Five years after the Affordable Care Act passed, its Medicaid expansion provision is still causing huge fights in state legislatures.

Twenty-four states and the District of Columbia said yes to Medicaid expansion when the law went into effect. Since then, just six more have signed on. States that do get billions of additional federal dollars, but many Republican lawmakers are loathe to say yes to the Obama administration.

The fight’s garnered many headlines in Florida recently as the Republican-led House and Senate are at odds on expansion and the legislative work—including setting a budget—came to a standstill. But the issue has also been hot out west this year where four Republican majority states took up Medicaid expansion. Wyoming said no, Utah’s governor is seeking to negotiate a compromise with Washington to offer legislators, and Alaska legislators are still wrestling with the issue. And after some legislative fireworks, Montana said yes.

Montana lawmakers have been stewing over Medicaid expansion since they said no to it in 2013 – the last time they met. When they reconvened in January, Americans for Prosperity, a conservative group supported by the billionaire brothers Charles and David Koch, staffed up in the state and targeted moderate Republicans, organizing anti-expansion “town hall” meetings in their districts.

But AFP didn’t invite targeted lawmakers themselves and that backfired. Many voters called AFP’s tactics meddling by outsiders, and some AFP meetings were disrupted.

Tea Party lawmakers in the Montana House fought hard against Medicaid expansion. They killed a proposal by Democrats, and then nearly derailed a Republican-sponsored compromise. The House had to bend its rules to even bring the bill to the floor for a vote. But in the end, 20 Republicans felt politically safe enough to cross party lines and vote with all the Democrats to pass it.

Still, at the bill’s signing ceremony Republican Senator Ed Buttrey, who sponsored the bill, said, “This not Medicaid expansion.”

Buttrey says Republicans won important concessions from Democrats to make Montana’s bill more palatable to conservatives. People will have to pay small premiums and the bill also sets up job training and education programs. Buttrey insisted that Montana isn’t just doing the bidding of the White House.

“I’ll say it again, and I hope the media will report this exciting and unique story,” he said.  “This is not Medicaid expansion.”

Montana’s proposal is now on its way to federal officials, who will have the last word on whether it’s legitimate under the Affordable Care Act.

In Alaska, Governor Bill Walker, a former Republican who is independent, has made Medicaid expansion one of his top priorities.

But Republicans leading the state House and Senate blocked expansion during the legislative session that just wrapped up.

One of those opposed is Senator Pete Kelly.

“I think everyone agrees that Medicaid is broken,” he says.  “To put more money into it, to bring more people into it, that’s certainly not going to help its brokenness.”

But surveys show 65 percent of Alaskans favor Medicaid expansion. Supporters testified in large numbers at legislative committee hearings and attended rallies. In one, organized by an interfaith church group, Lutheran pastor Julia Seymour turned the crowd into a choir. She led them in singing, “Medicaid expansion, I’m going to let it shine” to the tune of “This Little Light Of Mine.”

Seymour’s determined to make sure all Alaskans have access to health insurance.

“The Bible tells us that faith, hope and love go on and do not end. And I’m keeping the faith and I am hopeful, but my love for some of the leaders is waning now and then,” she says.

As soon as the regular session ended,  Gov. Walker called lawmakers into special session.

The state is currently facing a massive budget deficit because of the plunge in oil prices. And Walker says even in better financial times, Alaska doesn’t usually decline more than a billion federal dollars.

“If that was a road project or if that was some infrastructure project, we would be all over that,” he says.  “This is healthcare.”

Walker has proposed expanding on his own if lawmakers don’t act but it’s not clear he has this authority. About 40,000 people would qualify for Medicaid if the state expands. About 30 percent of this group are Alaska Natives.

This story is part of a partnership with NPR, Montana Public Radio, Alaska Public Media and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Symphonie Dawson was 23 and studying to be a paralegal while working part-time for a temporary staffing agency when she learned that the reason she kept feeling sick was because she was pregnant.

Living with her mom and two siblings near Dallas, Dawson worried about what to expect during pregnancy and what giving birth would be like, not to mention how to juggle having a baby with being in school.

At a prenatal doctor visit she learned about a group that offers help for first-time mothers-to-be called the Nurse-Family Partnership. A registered nurse named Ashley Bradley began to visit Dawson at home every week to talk with her about her hopes and fears about pregnancy and parenthood.

