. Everywhere they sweated – under their arms, around their groins – their skin peeled, like it had been sunburned.

Dillman later learned the warehouse was filled with boxes treated with a flame-retardant chemical that sent toxic gases into the air – including formaldehyde, a known carcinogen.

Dillman was diagnosed with prostate cancer 16 years later, and throat cancer seven years after that.

“It’s just an evil thing that we have to deal with,” 74-year-old Dillman says.

Research from National Institute for Occupational Safety and Health (NIOSH) published in 2013 shows that firefighters are diagnosed with and die from cancer at higher rates than the general population. It confirmed earlier research finding elevated risk for the profession for certain cancers.

The correlation between firefighters’ on-the-job exposure to carcinogens and their subsequent illnesses is concerning enough to policy makers that a growing number of states have passed laws — 42 states and Washington, D.C. — designed to help firefighters who develop cancer, according to the non-profit Firefighter Cancer Support Network.

Generally, these laws say that firefighters diagnosed with cancer while on the job or within a certain time after retirement are presumed to have become ill because of their work. And that should make it easier for them to get workers’ compensation, disability benefits or death benefits for their families.

But firefighters say those protections often fall short.

Leaders of organizations that work with firefighters say, despite these laws, firefighters are often denied workers’ compensation claims after a cancer diagnosis. Firefighters have challenged denials in a number of states, including California, Pennsylvania, Texas, and Washington.

“Presumptive laws aren’t the golden ticket that people think they are,” says Jim Brinkley, director of occupational health and safety for the International Association of Fire Fighters, a Washington, D.C.-based lobbying organization. “Our detractors are the ones who will say it’s not connected to the job because they don’t want to pay the benefits.”

It’s difficult to estimate how many firefighters have been denied benefits, says Keith Tyson, vice president for education and research for the Firefighter Cancer Support Network. He’s a prostate cancer survivor who spent 34 years on the job in Florida, where there is no presumptive law.

Tyson doesn’t know of any organization that tracks such workers compensation claims nationwide. And other than his organization’s analysis of state laws, there isn’t a comprehensive listing of the states offering protection.

“That’s the problem. Nobody is consistent on any of this,” Tyson says. “It’s unfortunate that there couldn’t be a one-standard-fits-all [law]. That would make it so much easier.”

Exposed to contaminants

Heart disease was the leading cause of firefighter deaths until the mid-1990s, when “the burden of cancer significantly surpassed heart disease,” according to a paper on firefighters and cancer published last year in the American Journal of Industrial Medicine.

That study surveyed 2,818 Indiana firefighters who died between 1985 and 2013, and found that they had a 20 percent greater likelihood of dying due to cancer than non-firefighters.

This builds on the findings of the 2013 NIOSH study, which included nearly 30,000 firefighters from Chicago, Philadelphia and San Francisco. It found that firefighters are exposed to contaminants that are known or suspected to cause cancer — everything from asbestos in old buildings to the diesel exhaust from fire trucks — and they are more likely to develop respiratory, digestive and urinary system cancers than the general public.

For one rare cancer, mesothelioma, which is linked to asbestos exposure, the rate is two times greater in firefighters than the general U.S. population.

In July 2018, President Trump signed the Firefighter Cancer Registry Act directing the Centers for Disease Control and Prevention to collect national data about the issue. Fire stations can send information on cancer rates among their staff to the National Institute for Occupational Safety and Health.

NIOSH will look for trends in how cancer affects male and female firefighters, firefighters of different races and those in urban and rural areas.

Brinkley hopes this data will make it “very clear to the legislators and those controlling the purse strings that we need better protection for firefighters.”

Presumptive laws in action

State presumptive laws vary in many ways. Some cover only certain cancers. Some states limit how long after retirement a cancer diagnosis is covered. And in some states, a diagnosis alone isn’t enough to trigger protections such as disability benefits.

Of the states with presumptive cancer laws, the Firefighter Cancer Support Network found one that extends coverage up to three months after retirement. Six states, including Indiana, provide coverage up to five years. One state allows seven years, one state allows 600 weeks and three cover up to 20 years.

This reflects a misunderstanding of science, says Dr. Jefferey Burgess, an environmental health researcher at the University of Arizona College of Public Health. He says cancer can develop “anywhere from less than five years to over 30 years” after exposure to carcinogens.

Burgess, who has researched firefighters and cancer for more than 25 years, says the evidence shows firefighters are regularly exposed to carcinogens in the field, and that firefighters are diagnosed with cancer more than the general public.

“From my perspective, I believe we’ve clearly demonstrated that firefighting is associated with cancer,” he says.

