Over the past few years, abortion providers in Texas have struggled to reopen clinics that had closed because of restrictive state laws.

There were more than 40 clinics providing abortion in Texas on July 12, 2013 — the day lawmakers approved tough new restrictions and rules for clinics.

Even though abortion providers fought those restrictions all the way up to the U.S. Supreme Court, and managed to get the restrictions overturned in 2016, most of the affected clinics remain closed.

Today, there are just 22 open clinics in a state that is home to 29 million people.

Although abortion providers won the legal battle, they appear to be losing the ground war. Most clinics are clustered in the major cities of Dallas, Houston and Austin, while women who live in smaller cities and towns that once had clinics now have to travel long distances to get an abortion.

The town of San Angelo, for example, once had a Planned Parenthood clinic, but it had to close in 2013. It had been one of the last abortion providers in West Texas, a sprawling, dry and mostly rural region where most residents must drive at least three hours to reach a major city.

Susanne Fernandez, who worked at the San Angelo clinic for almost 30 years, gets emotional talking about its closure. “I loved working for Planned Parenthood.”

Fernandez blames the closure on the 2013 state law, known as House Bill 2, which required abortion clinics to have the same sort of equipment, standards and staffing as surgical centers — and also required the doctors performing abortions to obtain admitting privileges at a nearby hospital. She says complying with those rules would have been extremely difficult and expensive. Still, the decision to close the San Angelo clinic was tough.

“The last day was sad. It was somber,” Fernandez says. “We did a lot of cleaning up. We all knew that was it.”

Abortion providers in Texas eventually sued the state. But as the legal challenge worked its way through the courts, many of the clinics were forced to stop providing services.

At one point, Texas had only 17 clinics, says Kari White, an investigator with the Texas Policy Evaluation Project at the University of Texas, Austin. She says women living in rural Texas were affected the most.

“What we saw is that [in] West Texas and South Texas, access was incredibly limited,” White says, “and women living in those parts of the state were more than 100 miles — sometimes 200 or more miles — from the nearest facility.”

White’s research team conducted surveys and interviews with women who were seeking abortions as clinics were shutting down. A 19-year-old woman told the researchers she considered giving up because it was so hard to find an open clinic.

“It was a very hard thing to do, like to keep calling and calling and calling,” the woman told researchers. “I almost was like, you know, ‘Well, forget it.’ … But then, because I knew at the end of the day it was something that I had to do, it was like I don’t care how many people I have to call or how far I have to go. I have to do it.”

That woman eventually found a clinic 70 miles away and was able to get the abortion. But in some other cases, women had to carry unwanted pregnancies to term.

Under Texas law, women have to have two appointments with an abortion provider. After an initial appointment at a clinic, the women must wait 24 hours before getting the procedure. That means they often have to make a long trip at least twice, or pay for a hotel nearby. The waiting period is only waived if a woman lives more than 100 miles away from the closest clinic.

One 23-year-old woman from Waco, a married mother of two, told researchers she made appointments to get an abortion at two different clinics. But both appointments were canceled after the clinics were forced to close. She was unable to end the pregnancy.

“I was pretty upset, but I just decided that I guess I’ll have to just ride it out,” she told researchers. “I didn’t know what else to do, who else to call.”

Eventually, in the summer of 2016 — three years after H.B. 2 passed — the U.S. Supreme Court struck down the tough new restrictions on clinics. But most of the clinics never reopened.

“There hasn’t been this rush of clinics reopening following the Supreme Court decision,” White says. “So there are still just clinics concentrated in the major metropolitan areas of Texas.”

The ruling has also been a mixed bag for anti-abortion activists, says John Seago, the legislative director for Texas Right to Life.

“The closures of clinics is definitely a victory for the movement, obviously,” he says. “However, how are we in this situation in the first place is what my organization looks at.”

Seago says anti-abortion activists in Texas are in this situation because of Roe v. Wade, the Supreme Court case that made abortion legal in the U.S. He says it’s the reason anti-abortion activists fight legal battles on the state level in an effort to reverse Roe.

Seago says the Supreme Court ruling on Texas’ law was a big blow to the larger goal of slowly dismantling Roe.

