“I work at the YMCA Monday through Friday with kindergartners through fifth-graders. It’s split shift; 7ÌýtoÌý9, 2Ìýto 6Ìýdaily,” he said. “With the rest of my day, I also work at a local pizza place. And in addition to that, I also own and operate a small skateboard company.”

But none of his jobs comes with an offer of health insurance. Does that worry him?

“Yes, especially being an avid skateboarder,” the 26-year-old said. “That’s constantly something in the back of my head now — before I try this trick, what happens if I get hurt?”

So he’s looking for a full-time job with benefits.ÌýBeyond that, Franco hasn’t fully explored his insurance options. He’s a member of the . They represent more than a quarter of the nation’s population. These are people loosely defined as 18 to 34 years old, and they figure prominentlyÌýin the health care debate. How they fare under the GOP health care bill going through Congress is complicated.

“I’m assuming that paying full price for it [health care] would be completely unaffordable for me,” he said.

The GOP plan would offer Franco a tax credit of $2,000 a year — that’s the flat amount available toÌý26- to 29-year-olds to help them buy insurance. The amount goes up to $2,500 for those ages 30 to 39. But even if Franco could buy a plan for a few hundred dollars a month, he doesn’t want to. He would rather hold on to what little pocket money he has for dinner or drinks with friends.

Jen Mishory heads an organization called , a tongue-in-cheek name for millennials who think they’re too healthy to need health insurance. But the organization is serious about advocating for young people. Mishory said the ACA helped this generation.

“You’re starting pre-ACA with an uninsurance rate of about 29 percent for young people. We see that uninsurance rate drop, over the course of the last five, six years to about 16 percent,” she said. That’s dueÌýto many factors, the expansion of Medicaid, for one, and children being able to stay on their parents’ insurance until age 26. That’s how Franco was insured until his last birthday.

But coverage on the exchange is still expensive for some millennials. Even with subsidies, they didn’t sign up for the ACA exchanges in the numbers insurers were hoping for.

Mishory points out the GOP proposal to roll back Medicaid expansion could hurt some young, single adults. The proposed tax credit might help others.

“For some young people, [the tax credit] may be more than what they received under the ACA,” she said. “But for a lot of the low-income young people, they could see reductions in that subsidy.”

What concerns Mishory most is the Republican provision that insurance companies could charge customers 30 percent more for a plan if their coverage lapses.

“Young people are the most likely to see gaps in coverage,” she said. That’s because young adults move and . They also tend to have lower incomes [than their elders], so the penalty might discourage millennials, especially healthy ones, from enrolling in coverage again.

Molly Tracy, 25, is in a different category than Franco: She’ll buy insurance, penalty or not. But she worries the Republican model won’t be affordable.

“I’m not rich! I work in public education,” said Tracy, who works in a charter school. “So even if I do have coverage, having a $3,000 medical bill … that’s going to pose a significant challenge for me.”

Right now, Tracy is covered by her father’s health insurance. But her 26th birthday is coming soon, “so I’m trying to get a tonsillectomy before my insurance lapses. That’s one of the issues. The other issue is scheduling, having enough time to recover.”

When Tracy does get her own health insurance through work this fall, she wants to know what she will be getting. Will birth control remain affordable? Will mental health care be covered? A Congressional Budget Office finds that people like Tracy might end up paying much more out-of-pocket for those benefits than they doÌýnow.

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First, it’s likely that fewer patients would be able to pay their hospital bills, health policy analysts say, so the institutions would be stuck with that bad debt, as they were before Obamacare.

“If the Medicaid expansion goes away wholesale, and things go back to the way they were before this expansion was in place, a lot of those hospitals would see an increase in their uncompensated care costs,” saidÌý, an analyst with the Kaiser Family Foundation. The American Hospital Association estimates that hospitals across the U.S. could more than $160 billion from the reduction in Medicaid revenue and the increase in unpaid medical bills.Ìý(KHN is an editorially independent program of the foundation.)

Then there’s this: The ACA has used financial incentives to encourage hospitals to experiment with ways to improve their care of patients, while reducing health care’s cost. That sort of experimentation has included a sizable upfront investment by many hospitals.

