No one answers at the first couple of houses. But as Mahoney heads up the street, she sees a woman out for a walk.

“Hey! We’re out canvassing,” she says. “Would you mind having a conversation with us?”

Mahoney wants to talk about abortion — not a typical topic for a conversation, especially with a stranger. But the woman, Kerry Kelchner, agrees to talk. If this were typical door-to-door canvassing, Mahoney might ask Kelchner about a political candidate, remind her to vote and then be on her way. But Mahoney is deep canvassing — a technique that employs longer conversations to move opinions on hot-button issues.

Planned Parenthood in Maine has deployed the strategy for several years amid what it says are increasing threats to reproductive rights. This year alone, states have enacted more than 100 restrictions on abortion, including one in Texas that bans most abortions after six weeks. This month, the U.S. Supreme Court heard arguments in a case about a Mississippi law that could lead to the overturning of Roe v. Wade, the landmark 1973 ruling that established a constitutional right to abortion. And though state law in Maine protects abortion rights even if Roe v. Wade is overturned, abortion opponents have gained traction in the state in recent years. So volunteers like Mahoney start conversations. And they can get quite personal.

Mahoney first assesses Kelchner’s baseline attitude on abortion access on a scale of 0 to 10. A 10 means the interviewee believes anyone should be able to get an abortion for any reason.

Kelchner says she’s a 7.

Next, Mahoney asks Kelchner a series of questions to better understand her values.

“Can you tell me a little bit about what shaped your views on abortion?” she asks. “Have you known anybody who’s had an abortion, a friend or a family member?”

“My mother,” says Kelchner. She explains her parents were young when she was born, and they weren’t ready for another baby.

Then Mahoney, who’s 60, shares that she also had an abortion. “I was in my early 20s,” she says. “I was a little conflicted about it, and I wanted to have a family. I knew I wanted to have a family, but I was in no way ready to do that.”

Mahoney points out that she and Kelchner have similar views on what an unplanned pregnancy can mean. Then she asks her opening question again, to see whether Kelchner’s feelings about abortion access have shifted on the 0-to-10 scale.

“Still around 7,” Kelchner says.

Mahoney probes further. “What would be the circumstances where you would say, ‘No — they shouldn’t have the right to have an abortion?’”

Kelchner pauses. “That’s a good question.”

They talk more. Ultimately, Kelchner can’t think of any circumstance in which she believes someone should be denied an abortion.

“There should be no judgment,” she says.

“So that would be a 10?” Mahoney asks.

“Yep,” says Kelchner.

In the five years she’s been deep canvassing for Planned Parenthood, Mahoney said, she hasn’t had a single unpleasant conversation.

“What we’ve found doing this is that it is an effective way to change minds about abortion,” said Amy Cookson, director of external communications for Planned Parenthood of Northern New England.

Cookson said Planned Parenthood started deep canvassing in Maine in 2015, after Paul LePage, an anti-abortion Republican, won a second term as governor. Gay rights advocates in California had used deep canvassing on the same-sex marriage issue, and she wondered: “Can it work around abortion stigma?”

Joshua Kalla, a political scientist at Yale University, has that found the technique can change people’s deeply held beliefs. The crucial elements are that canvassers listen without judgment and share their own stories.

“So whether the person had an abortion and is talking about their abortion story,” said Kalla, “or whether the person is an ally and is talking about a friend or family member who had an abortion and is sharing that story, the effects seem to be quite similar.”

Kalla has also in Maine and said the group has added something else that’s effective: moral reframing. Canvassers listen for the moral values a voter emphasizes and then incorporate those values into the story they share.

But deep canvassing is not exclusively a progressive tactic, Kalla said. Conservative groups can use it, too, and he thinks that would improve political discourse: “You know, it would be good for American society if the way we had political conversation was more grounded, and listening to the other side, and being nonjudgmental, and being curious.”

Back in Windham, Mahoney continues to walk through the neighborhood. She meets a man outside his apartment building who gives only his first name, Chris. He says he’s a 4 on the abortion access scale. He opposes abortion except in cases of sexual assault. Chris tells Mahoney he had a daughter when he was 15.

“Do you talk about, I’m curious, birth control and abortion?” Mahoney asks.

“I do with her a lot,” Chris says. She’s a teenager, he says, and he’s not sure what he’d do if she got pregnant accidentally.

“It’s her own life,” he says. “I don’t know if I would even try to change her mind. Because it’s her decision.”