Future research is needed, Burgess says, to determine more specific links between those exposures and a firefighter’s cancer diagnosis. At this point, it’s not possible to prove that a single exposure to a carcinogen caused a specific cancer. In fact, there isn’t definitive research that shows even a career of exposure causes a specific cancer diagnosis.

Instead of demanding documentation of possible exposures from fires long ago, Burgess says fire departments should understand that firefighters’ health is affected by their work.

“To tell you whether it was an individual fire or was a lifetime exposure, I don’t know we have that particular information right now,” Burgess says. “Every fire tends to have these chemicals, and therefore it should just, from my mind, be a question of whether you’re a firefighter and you’ve gone to fires rather than documenting that a specific fire was a problem.”

Even with presumptive laws in place, municipalities across the country often fight firefighter’s cancer-related workers’ comp claims. And firefighters are pushing back.

In Texas, the Houston Chronicle found that in the past six years, nine in 10 Texas firefighters with cancer have had their workers compensation claims denied.

In Philadelphia, the city denied a firefighter’s claim in 2012, leading to a lengthy process of appeals. Ultimately, the Pennsylvania Supreme Court ruled in 2018 in favor of the firefighter, arguing that firefighters diagnosed with cancer must only show that their cancer could be caused by exposure to a known carcinogen. It’s up to their employers to prove it was not work-related.

Brinkley says the International Association of Fire Fighters has tried to develop more information about these claims nationwide. It has asked municipalities for data on workplace injury claims related to cancer — and how often they’re denied. The requests have been refused.

The National Council on Compensation Insurance, which gathers and analyzes data related to states’ workers compensation systems, released a report in 2016 on the impact of presumptive laws.

The report noted that firefighters are typically employed by state and local governments, which are often self-insured. Self-insured entities aren’t required to report claims to the council. Still, the NCCI stated in the report that it “expects that the enactment of such presumptions will result in increases in workers compensation costs.”

‘A moment of weakness’

In Indiana, as in some other states with presumptive laws, when a firefighter makes a cancer-related claim, the city wants to know the specific fire that led to the cancer diagnosis.

But firefighters traditionally haven’t kept records of chemical exposures, Brinkley says.

“To ask a member who is fighting a horrific disease that could end their life to then find that one call that they were exposed to one chemical that causes that one cancer is just a way of holding on to the money and not paying the claim,” he says. “That’s not taking care of your firefighter, who risks their life every day.”

Indianapolis Fire Department division chief for health and safety Kevan Crawley advocates for firefighters’ benefits. He says he spends months arguing with city officials and Broadspire, the company that manages workplace injury claims.

Asked about the issue, a Broadspire spokeswoman said the company won’t comment on how it manages its clients’ claims.

Brett Wineinger, risk manager for Indianapolis, oversees the city’s insurance policies. He says that few of the claims have dealt with cancer.

“We’re going to monitor any claim that’s filed with us against [Indiana’s presumptive law],” Wineinger says. “If it’s something that is linked to a fire instance that’s clearly something they’ve gotten through an exposure, obviously we’re going to take that as a workplace injury because that should be the first line of defense.”

Crawley says he understands that the city is trying to protect its budget. And he doesn’t believe that the insurers who deny claims are “bad people.”

But he says they don’t understand what it’s like to sit down with a newly-diagnosed firefighter and explain that the city won’t help with cancer-related costs.

“Guys you’ve looked up to in your career, and you don’t ever expect to see them in a moment of weakness,” Crawley says.

Growing a culture of safety

Firefighters at the Indianapolis Fire Department say they can’t rely on the state’s presumptive law for protection, so they’re focusing on what is in their control: preventing exposure to carcinogens.

Firefighters can wear a protective mask that filters out gases and particles. Otherwise, they breathe in a lot of smoke.

In the old days, firefighters were called “smoke-eaters,” recalls retired firefighter Dillman, and they wore their charred, soot-covered gear as a badge of honor.

At fires, Dillman didn’t wear hisprotective mask.No one did. If you did you were a “sissy,” he says.

“It was just the way the job was,” Dillman recalls.

Procedures during fires have changed since Dillman retired in 2005. It’s now standard practice for firefighters to wearthese masks at a fire.

Dillman now travels to fire departments around Indiana to urge firefighters to use masks and practice other preventive cancer measures.

To make his point, Dillman brings a couple of props.

“The last thing I tell them, ‘You can either wear your [protective] air mask … ‘” he says, holding one up for emphasis.

Then he shows the oxygen mask he needed to breathe when his cancer was at its worst.

And he says, “Or you can wear this mask. And trust me, you don’t want to wear this mask.”

This story was produced by Side Effects Public Media, a news collaborative covering public health.

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