Bradley helped Dawson sign up for the Women, Infants and Children Program, which provides nutritional assistance to low-income pregnant women and children. They talked about what to expect every month during pregnancy and watched videos about giving birth. After her son, Andrew, was born in December 2013, Bradley helped Dawson figure out how to manage her time so she wouldn’t fall behind IN at school.

Dawson graduated with a bachelor’s degree in early May. She’s looking forward to spending time with Andrew and looking for a paralegal job. She and Andrew’s father recently became engaged.

Meanwhile, Bradley will keep visiting Dawson until Andrew turns two.

“Ashley’s always been such a great help,” Dawson says. “Whenever I have a question like what he should be doing at this age, she has the answers.”

Home visiting programs that help low-income, first-time mothers have a healthy pregnancy and develop parenting and other skills to get and stay self-sufficient have been around for decades. Lately, however, they’re attracting new fans. Home visiting programs appeal to people of all political stripes because the good ones manage to help families improve their lives and reduce government spending at the same time.

In 2010, the health law created the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program and provided $1.5 billion in funding for evidence-based home visiting programs. There are now 17 home visiting models approved by the Department of Health and Human Services, and Congress reauthorized the program in April with $800 million in funds for the next two years.

The Nurse-Family Partnership is one of the largest and best-studied programs. Decades of research into how families fare after participating in it have documented reductions in the use of social programs such as Medicaid and food stamps, reductions in child abuse and neglect, better pregnancy outcomes for mothers and better language development and academic performance by their children, among other things.

“Seeing follow-up studies 15 years out with enduring outcomes, that’s what really gave policymakers comfort,” says Karen Howard, vice president for early childhood policy at First Focus, an advocacy group.

But some experts, while supporting the MIECHV program overall, say that only a handful of the approved models have as strong a track record as that of the Nurse-Family Partnership. They say the standards for what constitutes an evidence-based program are too lenient.

“If the evidence requirement stays as it is, almost any program will be able to qualify,” says Jon Baron, vice president for of evidence-based policy at the Laura and John Arnold Foundation, which supports initiatives that encourage policymakers to make decisions based on data and other reliable evidence. “It threatens to derail the program.”

Nurse-Family Partnership founder David Olds, professor of pediatrics at the University Of Colorado Denver, began testing the model in randomized controlled clinical trials starting in 1977 and continues to conduct long-term follow-up research today.

A study by the Pacific Institute for Research and Evaluation found that the Nurse-Family Partnership reduced Medicaid spending on a first child by 8 percent, resulting in a savings to Medicaid of $12,308 per family served. When adding in cost reductions in food stamps, special education, Child Protective Services and criminal justice costs, total government savings are closer to $19,000 per family, the study found.

However, many of the models approved by HHS do not have a lengthy track record nor strong evidence of having made meaningful changes in mothers’ or their children’s lives, according to Baron.

Although MIECHV programs must show statistically significant effects in order to qualify as evidence-based, those effects need not have any policy or practical importance to qualify, Baron says.

He offered the example of one program that increased the percentage of mothers who brought their babies to the doctor for a one-month checkup, a process measure. But a few years later, further evaluation found no statistically significant effect on child health or safety, no measurable improvement in concrete outcomes.

“We think this is an important program,” Baron says. “I testified for its reauthorization. We just think that as it goes forward the loophole needs to be adjusted.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The politics of the Affordable Care Act in the state of Louisiana are not subtle: It is not popular. The state was part of the lawsuit to strike down the law in 2012; it didn’t expand Medicaid and has no plans to, even as other Republican-led states have done so. And Louisiana didn’t set up its own marketplace to sell Obamacare insurance.

Nevertheless, about 186,000 people in Louisiana signed up for health insurance under the law and almost all of them got help from the federal government to pay their premiums.

The U.S. Supreme Court could soon rule illegal the insurance subsidies in Louisiana and more than 30 other states that use the federal website healthcare.gov. If the subsidies are eliminated, the number of uninsured people in the affected states would rise by 8.2 million in 2016, according to recent Senate testimony by Linda Blumberg, a senior fellow at the Urban Institute.

Jeff Cohen from member station WNPR spent three days driving around his home state of Louisiana speaking with people who got insurance under the law. Here are the stories of three people who say their financial independence is riding on the latest health law case before the Supreme Court.