Some new options in recent years

Over the past three years, a few abortion providers have decided to open clinics in Texas.

For example, earlier this year Kathy Kleinfeld opened a new abortion clinic in Houston — a city that already has a few clinics providing abortion.

Kleinfeld, a longtime consultant for abortion providers in Texas and other states, decided to open in Houston after carefully looking at the demand for services in that region. Her clinic provides medical abortions using pills, but not surgical abortions.

“Due to the closure of so many clinics, the remaining clinics that are open are very busy, and they are very strict in the scheduling,” Kleinfeld says. “So our goal was to offer flexibility in scheduling.”

Kleinfeld says her clinic could help take some pressure off the remaining clinics in Houston. She says so far her patients have been professionals, students and women who drive over from Louisiana.

But she emphasizes that getting her clinic up and running was not easy, despite her intimate knowledge of the complex rules and mandatory paperwork and the surprise inspections involved in operating as a licensed abortion provider in the state of Texas.

Kleinfeld predicts that opening, running and keeping a clinic open will always be difficult in Texas.

“There’s always been volatility and conflict and struggles,” she says. “Always. And this is not for the faint of heart.”

Andrea Ferrigno agrees with that assessment. As the corporate vice president of Whole Woman’s Health, Ferrigno helps operate several clinics that offer abortion in Texas.

She recalls that after H.B. 2 passed in 2013, Whole Woman’s Health was forced to close two clinics — one in Austin and another in Beaumont, a small city near the Louisiana border. So far, Whole Woman’s Health has only been able to reopen the Austin clinic.

“It’s basically starting from scratch,” Ferrigno says. “You laid off the staff, you don’t have any physicians that work there anymore. Some of the doctors didn’t even renew their physician licenses.”

Ferrigno says clinics that closed may have lost the required state-issued license needed to operate in Texas. Applying for a new one is a significant bureaucratic hurdle. Some clinics might have lost their leases, been forced to vacate their buildings, and sell off equipment.

“There are a lot of different limitations,” she says. “There’s also the question of — or the fear of — security challenges. People picketing the clinic, picketing their homes. There’s a lot that goes into that.”

But the cost of not reopening — particularly in a community that had only one clinic to begin with — may be high.

Take San Angelo, for example: Fernandez says she doubts there will be a clinic offering abortions opening in her town anytime soon. She sometimes wonders what happened to the women she used to help.

“Where did these women go? Where do they go now?” Fernandez says. “I don’t believe a lot of them found any other health care afterward.”

This story comes from NPR’s reporting partnership with KUT and Kaiser Health News.

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When José moved his family to the United States from Mexico nearly two decades ago, he had hopes of giving his children a better life.

But now he worries about the future of his 21-year-old-son, who has lived in central Illinois since he was a toddler. José’s son has a criminal record, which could make him a target for deportation officials. We’re not using the son’s name because of those risks, and are using the father’s middle name, José, because both men are in the U.S. without permission.

José’s son was diagnosed with schizophrenia and bipolar disorder last year and has faced barriers to getting affordable treatment, in part because he doesn’t have legal status. His untreated condition has led to scrapes with the law.

Mental health advocates say many people with untreated mental illness run the risk of cycling in and out of the criminal justice system, and the situation is particularly fraught for those without legal status.

“If he gets deported he’d practically be lost in Mexico, because he doesn’t know Mexico,” says José, speaking through an interpreter. “I brought him here very young and, with his illness, where is he going to go? He’s likely to end up on the street.”

Legal troubles

José’s son has spent several weeks in jail and numerous days in court over the past year.

On the most recent occasion, the young man sat nervously in the front row of a courtroom in the Champaign County courthouse. Wearing a white button-down shirt and dress pants, his hair parted neatly, he stared at the floor while he waited for the judge to enter.

That day, he pleaded guilty to a criminal charge of property damage. The incident took place at his parents’ house earlier that year. He had gotten into a fight with his brother-in-law and broke a window. His father says it was yet another out-of-control moment from his son’s recent struggles with mental illness.

Before beginning proceedings, the judge read a warning aloud — something that is now standard practice to make sure noncitizens are aware that they could face deportation (or be denied citizenship or re-entry to the U.S.) if they plead guilty in court.