As the conversation goes on, Chris seems as though he supports access to abortion. But at the end, he doesn’t budge on his rating.

Mahoney said that’s OK. Some people won’t change their minds right away.

“The worst way to think about this is that it’s some kind of Jedi mind trick,” she said, “and I’m going to let them talk about themselves and then — pow! — I’m going to change their mind.”

What Mahoney wants most from these conversations is for people to think more deeply about the nuances around abortion and identify common ground: “I just feel like we all need to be taking steps to hear one another and move towards each other, instead of just diving into this divisive, contrary, hostile, red and blue world.”

Because of the success Planned Parenthood in Maine has had with deep canvassing, it has trained volunteers in other states, including Texas and Kansas. Next year, Kansas voters will cast ballots on a that seeks to revoke abortion access as a fundamental right.

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They told the woman, bundled under blankets to keep warm, they would contact her doctor with the result.

“Is there anything else we can do?” Dinsmore asked.

“No,” she said. “I’m all set.”

This wellness check, which took about 10 minutes, is one of the duties Dinsmore and LeCaptain perform in addition to the emergency calls they respond to as staffers with Waldoboro Emergency Medical Service.

EMS crews have been busier than ever this year, as people who delayed getting care during the covid-19 pandemic have grown progressively sicker.

But there’s limited workforce to meet the demand. Both and in Maine, staffing issues have plagued the EMS system for years. It’s intense work that takes a lot of training and offers low pay. The requirement in Maine and elsewhere that paramedics and emergency medical technicians be vaccinated against covid is another stress on the workforce.

Dinsmore and LeCaptain spend more than 20 hours a week working for Waldoboro on top of their full-time EMS jobs in other towns. It’s common in Maine for EMS staffers to work for multiple departments, because most EMS crews need the help — and Waldoboro may soon need even more of it.

The department has already lost one EMS worker who quit because of Maine’s covid vaccine mandate for health care workers, and may lose two more.

The stress of filling those vacancies keeps Town Manager Julie Keizer awake at night.

“So, we’re a 24-hour service,” Keizer said. “If I lose three people who were putting in 40 hours or over, that’s 120 hours I can’t cover. In Lincoln County, we already have a stressed system.”

The labor shortage almost forced Waldoboro to shut down ambulance service for a recent weekend. Keizer said she supports vaccination but believes Maine’s decision to mandate it threatens the ability of some EMS departments to function.

Maine is one of 10 that require health care workers to get vaccinated against covid or risk losing their jobs. Along with Oregon, Washington and Washington, D.C., it also explicitly includes the EMTs and paramedics who respond to 911 calls in that mandate. Some ambulance crews say it’s making an ongoing staffing crisis even worse.

Two hundred miles north of Waldoboro, on the border with Canada, is Fort Fairfield, a town of 3,200. Deputy Fire Chief Cody Fenderson explained that two workers got vaccinated after the mandate was issued in mid-August, but eight quit.

“That was extremely frustrating,” Fenderson said.

Now Fort Fairfield has only five full-time staffers available to fill 10 slots. Its roster of per-diem workers all have full-time jobs elsewhere, many with other EMS departments that are also facing shortages.

“You know, anybody who does ambulances is suffering,” said Fenderson. “It’s tough. I’m not sure what we’re going to do, and I don’t know what the answer is.”

In Maine’s largest city, Portland, the municipal first-responder workforce is around 200 people, and eight are expected to quit because of the vaccine mandate, according to the union president for firefighters, Chris Thomson.

That may not seem like a significant loss, but Thomson said those are full-time positions and those vacancies will have to be covered by other employees who are already exhausted by the pandemic and working overtime.

“You know, the union encourages people to get their vaccine. I personally got the vaccine. And we’re not in denial of how serious the pandemic is,” Thomson said. “But the firefighters and the nurses have been doing this for a year and a half, and I think that we’ve done it safely. And I think the only thing that really threatens the health of the public is short staffing.”

Thomson maintains that unvaccinated staffers should be allowed to stay on the job because they’re experts in infection control and wear personal protective equipment such as masks and gloves.

But Maine’s public safety commissioner, Mike Sauschuck, said EMS departments also risk staff shortages if workers are exposed to covid and have to isolate or quarantine.

“Win-win scenarios are often talked about but seldom realized,” he said. “So sure, you may have a situation where staffing concerns are a reality in communities. But for us, we do believe the broader impact, the safer impact on our system is through vaccination.”