“We have now more than 20 different programs,” saidÌý, an internist and medical director of the Mass General Physicians Organization. “Video visits, electronic consultation with specialists, home hospitalization, [and] programs for patients with diabetes and heart disease. I would be worried that a repeal of the ACA would undermine our ability to invest in services for our patients.”

Ferris acknowledged that most of those experiments saved money. But they need more time to work out the kinks safely, he said.

“One of the things that it’s difficult for people outside of health care to appreciate — particularly politicians — is how long it takes to make significant improvements in the delivery of care,” Ferris said. “You have to be very careful when you make changes.”

Ferris said the threatened repeal of the ACA makes him worry “that the progress we’ve made over the past five years would be threatened.”

Many other have invested in accountable care organizations — often overhauling their medical records systems, hiring staff and creating new services. , head of a large hospital chain called in Rhode Island, said he, too, worries about the future of his ACO, .

“I think, if there’s a real change in direction away from these alternative payment models, we will be assuming risk to care for a population,” Keefe said. “We have invested enormously to be successful in this area.”

But these seismic changes in the way hospitals do business were predicated, he adds, on long-term support from the federal government — support that might disappear if the ACA is repealed.

This story is part of a partnership that includes , and Kaiser Health News.

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A comienzos del siglo XX, las mujeres lo usaban para superar los dolores del parto, pero su uso disminuyó en favor de la potente analgesia. Ahora, una pequeña banda de parteras está ayudando a reflotar su uso en los Estados Unidos.

Un hospital en Rhode Island, el South County Hospital en North Kingstown, acaba de agregar óxido nitroso, el nombre oficial del gas de la risa, a su menú de opciones para aliviar el dolor durante el parto.

Amy Marks saltó ante la oportunidad de usarlo porque quería evitar una epidural — una inyección en el líquido alrededor de la médula espinal que bloquea la sensación por debajo de la cintura. Al día siguiente de dar a luz, se sentó con su hijo, Ethan Thomas, acurrucado en su brazo.

“Cuando las contracciones comenzaron a ser bastante intensas, yo estaba como, ‘guau, esto es bastante malo’”, dijo. “Así que trajeron (el gas) y realmente fue mejor”.

¿Pero es esto realmente suficiente alivio para el dolor de parto? Lo fue para Marks, una vez que consiguió respirar el gas a través de una máscara facial, a tiempo para anticipar el pico de dolor de una contracción por 15 a 30 segundos.

“Estás pasando por la contracción, estás respirando dentro y fuera, tal vez respirando cinco, seis veces, llegas al pico de la contracción, y realmente no necesitaba más. Podía soportar el resto de la contracción”, dijo. “Me reía. Pero sólo por 15 a 30 segundos”.

Su partera, Cynthia Voytas, dijo que Marks respiró una mezcla de 50 por ciento de óxido nitroso y 50 por ciento de oxígeno.

“Te da esta euforia que te ayuda a olvidarte un poco del dolor”, dijo Voytas.

“Absolutamente. Fue exactamente lo que pasó”, dijo Marks.

El gas de la risa se instala en dos pequeños tanques que se colocan sobre un carro. Es móvil, por lo que las enfermeras pueden trasladarlo hasta la cabecera de la cama de la mujer. Hay una manguera con una máscara para respirar. Cuando quiere un poco de gas, una mujer puede simplemente recoger la máscara y respirar. Voytas dijo que le da a una mamá más control sobre su alivio del dolor.

Hasta el 2011, sólo un par de hospitales en los Estados Unidos ofrecían óxido nitroso a las mujeres en trabajo de parto. Hoy en día, son cientos, según los dos principales fabricantes de sistemas de óxido nitroso. Uno de esos fabricantes, Porter Instrument, fabricante de Nitronox, dice que casi 300 hospitales y clínicas de partos usan esta opción para el manejo del dolor.

La Dra. Michelle Collins, profesora y directora de enfermería de parto en la Vanderbilt University School of Nursing está ayudando con la carga de volver a traer al óxido nitroso como una de las variadas opciones que se les ofrece a las mujeres para el alivio del dolor durante el parto. Ella considera que el esfuerzo es acorde con lo que las parteras siempre han hecho: abogar para que las mujeres tengan más control sobre la experiencia de dar a luz.