Sheron Bazille

Sitting at her kitchen table in the Baton Rouge home she owns by herself, Sheron Bazille says she had a good job that offered benefits — like health insurance. But she got sick and had to stop working: “It was either me or my job. And my life and my health was more important.”

Bazille, 62, retired early, and she says leaving that job of 10 years meant losing her insurance – and some of her dignity, too.  Now, under Obamacare, she’s got subsidized insurance. She knows exactly how much her share is: “My monthly is 219. And one cent.”

The coverage has given her a sense of security, because she can take care of her health and her health care bills.

“Peace. I have peace now that I know I have hospitalization [coverage],” says Bazille. “If anything happens, I can go to the hospital.”

She worries the Supreme Court justices could take away that peace and asked what she would tell the justices if she could, she says: “Think about your kids, your family. If they could not afford to pay for health insurance. Wouldn’t you want someone to help them?”

Jimmy See

At a coffee shop in Zachary, half an hour north of Bazille’s home in Baton Rouge, Jimmy See says he never felt like he needed health insurance – until he did. He’s 54, a self-employed housing and maintenance worker, and he’d always felt like health insurance was too expensive. But then he started having trouble breathing and he went to the hospital: “They said, ‘Well do you have any insurance? And I said, ‘No.’”

Rather than pay a lump sum up front, he went home and got worse.  Eventually, he collapsed and had to be hospitalized for close to two weeks for pneumonia. His remembers his bill being between $8,000 and $9,000. See negotiated with the hospital and received financial assistance to settle the bill.

“If I hadn’t gotten that, I’d be looking for bill collectors after me,” See says. “And bill collectors don’t play. They come after you.”

See’s Obamacare subsidy covers all of his premium, and he says having insurance is a relief.

“If I had a big operation or whatever, you can’t afford no $70,000, $80,000, $90,000,” he says. “So, through the Affordable Care Act, the government’s going to help you out with all that.”

If the Supreme Court rules against subsidies, See says, for him it would be, “Back to square one. No insurance.”

James Marks

James Marks lives four hours north of Baton Rouge in Shreveport. He doesn’t want to go back to square one, either.

Marks is 36 and works as a freelance computer technician and an afterschool art teacher. Neither job provides insurance and being uninsured has been a blow to his self-esteem.

“It made me feel lousy,” Marks says. “It made me feel like I was sponging off my parents. It made me feel like I wasn’t able to take care of myself.”

Marks lives with a mental health issue – and, for the better part of 10 years, his parents paid for both his psychiatrist and his expensive medications. Now, he pays about $180 a month for a subsidized insurance policy, and he says it makes him feel like an adult.

Asked what he would tell the justices, Marks says: “I know the Supreme Court tries to decide stuff based on the law and not based on the impact that it has on America.  But it’ll wind up making a lot of people who were insured, who had insurance, who were able to go to the doctor and pay for their pills, not be able to anymore. And that’s just pretty lousy.”

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Free means free.

The Obama administration said Monday that health plans must offer for free at least one of every type of prescription birth control — clarifying regulations that left some insurers misinterpreting the Affordable Care Act’s contraceptive mandate.

“Today’s guidance seeks to eliminate any ambiguity,” the Health and Human Services Department said. “Insurers must cover without cost-sharing at least one form of contraception in each of the methods that the Food and Drug Administration has identified … including the ring, the patch and intrauterine devices.

The ruling comes after reports by the Kaiser Family Foundation and the National Women’s Law Center, an advocacy group, found many insurers were not providing no-cost birth control for all prescription methods. (KHN is an editorially independent project of the Kaiser Family Foundation.)

Gretchen Borchelt, a vice president with the women’s law center, applauded the guidance.

“Insurance companies have been breaking the law and, today, the Obama Administration underscored that it will not tolerate these violations,” she said. “It is now absolutely clear that ‘all’ means ‘all’— ‘all’ unique birth control methods for women must be covered.”

The law requires that preventive services, such as contraception and well-woman visits, be covered without out-of-pocket expenses, such as a co-pay or deductible.

While HHS said insurers must offer for free at least one version of all 18 FDA approved contraceptives, the plans may still charge fees to encourage individuals to use a particular brand or generic. For example, a generic form might be free, while a brand name version of the drug can include cost sharing, HHS said.