Some EMS departments in Maine have complied fully with the mandate, with no one quitting. Andrew Turcotte, the fire chief and director of EMS for the city of Westbrook, said all 70 members of his staff are now vaccinated. He doesn’t see the new mandate as being any different from the vaccine requirements to attend school or enter the health care field.

“I think that we all have not only a social responsibility but a moral one,” Turcotte said. “We chose to get into the health care field, and with that comes responsibilities and accountabilities. That includes ensuring that you’re vaccinated.”

Statewide numbers released last week show close to 97% of EMS workers in Maine have gotten vaccinated. But that varies by county: Rural Piscataquis and Franklin counties reported that 18% and 10% of EMS employees, respectively, were still unvaccinated as of mid-October.

Not all EMS departments have reported their vaccination rates to the state. Waldoboro is in Lincoln County, where only eight of 12 departments have reported their rates. Among those eight, the rate of noncompliance was just 1.6%.

But in small departments like Waldoboro, the loss of even one staff member can create a huge logistical problem. Over the past few months, Waldoboro’s EMS director, Richard Lash, started working extra long days to help cover the vacancies. He’s 65 and is planning to retire next year.

“I’ve told my town manager that we’ll do the best we can do. But, you know, I can’t continue to work 120 hours a week to fill shifts,” said Lash. “I’m getting old. And I just can’t keep doing that.”

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Molly Frost of Newcastle wants the new law to stay. Her 11-year-old son, Asa, has a compromised immune system. He was diagnosed with at age 5. The cancer has gone in and out of remission, Frost said, relapsing three times. Asa’s treatment has included several rounds of chemotherapy, radiation and, most recently, a stem cell transplant.

“He at this point has no immunity against any of the things he was vaccinated for in the past and could get very sick from those diseases were he to catch them,” she said.

That worries Frost, especially because her family lives in a coastal county where vaccine exemption rates are at least — among the state’s highest rates. She was glad when the Maine legislature last year intended to protect kids like her son. It aims to boost immunization rates of kids entering school by eliminating nonmedical exemptions. It’s not in effect yet, but if opponents have their way Tuesday, it never will be.

“It’s a huge infringement on personal freedoms,” said Cara Sacks, co-chair of . “On medical freedom in particular.”

The repeal group includes parents like Angie Kenney who want to keep the philosophical exemption for vaccines. Kenney has used the philosophical exemption to refuse immunizations for her kids — ever since her older daughter had an adverse reaction after receiving the chickenpox vaccine at 18 months old.

“She could not crawl,” Kenney said. “She couldn’t walk. She couldn’t even feed herself. And this went on for almost a year.”

Her daughter was diagnosed with , a brain injury listed by the Centers for Disease Control and Prevention as a rare adverse event after chickenpox vaccination. Kenney said she received a payment from the National Vaccine Injury Compensation Program. Her daughter has recovered and is now a teenager. But Kenney also has a 4-year-old and doesn’t think the state should force her to get either girl vaccinated: “I am not sacrificing my child for the greater good of the community.”

Across Maine, though, physicians and health organizations say the new law is needed to protect public health because more and more parents are using exemptions.

More than 5% of kindergartners in Maine now have nonmedical exemptions, more than double the national average. That has pushed vaccination rates for many diseases below 95% — the critical threshold to achieve herd immunity and avoid spreading a disease to kids with compromised immune systems, like Asa Frost. Pediatrician Dr. Laura Blaisdell said she has daily conversations with parents about vaccines but has felt helpless as she’s witnessed immunization rates drop.

“We have gotten to a point where there are no other solutions,” Blaisdell said.

Maine has the second-highest rate of pertussis in the country. And Blaisdell said she worries that outbreaks of measles in other states could easily arrive through the millions of tourists who visit each summer.

“That sort of traffic is exactly the sort of traffic that diseases like measles would just love,” she said.

More than $1 million has been spent on the referendum battle. The received its initial support largely from doctors, nurses and health organizations. In the latest campaign filings, the group got a $500,000 boost from pharmaceutical companies Pfizer and Merck & Co. The trade organization Biotechnology Innovation Organization, which represents the biotech industry, also contributed $98,000.

The campaign to repeal the law, Yes on 1 for Maine, adopted “Reject Big Pharma” as its primary slogan. Much of the early support came from individual donations and chiropractors. More recently, the Organic Consumers Association contributed $50,000. The Minnesota-based group has been criticized for stoking vaccine fears and causing a measles outbreak in the state’s Somali community three years ago.