Antes de la década de los 50, Collins dijo que el óxido nitroso se usaba comúnmente en el parto. Pero entonces, en los años 50 y 60, los doctores comenzaron a usar las drogas que hacían que las personas estuvieran somnolientas. Las mujeres irían al hospital, se las noquearía completamente, y despertarían con un bebé en sus brazos. La epidural, que entró en escena en la década de los 70, dio a las mujeres la posibilidad de un trabajo de parto sin dolor mientras estaban despiertas. Pero hay consecuencias: las epidurales pueden dificultar el movimiento y prolongar la segunda etapa del parto.

Collins dijo que las mujeres quieren más opciones para estar más involucradas en el nacimiento de sus bebés.

“Ahora, las mujeres están más informadas, y están demandando que se escuchen sus voces, lo que es algo realmente fantástico en opinión,” dijo

El óxido nitroso se ha continuado usando regularmente en Europa, por lo que hay información que muestra que es seguro, especialmente en dosis pequeñas. No reduce el dolor como una epidural. Más bien produce una sensación de euforia o relajación.

“Para algunas mujeres, la epidural va a ser su opción número uno. Otras quieren permanecer sin medicación y no recibir nada, y ése es su derecho. Para otras, el óxido nitroso es una opción viable”, dijo. “Se ve un poco como un menú y todo lo que es seguro debe estar en ese menú y disponible para la mujer”.

Ìý

Otra líder de esta mini-revolución, Judith Rooks, enfermera partera jubilada y epidemióloga, dijo que el gas deja el cuerpo en cuestión de segundos.

“Pasa a la placenta y entra en la circulación fetal, pero tan pronto como el bebé respira una o dos veces, ya se ha ido”, dijo Rooks.

En el 2011, el American College of Nurse-Midwives se posicionó a través de un documento, diciendo que es importante que las parteras sean conscientes del óxido nitroso como una buena opción para las mujeres en el trabajo de parto y que reciban entrenamiento sobre cómo administrarlo. La Dra. Laura Goetzl, profesora de obstetricia y ginecología en la Temple University School of Medicine, investiga el alivio del dolor en el parto. Ella considera al óxido nitroso una opción “segura y razonable” y está animando a Temple a ofrecerlo en su hospital.

La American Society of Anesthesiologists revisó investigaciones y, en mayo del 2011, dijo en un artículo científico que querría ver más estudios rigurosos sobre su seguridad y efectividad, porque una gran parte de la investigación tiene décadas de antigüedad. También advierten que las instalaciones deben tener un buen sistema para capturar cualquier gas que se escapa en el aire, para que las personas que están cerca no lo respiren. Ellos observan que su uso en Europa mostró “buenos resultados de seguridad para la madre y el niño”.

El óxido nitroso es menos costoso que una epidural por cientos de dólares, a veces miles. Collins dijo que el aparato desechable para respirar puede costar unos 25 dólares y el costo del gas solo unos 50 centavos la hora. Un anestesiólogo no necesita administrarlo. Puede hacerlo una enfermera partera u otro personal médico capacitado. Sin embargo, los hospitales están teniendo dificultades para calcular la facturación porque es algo tan nuevo, dijo Collins.

“Lo interesante es que no hay un código para facturar por este uso particular del óxido nitroso en el parto”, dijo. “Así que los lugares en todo el país están siendo muy creativos en abordar la parte de la facturación”.

Una aseguradora en Rhode Island lo cubre como si fuera otro analgésico. Algunos hospitales, dice Collins, simplemente pasan la tarjeta de crédito de un paciente, o no cobran en absoluto.

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In the early 20th century, women used it to ease the pain of labor, but its use declined in favor of more potent analgesia. Now, a small band of midwives is helping to revive its use in the U.S.

One hospital in Rhode Island, South County Hospital in North Kingstown, has just added nitrous oxide, the formal name for laughing gas, to its menu of pain relief options for labor.

Amy Marks jumped at the chance to use it because she wanted to avoid an epidural — an injection in the fluid around the spinal cord that blocks feeling below the waist. The day after she gave birth, she sat with her son, Ethan Thomas, snug in the crook of her arm.

“When the contractions started getting pretty intense, I was like, ‘wow, this is pretty bad,'” she said. “So they brought it in and it really took the edge off.”