The administration Monday said insurers could have misinterpreted prior rules to mean they only had to offer certain types of contraception without cost-sharing. Plans have until July to implement the policy, which will generally not take effect until a new plan year begins. That means for most people the new rule will start in January.

Cecile Richards, president of Planned Parenthood Action Fund, the political arm of Planned Parenthood of America, thanked the administration.

“This is a victory for women and the more than 30,000 Planned Parenthood supporters who spoke out to ensure all women, no matter what insurance they have, can access the full range of birth control methods without a copay or other barriers,” she said. “We know that increased access to birth control has helped bring teen pregnancy rates to a 40-year low and we must continue to drive forward policies that build on this progress.”

The Kaiser study  — which looked at a sample of 20 insurers in five states — found one that simply didn’t cover the birth control ring (NuvaRing) at all and four that “couldn’t ascertain” whether they covered such birth control implants. More commonly, insurers would restrict access to certain contraceptives when they believed a cheaper, equally effective way for patients to get the same treatment was available.

The report by the health law center, which analyzed coverage from 100 insurance companies during 2014 and 2015, found that 15 plans in seven states failed to cover all FDA-approved methods of birth control. Among the companies named as not complying with the law’s requirements in some states are Aetna, Cigna, Physicians Plus and Anthem Blue Cross Blue Shield.

The insurance industry disputes the reports’ conclusions that the problem is widespread. “This report presents a distorted picture of reality,” Karen Ignagni, president and CEO of America’s Health Insurance Plans, the industry’s primary trade group, said when the report came out.

AHIP did not have an immediate comment Monday on the federal guidance.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

NEWPORT BEACH, Calif.— Hoag Memorial Hospital Presbyterian, one of the largest and most respected facilities in Orange County, needed to move quickly.

A big insurer had warned that its maternity costs were too high and it might be cut from the plan’s network. The reason? Too many cesarean sections.

“We were under intense scrutiny,” said Dr. Allyson Brooks, executive medical director of Hoag’s women’s health institute.

The C-section rate at the time, in early 2012, was about 38 percent. That was higher than the state average of 33 percent and above most others in the area, according to the California Maternal Quality Care Collaborative, which seeks to use data to improve birth outcomes.

Within three years, Hoag had lowered its cesarean section rates for all women to just over a third of all births. For low-risk births (first-time moms with single, normal pregnancies), the rate dropped to about a quarter of births. Hoag also increased the percentage of women who had vaginal births after delivering previous children by C-section.

In medicine, this qualifies as a quick turnaround. And the story of how Hoag changed sheds light on what it takes to rapidly improve a hospital’s performance of crucial services, to the benefit of patients, insurers and taxpayers.

Decreasing C-sections results in “better health to mothers and better health to babies and lower costs,” said Stephanie Teleki, senior program officer at the California HealthCare Foundation, which helped fund the data collection and analysis by the California Maternal Quality Care Collaborative. “That’s like a nirvana moment in health care.”

Experts have long been troubled by the wide variation of C-sections among hospitals nationally. (In California, the rates range from 18 percent to 56 percent.)  Certainly there are instances in which C-sections are typically recommended – such as a baby in breech position. But the disparities suggest that decisions are being driven by factors other than medical necessity – such as doctors’ time constraints and malpractice concerns.

Over the past few years, there has been a coordinated push to cut C-section rates in other states and in births covered by Medicaid, the health coverage program for low-income Americans.

Across California, data publicly released by the California HealthCare Foundation, the Pacific Business Group on Health and others in the past few years have underscored the differences in how hospitals handle maternity care. http://www.chcf.org/publications/2014/11/tale-two-births  http://www.pbgh.org/storage/documents/PBGH_C-Section_NTSV_Variation_Report.pdf

Despite the increased transparency, however, many hospitals don’t act until dollars are at stake, said Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative. That’s what happened with Hoag, which Main said is now becoming a model for others.

“In quality improvement, we call it ‘the burning bridge,’” he said. “You can’t just stay still. You’ve got to move.”

Focus on Physicians

At Hoag, where more than 6,000 babies are born each year, Brooks and other administrators knew that they had to focus on changing the mindset and behavior of physicians. “Hospitals don’t do C-sections, doctors do,” she said.