The backlash that has erupted over Maine’s new law doesn’t surprise , an assistant professor of health policy at the University of Pennsylvania who studies vaccine hesitancy and state exemptions. She said when states eliminate entire categories of exemptions, some people perceive that as parental rights being sacrificed for public health.

“And you sort of wonder, could Maine have taken a different policy step? Maybe making those exemptions harder to get and accomplish the same goal of coverage and disease protection without having to go through a big repeal effort.”

If the new law is preserved, Maine would join that don’t allow any nonmedical exemptions for vaccinations: California, New York, Mississippi and West Virginia.

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With these laws, Maine joins New York, Illinois, Rhode Island and Vermont as states that are trying to shore up the right to abortion in advance of an expected U.S. Supreme Court challenge. What sets Maine apart is how recently in the state.

“Elections matter,” said Nicole Clegg of Planned Parenthood of Northern New England. Since the 2018 elections, Maine has its largest contingent of female lawmakers, with 71 women serving in both chambers. “We saw an overwhelming majority of elected officials who support reproductive rights and access to reproductive health care.”

The dramatic political change also saw , Janet Mills, a Democrat who took over from Paul LePage, a Tea Party stalwart who served two terms. LePage had blocked Medicaid expansion in the state even after voters approved it in a referendum.

Clegg and other supporters of abortion rights hailed the new abortion legislation: “It will be the single most important event since Roe versus Wade in the state of Maine.”

Taken together, the intent of the two laws is to make it easier for women to afford and to find abortion care in the largely rural state.

Nurse practitioners like Julie Jenkins, who works in a small coastal town, said that increasing the number of abortion providers will make it easier for patients who now have to travel long distances in Maine to have a doctor perform the procedure.

“Five hours to get to a provider and back ― that’s not unheard of,” Jenkins said.

Physician assistants and nurses with advanced training will be able to perform a surgical form of the procedure known as an aspiration abortion. These clinicians already are allowed to use the same technique in other circumstances, such as when a woman has a miscarriage.

Maine’s other new law, set to be implemented early next year, requires all insurance plans ― including Medicaid ― to cover abortions. Kate Brogan of Maine Family Planning said it’s a workaround for a U.S. law known as the Hyde Amendment that prohibits federal funding for abortions except to save the life of the woman, or if the pregnancy arises from incest or rape.

“[Hyde] is a policy decision that we think coerces women into continuing pregnancies that they don’t want to continue,” Brogan said. “Because if you continue your pregnancy, Medicaid will cover it. But if you want to end your pregnancy, you have to come up with the money [to pay for an abortion].”

State dollars will now fund abortions under Maine’s Medicaid, which is funded by both state and federal tax dollars.

Though the bill passed in the Democratic-controlled legislature, it faced staunch opposition from Republicans during floor debates including Sen. Lisa Keim.

“Maine people should not be forced to have their hard-earned tax dollars [used] to take the life of a living pre-born child,” said Keim.

Instead, Keim argued, abortions for low-income women should be funded by supporters who wish to donate money; otherwise, the religious convictions of abortion opponents are at risk. “Our decision today cannot be to strip the religious liberty of Maine people through taxation,” Keim said during the debate.

Rep. Beth O’Connor, a Republican who says she personally opposes abortion but believes women should have a choice, said she had safety concerns about letting clinicians who are not doctors provide abortions.

“I think this is very risky, and I think it puts the woman’s health at risk,” O’Connor said.

In contrast, advanced practice clinicians say the legislation, which will take effect in September, said this law merely allows them to operate to the full scope of their expertise and expands access to important health care. The measure has the backing of physician groups like the Maine Medical Association.

Just as red-state laws restricting abortion are being challenged, so are Maine’s new laws. Days after Maine’s law on Medicaid abortion passed, organizations that oppose abortion rights announced they’re mounting an effort to put the issue on the ballot for a people’s veto.

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In exchange for that vote, she has assurances that payments for low-income consumers called cost-sharing subsidies will be restored and that a bill to stabilize the markets will move forward. Collins maintains  the trade-offs will make up for losing the mandate, but that’s still a question mark. Maine Public Radio’s Patty Wight filed this NPR story on the issue.

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“Give me the money and I will enforce the referendum,” LePage said. Unless the Legislature fully funds the expansion — without raising taxes or using the state’s rainy day fund — he said he wouldn’t implement it.

LePage has long been a staunch opponent of Medicaid expansion. The Maine Legislature has passed bills to expand the insurance program five times since 2013, but the governor vetoed each one.

