Hawes, 55, is from Charlotte, N.C. She ended up going without insurance for a few years, but in 2015 she bought coverage on HealthCare.gov, the Affordable Care Act marketplace, with the help of a big subsidy.

“I was born with heart trouble and I also had, in 2003, open-heart surgery,” she said. “I had breast-cancer surgery. I have a lot of medical conditions, so I needed insurance badly.”

After the results of the 2016 election, she was scared she’d lose her insurance immediately. For years, Republicans have vowed to scrap the health care law. The new Congress is working on a plan to undo the Affordable Care Act. But they have not settled on how to replace the health care structure that Obamacare created.

Hawes is one of North Carolinians who relies on the Obamacare marketplace for health insurance. She was relieved after she talked with an enrollment specialist last month who told her she can renew her policy for 2017.

Some Republican leaders have said repeal should happen immediately with a transition period to come up with a replacement. Still, the CEO of HealthCare.gov, Kevin Counihan, said he can’t guarantee coverage will remain. “It’s not my place to promise anything about a new administration,” he said.

“But what I can tell you is not only are we moving forward, but our enrollment is higher than expected.” At the end of 2016, enrollment for 2017 plans spiked and as of the end of December, North Carolina had the for 2017 plans among states using HealthCare.gov.

r with Legal Services of Southern Piedmont is helping people sign up. She said about a third of them have asked about the election.

“But generally when we’re calling, people are really excited to have their appointment and come in and look at the plans for 2017,” she said. “I think they’re mostly interested in how much they’re going to be paying.”

In some ways, North Carolina is in tough shape. Premiums are going up and insurance companies have dropped out, leaving as the only insurer in 95 percent of the state.

Blue Cross actuary said it’s simply an expensive market that has older, sicker people who cost more to cover.

“There is continuing demand for services and continuing high utilization within this block of business,” he said.

What he calls “this block of business” means the customers who buy insurance on the exchange. It’s a small slice of the overall health insurance market, because most people are covered through work or Medicare. The overwhelming majority of consumers who buy coverage on the exchange get federal subsidies that .

Still, it’s been a turbulent market for consumers and insurers. Over the past two years, Blue Cross has lost $400 million in North Carolina on that part of its business.

Amid the post-election uncertainty, Tajlili said Blue Cross is committed to offering plans in 2017.

“2017 will be another pivotal year for us as we look at the individual market,” he said.

Federal researchers have said that North Carolina’s decision not to expand Medicaid in its ACA marketplace, and the new Democratic governor of the state, Roy Cooper, n in recent days.

One of Blue Cross’ new customers will be Sara Kelly Jones, 46, who works at Letty’s restaurant in Charlotte, N.C. She recognizes Obamacare isn’t perfect. But before the law, health insurance was a financial vise that kept tightening on her.

“I could not afford it at all,” she said. “Every year it was going up $100 to $120, $150 a month. It got to the point where it was going to be at least $200 more a month than my mortgage.”

But under Obamacare, Jones qualifies for a subsidy. Her premium will go up with Blue Cross, but she said she can afford it with that help.

Jones said the political debate over the law ignores people like her.

“I’m terrified,” she said. She’s worried about the Republican Congress’ pledge to scrap and replace Obamacare without presenting a detailed proposal.  “What on Earth are you going to do with all these people, myself included, that are counting on this?”

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“This is the numbing medicine, so you’re going to feel me touch you here,” she said, taking the teen’s arm. “Little stick, one, two three, ouch. And then a little bit of burn.”

Hamm works at the Gaston County Teen Wellness Center, in Gastonia, N.C., which provides counseling, education and medical care. The teenager had already talked through her birth control options with another health care provider and chosen the implant — a flexible rod, about the size of a matchstick, that slowly releases low levels of hormones to prevent pregnancy.

“You’re going to feel tons of pressure here,” Hamm says, using a small device to insert the implant. “That’s it!”

And, in terms of preventing pregnancy, that will be it for the teen for the next several years.

Long-acting reversible contraception methods — including and intrauterine devices, or — are safe forms of birth control, and 99 say specialists in reproductive medicine.They are by the American Academy of Pediatrics and the American Congress of Obstetricians and Gynecologists as a good line of defense against teen pregnancy.

“Some of the other developed countries that we look at are in the high teens, maybe low 20s in terms of percentage of use,” she said.

Kavanaugh said better provider training and patient education should lead to higher usage of the long-term devices in the United States.

That’s exactly what is happening in Gaston County, N.C., where clinics have seen usage rates climb to nearly 30 percent among teens. Since 2009, all providers in Gaston County clinics have been trained to insert the devices. The county uses federal funding to help cover the cost for the uninsured, which can be roughly $1,000 for an IUD.

Colorado is also of long-acting, reversible contraceptive methods, said Jody Camp of Colorado’s public health department, and has seen higher usage and subsequent drops in teen pregnancy and abortion.

“While we are not claiming full responsibility for all the decreases in these public health indicators, we do believe that our LARC investment made a huge impact on those,” Camp said.

Recently, the federal Department of Health and Human Services has started  to make the methods more accessible through Medicaid, government insurance that covers many low-income women. The government is asking doctors to talk to their patients about long-acting reversible contraception and allowing higher reimbursement rates for the devices.

By using effective contraception to space out their children, teens and other young women can help reduce the risk of delivering a premature or low-birth-weight baby, research shows. And preventing unplanned pregnancies can be “essential to a woman’s long-term physical and emotional well-being,” according to HHS.