So they took some aggressive steps. First, they shared the data with all the physicians in the department without names — then decided to reveal the names. Suddenly, everyone knew who had exceeded or come in under the average.

“There was a lot of upheaval,” Dr. Jeffrey Illeck, a community OB-GYN and the hospital’s obstetrics department chair. “None of us want to look bad in front of our peers. … And some looked horrible.”

Some physicians reacted with surprise and frustration. Initially, many attributed the high rates to the patients, saying they were older, had more complicated pregnancies or demanded scheduled C-sections.

Dr. Amy VanBlaricom, an OB-GYN who delivers about 25 to 30 babies a month, said she wasn’t opposed to sharing the data. But she said doctors were worried that the rates would be used to penalize them rather than to drive improvement.

“It’s very heated,” she said. “We should use this data as an opportunity rather than a polarizing topic.”

VanBlaricom already tracked her own rates, which she said fell in the middle of the pack, and has only seen a small drop since. But she said being aware that Hoag is monitoring the C-sections has changed how she thinks about her practice and has encouraged her to let women remain in labor longer.

That’s what Hoag administrators were aiming for – a realization among doctors that C-sections should not be undertaken lightly. They carry surgical risks, including serious infection and blood clots, and require longer hospital stays.

“Doctors and patients look at cesareans as an easy way to time the birth,” said Dr. Marlin Mills, chief of perinatology at the hospital. “But a C-section is not benign. It’s a big surgery.”

The costs are also well-documented. Surgical births cost nearly $19,000, compared to about $11,500 for vaginal births, according to the Pacific Business Group on Health, an organization of employers that is also working to bring down C-section rates around the state.

The business group worked with the hospital on the financial side. It enlisted the help of some of the biggest local employers, including Disney, and another insurer, Blue Shield, to adjust payments so the hospital didn’t earn more from elective C-sections than vaginal births.

In addition, the hospital set new scheduling rules. In the past, doctors could simply call in with the woman’s due date and schedule the birth. Now, they would have to fill out a detailed form, with some requests needing special approval.

The hospital also stepped up its patient education, encouraging women to wait for labor to come naturally.  If patients did want an elective C-section, they would have to sign an easy-to-understand consent form in the doctor’s office that detailed the risks.

The nurses received end-of-year bonuses if they helped the hospital reach certain goals on reducing surgical births.

The hospital opened an obstetrics emergency department and gave more responsibility to “laborists,” doctors who were there around the clock to respond to emergencies, monitor women in labor and deliver babies.

Dr. Alex Deyan, who delivered more than 500 babies at the hospital last year, used to turn away patients who wanted vaginal births after cesarean sections. With a busy private practice, Deyan said he couldn’t always be immediately available if labor didn’t go as expected and a woman needed a C-section. That changed with the laborist program.

“Having in-house doctors 24/7 is a huge benefit,” Deyan said. “I can be a little more patient.”

Good for Patients Too

Holly Grim appreciated Hoag’s approach. She knew she didn’t want a C-section with her second baby. Her first labor at another hospital in December 2013 was long and painful and ended with a cesarean section that kept her in the hospital for days. Her son was healthy, but she said, “this wasn’t exactly how I had it planned – not even close.”

This time, she needed to get back on her feet quickly so she could chase after her 16-month-old. She decided to switch doctors and hospitals. And in early April, she got her wish — giving birth naturally to an 8-pound girl, Agnes, at Hoag.

The day after Agnes was born, the family was packing up to go home. She didn’t have any restrictions on lifting or driving, and she wasn’t in severe pain. This, she said, is how childbirth is supposed to be.

“I’m feeling really good,” she said as she nursed Agnes, wrapped in a blanket decorated with pastel footprints. “I’m relieved I’ll be able to run around after my son.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

CLEVELAND — It’s difficult to imagine that a seven-story glass building will soon take the place of what’s now a vast hole near the corner of Carnegie Avenue and 105th Street in Cleveland. But Cliff Kazmierczak, who is with Turner Construction and overseeing the transformation, points to the gray sky, tracing a silhouette with his fingertips. In two years, he says, the Cleveland Clinic’s nearly $300 million cancer center is slated to open here.