That track record prompted Robyn Merrill, co-chair of the coalition Mainers for Health Care, to take the matter directly to voters Tuesday.

The strategy worked. Medicaid expansion, or Question 2, passed handily, with 59 percent of voters in favor and 41 percent against.

As a battle now brews over implementation in Maine, other states will likely be watching: groups in Idaho and Utah are trying to put Medicaid expansion on their state ballots next year.

With passage of the ballot measure, Maine is poised to join the 31 states and the District of Columbia that have already expanded Medicaid to cover adults with incomes up to 138 percent of the federal poverty level. That’s about $16,000 dollars for an individual, and about $34,000 for a family of four.

Currently, people in Maine who make too much for traditional Medicaid and who aren’t eligible for subsidized health insurance on the federal marketplace fall into a coverage gap. It was created when the Supreme Court made Medicaid expansion under the Affordable Care Act optional.

That’s the situation Kathleen Phelps finds herself in. She’s a hairdresser from Waterville who has emphysema and chronic obstructive pulmonary disease. She said she has had to forgo her medications and oxygen because she can’t afford them. “Finally, finally, maybe people now people like myself can get the health care we need,” she said.

Medicaid expansion would also be a win for hospitals. More than half of those in Maine are operating in the red. Across the state, hospitals provide more than $100 million a year in charity care, according to the Maine Hospital Association. Expanding Medicaid coverage will bolster their fiscal health and give doctors and nurses more options to treat their formerly uninsured patients, said Jeff Austin, a spokesman with the association.

“There are just avenues of care that open up when you see a patient from recommending a prescription drug or seeing a counselor,” he said. “Doors that were closed previously will now be open.”

But voter approval may not be enough. Though a legislative budget analysis office estimates Medicaid expansion would bring about $500 million in federal funding to Maine each year, it would also cost the state about $50 million a year.

The fate of the Medicaid expansion will now be in the hands of the Legislature, where lawmakers can change it like any other bill. Four ballot initiatives passed by Maine voters last year have been delayed, altered or overturned.

But state Democratic leaders pledge to implement the measure. “Any attempts to illegally delay or subvert the law … will be fought with every recourse at our disposal,” Speaker of the House Sara Gideon said. “Mainers demanded affordable access to health care yesterday, and that is exactly what we intend to deliver.”

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There are a number of strategies under consideration, but one option touted by House Republicans borrows an idea that Maine used just before the Affordable Care Act went into effect. It’s called an “invisible high-risk pool” — invisible because people in it didn’t even know they were.

The Maine pool earned higher marks than most state high-risk pools because it had a key ingredient: enough money.

“The problem is that in order to do the Maine model — which I’ve heard many House people say that is what they’re aiming for — it would take $15 billion in the first year, and that is not in the House bill,” . “There is actually $3 billion specifically designated for high-risk pools in the first year.”

Here’s how the Maine model worked: When a resident applied for health insurance, they had to fill out a questionnaire. If they had certain medical conditions known to be costly, their application was flagged for the high-risk pool. To consumers, it was seamless: They paid regular premiums and got the same sort of coverage as any other enrollee in their chosen health plan.

“An analysis that was done on what this program would need showed that it would need $15 billion to $20 billion per year to have any kind of reasonable impact on premiums,” Butterfield said.

The GOP bill does allocate about $15 billion to $20 billion — but that is supposed to last almost a full decade, not per year.

“One of our concerns,” Butterfield said, “is if the feds are going to put this in place and only kick in a token amount of money, is it going to be up to the states to pick up the slack and pay into this thing to make it work?”

Furthermore, Butterfield said, as the law stands now, under the Affordable Care Act, there’s no need for high-risk pools of any sort. The idea to use invisible high-risk pools is a solution to a problem that the GOP health care bill creates. Right now people can buy insurance regardless of their health status, whether or not they have a preexisting condition. It’s the GOP bill that would allow states to opt out of that Obamacare rule.

“I don’t understand,” Butterfield said, “why it would be a good idea to, on the one hand, say, ‘Well, we’re worried about preexisting conditions, so we’re going to throw not enough money at a problem we’re creating. At the same time, we’re going to allow insurance companies to charge sick people more.’ ”

And the invisible high-risk pool, said consultant Stein, is just one small proposal within the larger health bill.

“There’s nothing inherently wrong with it,” Stein said, “but it doesn’t really fix all the other problems of the bill.”

Which, he said, include cuts to Medicaid and potential changes to what are, under Obamacare, guaranteed “.”

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