Dr. , professor and director of nurse midwifery at the Vanderbilt University School of Nursing, is helping lead the charge to bring back nitrous oxide as one of several options women should be offered for pain relief during childbirth. She sees the effort as being in line with what midwives have always done: advocating for women to have more control of the experience of giving birth.

Prior to the 1950s, Collins said, nitrous oxide was commonly used in labor. But then in the 1950s and 1960s, doctors started using drugs that could make a person drowsy. Women would go to the hospital, be completely knocked out, and wake up with a baby in their arms. The epidural, which came on the scene in the 1970s, gave women the possibility of a pain-free labor while awake. But it came with trade-offs: epidurals can make it difficult to move around and can prolong the second stage of labor.

Collins saidÌýwomen want more options to be more involved in the birth of their babies.

“Now, women are more informed, and they’re demanding that their voices be heard, which is a really great thing in my book,” she said.

Nitrous oxide has continued to be used regularly in Europe, so there’s that shows it’s , especially in smaller doses. It doesn’t reduce pain, like an epidural. Rather, it induces a sense of euphoria or relaxation.

“For some women, the epidural is going to be their number one choice. For other women, they want to be unmedicated and have nothing and that’s their choice. For other women, nitrous oxide is a viable choice,” she said. “It’s seen somewhat like a menu and for everything that’s safe, it should be on that menu and available to the woman.”

Another of this mini-revolution, retired nurse midwife and epidemiologist Judith Rooks, said the gas leaves the body in seconds.

“It does pass the placenta and go into the fetal circulation, but as soon as the baby takes a breath or two, it’s gone,” Rooks said.

The American College of Nurse-Midwives came out with a in 2011, saying it’s important for midwives be aware of nitrous oxide as a good option for women in labor and get trained in how to administer it. Dr. Laura Goetzl, a professor of obstetrics and gynecology at Temple University’s medical school, researches pain relief in childbirth. She considers nitrous oxide a “safe and reasonable” option and she is encouraging Temple to offer it at its hospital.

The American Society of Anesthesiologists and in May 2011, said in a paper that they would like to see more and more rigorous studies on its safety and effectiveness — much of the research is decades old. They also warn that facilities should have a good system for capturing any gas that escapes into the air, so those nearby don’t breathe it in. They noteÌýits use in Europe showed, “good safety outcomes for both mother and child.”

Nitrous oxide is less expensive than an epidural by hundreds, sometimes thousands, of dollars. Collins said the disposable breathing apparatus may cost about $25 and the cost of the gas alone, she said, is about 50 cents an hour. An anesthesiologist does not need to administer it — it can be done by a nurse midwife or other trained medical staff. Hospitals are having a hard time figuring out the billing, however, because it’s so new, said Collins.

“The interesting thing is that there’s not a charge code for this particular use of nitrous oxide in labor,” she said. “So places around the country are being very creative in how they’re approaching the charge portion of it.”

One insurer in Rhode Island covers it as it would another painkiller. Some hospitals, says Collins, just swipe a patient’s credit card, or don’t charge at all.

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In 2013 and 2014, according to the The Centers for Disease Control and Prevention, people ages 45 to 64 accounted for Ìýof all deaths from drug overdose. Prince died on April 21 at his home and music studio Paisley Park in Minneapolis. He was 57.

Experts say there are a number of scenarios that increase risk of overdose, which is often accidental,Ìýfor people over 55. Imagine you are in that age group and you injured your shoulder a while back. It just hasn’t gotten better, so you take prescription painkillers — an opioid like OxyContin — to help with the pain. Let’s say you’ve been taking it for a couple of years. Your body has built up a tolerance to the drug, and now, you need to change it up to get the same amount of relief. When it comes to the potential for overdose, said Boston Medical Center epidemiologist , this is one of the most dangerous crossroads.

“There are wonderful medications used for treating anxiety,”Ìýshe said, but there’s a different calculus when they are taken with opioids.

“One opioid plus one benzo doesn’t equal the effect of two in the individual,” Green said. “It’s like one plus one equals four, or six.”

Opioids can depress the body’s drive to breathe and so can benzodiazepines. Combine them and that effect mounts. You could stop breathing and never wake up. And lots of people are taking these drugs in combination. In fact, people in their mid-40s to mid-60s are more likely than any other group to be prescribed opioids with benzodiazepines, according to the National Center for Health Statistics.