“The big thing is to make the patient comfortable with the treatments that they’re going through,” he says of the building’s design. “So lighting, light colors, [and] as much natural light as possible are always very important to cancer patients.”

Kazmierczak came to this project after overseeing construction of the cancer hospital at Ohio State University a few hours south of here. All around the U.S., the health care industry is building up to take care of an expected influx of cancer patients.

Ohio is not alone in this building boom. The Advisory Board Company, a firm that does health care consulting, works with hospitals and doctors. Last year it found that about 25 percent of its members that have oncology departments were either constructing a cancer center, or had built one in the past three years. The Advisory Board’s Deirdre Fuller says people are more likely to get cancer as they get older.

“Now that everyone is looking forward and seeing the aging of the baby boomers,” she says, “it’s certainly adding some fuel to that fire.”

And most boomers will get health insurance through Medicare — which is a steady paycheck for hospitals.

Dr. Brian Bolwell heads the Cleveland Clinic’s cancer institute. He says hospitals have to meet the need.

“In the past five years, volumes go up, depending on location, between 5 and 10 percent a year,” Bolwell says. “And there’s no end in sight to that volume of growth.”

The Cleveland Clinic, along with its local competitor, University Hospitals, treat about 70 percent of the region’s cancer patients. And when the Cleveland Clinic opens its new center, the two will be located within a five minute drive of each other.

Historically, state governments have required hospitals to meet a certificate of need before building a hospital. But beginning in the late 1980s, states across the country began deregulating. Ohio’s certificate of need requirements for hospitals ended in the late 1990s, though it still requires it for long-term care facilities.

Dr. Nathan Levitan, who heads the cancer center at University Hospitals, doesn’t seem worried about the competition. His 4-year-old hospital, he says, is mostly full every day.

“We discharged over 11,000 patients with cancer in 2014,” Levitan says, “which is about a 20 percent increase over just a few years beforehand.”

He says that’s because both hospitals employ and contract with thousands of doctors. And in the world of cancer care, doctors have a lot of influence.

People usually don’t shop for cancer treatment until they are diagnosed, and at that moment their doctor’s advice on where to go matters a lot.

Bill Ryan leads a hospital advocacy group in Cleveland. He says that with so many expected patients, building is good for a hospital’s bottom line and good for patients.

“If you can run enough procedures through a facility, you’re going to get some economies of scale that will generate [a profit] margin,” he says. “The other thing you get when you run enough procedures through a facility, is a level of expertise that improves the quality of care that the individual gets.”

And when talking about the future of cancer care, hospital leaders tend to talk about quality. They insist that focusing on the quality of care will eventually lower the cost to patients, too.

This story is part of a reporting partnership with NPR, WCPN and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Recovering from pneumonia is an unusual experience in the 10-bed intensive care unit at the Carolinas HealthCare System hospital in rural Lincolnton, North Carolina. The small hospital has its regular staff in Lincolnton, but Richard Gilbert, one of the ICU patients, has an extra nurse who is 45 miles away.

That registered nurse, Cassie Gregor, sits in front of six computer screens in an office building. She wears a headset, and her voice is piped into Gilbert’s room via computer speakers.

A doorbell sounds before the camera turns on, alerting Gilbert that the nurse is looking in. They chit-chat as Gregor monitors Gilbert’s vital signs. The nurse asks how he’s feeling and if there’s anything he needs.

Carolinas HealthCare System monitors ICUs in 10 of its hospitals from this command center near Charlotte. The command center is staffed 24-7 with a rotating crew of seven to nine nurses and doctors who specialize in critical care. Everyone on the team also does bedside shifts.

Carolinas HealthCare started this project about two years ago and says it’s good for staff and patients.

For one thing, medical staff at the command center can maintain a constant focus on patients. The command center is quiet — none of the alarms are going off that most ICUs need to alert nurses and doctors down the hall that they’re needed. Dr. Scott Lindblom says it’s a nice change of pace.

The peace, he says, “makes it a much more pleasant environment actually to work in than what we’re used to — the usual chaos of the ICU.”

Nurse Kimberly Purtill agrees.

“We might see a trend up with their white blood cells,” Purtill says, or “a trend up with their temperature, and their blood pressure going down.” All those symptoms might be warning signs of an infection.

“If you were off yesterday as a bedside nurse, and you’re on today, you don’t have the picture from yesterday,” she continues.