The young man received 12 months’ probation.

After the hearing, he agreed to an interview.

Just a couple of years ago, he says, his life was good: He was living on his own, working, and taking classes at community college. But all that changed when he started hearing voices and began struggling to keep his grip on reality. He withdrew from his friends and family, including his dad.

One time, he began driving erratically, thinking his car was telling him what to do. A month after that episode, he started having urges to kill himself and sometimes felt like hurting others.

In 2018, he was hospitalized twice, and finally got diagnosed with schizophrenia and bipolar disorder.

José says that during this time, his son — who had always been respectful and kind — grew increasingly argumentative and even threatened to hurt his parents. The psychiatric hospitalizations didn’t seem to make a difference.

“He asked us for help, but we didn’t know how to help him,” José says. “He’d say, ‘Dad, I feel like I’m going crazy.’ “

José’s son says he met with a therapist a few times and was taking the medication he was prescribed in the hospital. He was also using marijuana to cope, he says.

The prescribed medication helped, he says, but without insurance, he couldn’t afford to pay the $180 monthly cost. When he stopped the meds, he struggled, and continued getting into trouble with the police.

Undocumented and uninsured

For people who are both undocumented and living with a mental illness, the situation is “particularly excruciating,” says Carrie Chapman, an attorney and advocate with the Legal Council for Health Justice in Chicago, who represents many clients like José’s son.

“If you have a mental illness that makes it difficult for you to control behaviors, you can end up in the criminal justice system,” Chapman says.

People with mental illness make up only a small percentage of violent offenders — they are actually more likely, compared to the general population, to be a victim of a violent crime.

Chapman says the stakes are extremely high when people without legal status enter the criminal justice system: they risk getting deported to a country where they may not speak the language, or where it’s even more difficult to obtain quality mental health care.

“It could be a death sentence for them there,” Chapman says. “It’s an incredible crisis, that such a vulnerable young person with serious mental illness falls through the cracks.”

An estimated 4.1 million adults under the age of 65 who live in the U.S. are ineligible for Medicaid or marketplace coverage under the Affordable Care Act because of their immigration status, according to the Kaiser Family Foundation.

Among them are those who are undocumented and other immigrants who otherwise do not fall into one of the federal categories as lawfully in the U.S. People who are protected from deportation through the federal government’s Deferred Action for Childhood Arrivals policy, or DACA, also are ineligible for coverage under those programs.

For many people in all those groups, affordable health care is out of reach.

Some states have opened up access to Medicaid to undocumented children, including Illinois, California, Massachusetts, New York, Oregon, Washington and the District of Columbia, according to the National State Conference of Legislatures. But they lose that coverage at age 19, except in California, which recently expanded eligibility through age 25.

For those who can’t get access to affordable health insurance because of their undocumented status, medical care is largely limited to emergency services and treatments covered by charity care or provided by community health centers.

It’s unclear how many people have been deported because of issues linked to mental illness; good records are not available, says Talia Inlender, an attorney for immigrants’ rights with the Los Angeles-based pro bono law firm Public Counsel. But estimates from the ACLU suggest that tens of thousands of immigrants deported each year have a mental disability.

Inlender, who represents people who have mental health disabilities in deportation hearings, says when the lack of access to community-based treatment eventually leads to a person being detained in an immigration facility, that person risks further deterioration because many facilities are not equipped to provide the needed care.

On top of that, she says, immigrants facing deportation in most states don’t generally have a right to public counsel during the removal proceedings and have to represent themselves. Inlender points out that an immigrant with a mental disability could be particularly vulnerable without the help of a lawyer.

(Following a class-action lawsuit, the states of Washington, California and Arizona did establish a right to counsel for immigrants with mental illness facing deportation. For those in other states, there’s a federal program that tries to provide the same right to counsel, but it’s only for detained immigrants who have been properly screened.)

Medicaid for more people?

Chapman and other advocates for immigrants’ rights say expanding Medicaid to cover everyone who otherwise qualifies — regardless of legal status — and creating a broader pathway to U.S. citizenship would be good first steps toward helping people like José’s son.