“It is indeed a demographic to keep an eye on,” GreenÌýsaid, partly because of another risk factor. People in this older age range may be likely to live alone or be otherwise isolated — maybe from divorce or because their kids have moved out.

So, Green said, “If something happens, if no one’s there to revive you, then you’re more likely to die of that experience.”

University of Rhode Island pharmacy professor said the way people in this age group tend to take drugs is also putting them at higher risk.

“They’re taking longer-acting opioids,” he said. “They’re taking doses that, at certain thresholds, are associated with increased overdose death.”

Also, Bratberg said, they’re more likely to have chronic health conditions that put them at higher risk of respiratory depression.

Medical conditions like chronic obstructive pulmonary disease or even the flu can amplify opioids’ ability to depress breathing. And some percentage of these drug users, he said, will develop a .

So why are doctors prescribing so much, in such combinations? Bratberg said it’s how the physicians were trained.

“If you’re a primary care prescriber and your patients are doing OK, maybe you’re just not thinking about that,” he said. “Plus there’s difficulty in telling the person whose pain may be controlled by opioids, and their anxiety may be controlled by benzodiazepines, to say, ‘Now we’re going to taper you off because this is harmful.’ ”

So millions of people are on opioids — most of them over 45 — and that means some are at risk of overdose. Bratberg said we should be educating patients and doctors.

“We’re really making a push nationally and regionally to educate prescribers about those risks, and to use tools available to warn folks about that.”

Tools that help lower the risk include , the overdose rescue drug. There’s also medication, such as or , to assist people who have become addicted to painkillers to stop their use safely. In essence, those drugs keep a low level of opioids in the system to keep someone from going into withdrawal without getting them high.

This story is part of NPR’s reporting partnership with local member stations andÌý.

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As rates of opioid addiction have climbed in the U.S., the number of babies born withÌý has increased, too — from 2000 to 2012, according to the National Institute of Drug Abuse.

It can be a painful way to enter the world, abruptly cut off from the drug in the mother’s system. The baby is usually born with some level of circulating opioids. As drug levels decline in the first 72 hours, various withdrawal symptoms may appear — such as trembling, vomiting, diarrhea or seizures.

At some point, if symptoms mount in number or severity, doctors will begin giving medication to help ease them. The idea is to give the the baby just enough opioid to reduce their symptoms, and then then slowly, over days or weeks, decrease that dose to zero.

But Davis said no one’s really done the research to determineÌýwhich drug works better for babies, and doctors are left to figure that out by trial and error, case by case. Though the Food and Drug Administration hasn’t officially approved morphine or methadone for use in newborns, doctors prescribe these drugs to the children anyway, in smaller doses than they give adults.

“As I spoke to people around the country, everyone would have their own approach and a very different way of treating these babies,” Davis said. “And we thought that quite odd.”

So he and a colleague, Brown University developmental psychologist , have launched a major study to sort out what works best. The two are hoping to enroll 180 babies in their double-blind, randomized, controlled trial — no one will know which newborns are getting methadone, and which are getting morphine, for example, until the study’s end. And they’re taking the research further: No study yet has looked at the long-term effects of the drugs, so Davis and Lester will continue to follow-up with measures of cognitive and physical development until the children are 18 months old.

“It may be,” Davis says, “that one agent is safer short-term, but when we look longer-term it may actually be more dangerous.” Teasing out long-term effects of a drug isn’t easy, Lester says; many factors can influence a baby’s development.

“If you’re drug-exposed and you’re growing up in an inadequate environment — which may not be poverty, it may be inadequate parenting — that’s a double whammy,” he says. “Those are going to be your worst case scenarios.”

Despite many remaining unknowns, doctors have consistently found that treatment with morphine or methadone enables most babies to get through withdrawal in about six to eight weeks.

“It can be heartbreaking,” said Robin, who has helped shepherd many kids through dark days. “But at the end, it is also rewarding,” she said, “because you see them get better and you see them go home.”

This story is the firstÌýin our four-part series, “Treating the Tiniest Opioid Patients,”Ìýa collaboration produced by Kaiser Health News, NPR andÌýlocal NPR member stations.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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