But the command center staff has easy access to medical histories and other data on the computer screen, she says, so it’s easy to give the bedside staff a heads up.

Lindblom oversees critical care for Carolinas HealthCare System and says there are clear signs the virtual ICU is working.

“We’re taking care of more patients than we were two years ago,” he says, “and across the system, our mortality rate is dropping … and our length of stay is dropping. It’s almost the perfect storm of good care.”

Among the 10 hospitals in the program, ICU mortality is down 5 percent and length of stay is down 6 percent. Lindblom says virtual care doesn’t get all the credit. He notes the hospitals have also rolled out a program to better manage sepsis, which is a leading cause of death. But Lindblom says that virtual care helps with that program and nearly everything else in the ICU.

Leah Binder is president of The Leapfrog Group, a national advocate for better hospital care. She said the gold standard is to have critical care doctors on-site, not on-camera.

“However, that’s not always possible for every hospital and particularly in rural areas,” Binder says, “so second to that is a virtual environment.”

As technology leads to better care, she says, it could also lead to lower costs.

In the Midwest, Avera Health estimates its virtual ICU has resulted in $70 million worth of savings over the past 10 years. Deanna Larson, who oversees the project for Avera, says that from one hub in South Dakota, Avera monitors patients as far away as Minnesota and Wyoming.

“I think we quit calculating miles a while back,” she says, and laughs. “It’s a very vast area of land.”

Before virtual care, Larson says, complicated cases were often transferred to major medical centers. Now some of those patients can stay closer to home, and that’s good for them, their families, and the town’s economy.

“Keeping 10 or 12 patients more … means another nursing job that stays local,” Larson says, “maybe another lab tech job. What the technology is really doing is keeping those economics closer to home and helping them maintain viability.”

In other words, it may help the hospital in a small community stay open.

In Lincolnton, a town of about 11,000, Dr. Jessica Fox said her ICU has been much busier.

“The unit went from basically having a couple patients, and closing all the time because we were having to transfer so many patients, “to now being almost full all the time because we’re able to keep patients here, ” Fox says.

From his ICU bed, lifelong farmer Richard Gilbert says the more people looking after him, the better.

“That’s sort of like me and farming,” Gilbert says. “If I’ve got a five-man job, and I go out there with two people, [I] might miss something.” But if you have your whole crew working, he says, “you don’t miss anything. You get it done.”

This story is part of NPR’s reporting partnership with WFAE and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Requiring patients to get blood work and other tests before undergoing cataract surgery hasn’t been recommended for more than a dozen years. There’s good reason for that: The eye surgery generally takes less time than watching a rerun of “Marcus Welby, MD” — just 18 minutes, on average. It’s also incredibly safe, with a less than 1 percent risk of major cardiac problems or death.

Yet more than half of Medicare patients received at least one pre-operative test in the month before undergoing surgery to remove cataracts in 2011, a recent study found.

Some doctors were much more likely than others to order a complete blood count, urinalysis, cardiac stress test and the like. Thirty-six percent of ophthalmologists ordered pre-operative tests for more than 75 percent of their patients, according to the study, which was published last month in the New England Journal of Medicine.

“Their patients were no sicker or older,” says Catherine Chen, an anesthesiologist at the University of California, San Francisco, and the lead author of the study. “It suggests that it’s habit or practice patterns.”

The study compared the prevalence and cost of pre-operative testing in the month before 440,857 Medicare beneficiaries had cataract surgery. Testing expenditures for Medicare patients during the 30 days prior to cataract surgery were 42 percent higher than the average monthly Medicare spending for testing on those patients during the previous 11 months, a difference of $4.8 million.

Cataract surgery used to take a few hours and require general anesthesia. In those days, preoperative testing made more sense, says Chen. Now people often receive only a topical anesthetic eye drop to numb the eye or sometimes a local anesthetic that may include a sedative for relaxation.

But research shows that today, pre-operative testing for cataract surgery doesn’t result in fewer adverse events or better surgical outcomes, regardless of a patient’s health, says Chen.

“It’s so low risk it’s almost like saying you’re going to get your nails done,” she says. “There’s always a chance you’ll get hit by a car or have a heart attack on the way,” but it’s unlikely to happen at the nail salon.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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