“Everything else is kind of a ‘spit and duct tape’ attempt by families and advocates to get somebody what they need,” Chapman says.

Critics of the push to expand Medicaid to cover more undocumented people object to the costs, and argue that the money should be spent, instead, on those living in the country legally. (California’s move to expand Medicaid through age 25 will cost the state around $98 million, according to some estimates.)

As for José’s son, he recently found a pharmacy that offers a cheaper version of the prescription drug he needs to treat his mental health condition — so he’s back on medication and feeling better.

He now works as a landscaper and hopes to get back to college someday to study business. But he fears his criminal record could stand in the way of those goals, and he’s aware that his history makes him a target for immigration sweeps.

José says his greatest fear is that his son will end up back in Mexico — away from family and friends, in a country he knows little about.

“There are thousands of people going through these issues … and they’re in the same situation,” José says. “They’re in the dark, not knowing what to do, where to go, or who to ask for help.”

This story is part of NPR’s reporting partnership with Side Effects Public Media, Illinois Public Media and Kaiser Health News. Christine Herman is a recipient of a Rosalynn Carter fellowship for mental health journalism. Follow her on Twitter: @CTHerman

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Updated at 3:10 p.m. ET

President Trump has made price transparency a centerpiece of his health care agenda. Friday he announced two regulatory changes in a bid to provide more easy-to-read price information to patients.

The first effort targets hospitals, finalizing a rule that requires them to display their secret, negotiated rates to patients starting in January 2021. The second is a proposal to make insurance companies show patients their expected out-of-pocket costs through an online tool. That proposed rule is subject to 60 days of public comment, and it’s unclear when it would go into effect.

“Our goal is to give patients the knowledge they need about the real price of health care services,” said Trump. “They’ll be able to check them, compare them, go to different locations, so they can shop for the highest-quality care at the lowest cost.”

Administration officials heralded both rules as historic and transformative to the health care system.

“Under the status quo, health care prices are about as clear as mud to patients,” said Center for Medicare & Medicaid Services Administrator Seema Verma in a written statement. “Today’s rules usher in a new era that upends the status quo to empower patients and put them first.”

As NPR has reported, hospitals are currently required to post their “list prices” online, but that information has been very hard to use and doesn’t tell consumers much about what they are likely to pay. The new rule makes hospitals show what they really pay for services — not the list prices — and requires them to make that information easy to read and easy to access.

“I don’t know if the hospitals are going to like me too much anymore with this,” Trump said in a White House news conference Friday afternoon. “That’s OK.” He later added, “We’re stopping American patients from just getting — pure and simple, two words, very simple words — ripped off. Because they’ve been ripped off for years. For a lot of years.”

The second rule Trump announced Friday (which is a proposed rule, still subject to public comments before being finalized) affects insurance companies. It would essentially make insurers give patients their “explanation of benefits” upfront. It would require insurers to explain how much a service would cost, how much your plan would pay and how much you would owe — before the service is performed. The idea is that patients could use that information to shop around ahead of time for a better deal — assuming a better deal can be found, and the service isn’t a medical emergency.

Certainly these rules would give patients more information than they currently have. The other promise of these rules — that they will bring down health care costs — is more of an open question.

In public comments for the hospital rule, hospitals argued that having to make their negotiated rates public would backfire — if a hospital is charging less than another one nearby, it could theoretically raise its price to more closely match its competitor’s.

Secretary of Health and Human Services Alex Azar dismissed that argument on a call with reporters Friday morning.

“This is a canard,” he said. “Point me to one sector of the American economy where the disclosure of having price information in a competitive marketplace actually leads to higher prices as opposed to lower prices.”

Larry Levitt, executive vice president of the Kaiser Family Foundation, pointed out on Twitter that the penalty for hospitals that defy Trump’s transparency rule was “quite weak.”

“A maximum fine of $300 per day,” he wrote. “The technical term for that is ‘chump change.’ I wonder how many hospitals will just pay the fine.”

There’s also an open question about whether these rules will survive legal challenges. Another Trump administration proposal to show drug list prices in television ads was blocked in the courts.

“We may face litigation, but we feel we’re on a very sound legal footing for what we’re asking,” Azar told reporters.

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