There are versions of the implants that can be left in place to prevent pregnancy for five or 10 years at a stretch. But women can also choose to get them removed whenever they want, and restore their fertility. Kie’Ja Phillips is from Gastonia and 19-years-old. She had the three-year implant in her arm before heading to college last year.

“I do not want to have children until I’m done getting my education,” she said. “I want to be able to provide for my children and give them a stable household — financially and emotionally and physically.”

Phillips also teaches her friends and other teens about their options. She says a lot of them know about the contraceptive pill, but very few about IUDs or implants.

“They have a lot of misconceptions and myths about it,” she said. “Like, ‘how am I supposed to get it out?’ You go to a doctor to get it out. You don’t take it out yourself. It’s just things like that — common misconceptions that people have.”

Last year, nearly 30 percent of teens who got contraception at the Gaston County clinics chose the long-acting kind.

Gaston County Medical Director says the increased use of long-term contraception is a key reason the county’s teen pregnancy rate has been dropping faster than the state as a whole. Gaston County has also largely erased the disparity between African-Americans and whites in teen pregnancy rates.

“We feel very strongly that this is making a huge impact here,” Dr. Taormina said.

Medicaid in the state next-door — South Carolina — has also seen an increase in the use of these long-acting reversible contraceptives. In 2012, the state implemented a new way of paying hospitals so medical providers could offer and insert long-acting reversible contraception , which the nation’s leading obstetrician’s group says can be a “particularly favorable time.”

Staff with the Palmetto Health-University of South Carolina School of Medicine in Columbia demonstrated the procedure to health care providers recently in its , which is basically a truck outfitted, for training purposes, with two hospital rooms and high-tech mannequins that can simulate a variety of birth outcomes. Palmetto Health drives the coach around the state to teach hospital staff about a variety of procedures and topics, including contraception.

“The IUD is inserted 10 minutes after delivery of the placenta when a patient has had a vaginal delivery,” Dr. Judy Burgis said.

is director of the , a project within the state’s department of health and human services. Giese says the choice to have an IUD or implant inserted is always completely up to the woman, and only after she’s consulted with a health care provider. But the reason obstetricians within her program started offering it immediately after birth is simple: About half of women on Medicaid who gave birth weren’t showing up to their postpartum visit.

“We were missing a lot of moms who did not come back,” Giese says. “And, actually, the next time the doctor saw them, they came back pregnant with another child.”

Ana Walker, an 18-year-old in Columbia, S.C., chose to have an implant that lasts three years inserted in her arm. Walker got the implant after giving birth to her daughter Bella. She said she likes that she won’t have to remember to take a pill every day.

“Right when I heard about it, I went for it,” she says.

Breanna Martin, who is 20 and also lives in Columbia, recently chose an IUD after she had her baby. Martin said the device puts her in control of her fertility.

“That’s the wonderful thing about it,” she said. “If I want to wait five years, I’m protected for five years. And if I want to have kids sooner, then I can get it taken out.”

Giese calls getting the device after childbirth a win-win for the baby and the mom. “It is a cost savings,” she said. “It is a convenience for the mom. The satisfaction rate of the moms that we know leaving the hospital is extremely high.”

Now, she says, at some hospitals in South Carolina, around a third of new mothers leave with an IUD or implant in place. That number, Giese says, was basically zero just a few years back.

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Infection from Naegleria fowleri is extremely rare but almost always fatal. Between 1962 and 2015, there were only due to the organism, according to the Centers for Disease Control and Prevention. Just three people survived. This summer, two young people, one in Florida and one in North Carolina, became infected after water recreation. Only one had a happy ending.

DeLeon is a 16-year-old camp counselor. The Florida Department of Health thinks he got the infection while swimming in unsanitary water on private property in South Florida before his family came to visit Orlando’s theme parks.

So many things had to go right for DeLeon to survive. On a Friday, he had a bad headache. The next day, his parents decided this was way more than just a migraine and took him to the emergency room at Florida Hospital for Children.

Profounda CEO Todd MacLaughlin got the call from the pharmacy, but he was out of town so his son drove the drug to Florida Hospital.

“Within 12 minutes he had picked up the product and was on the way to the hospital,” MacLaughlin said. “Everybody was in the right place at the right time.”

DeLeon was given the drug along with others. Doctors put him into a coma and lowered his body temperature to give the drugs time to work and slow the infection.

Dr. Humberto Liriano was emotional talking about the experience. They knew the odds were not in DeLeon’s favor when he was placed into a coma.

“The family when they came to me, immediately within four hours, I had to tell them to say their goodbyes,” Liriano said. “I had to tell them, ‘Tell him everything you want to tell your child, because I don’t know from the time I put him to sleep to the time I take the tube out, [if he will] wake up.’ ”

DeLeon’s mother, Brunilda Gonzalez, thanked doctors at a press conference.

“We are so thankful that God has given us the miracle through this medical team and this hospital for having our son back and having him full of life,” Gonzalez said. “He’s a very energetic, adventurous, wonderful teen. We’re so thankful for the gift of life.”

Central Florida has coped with amoeba infections before, including the death of Jordan Smelski, who died at the same hospital where DeLeon was saved. Smelski’s parents started to raise awareness of the disease in the medical community and to advocate for hospitals to stock the drug in case of an infection.

Profounda says seven hospitals have taken it up on stocking the drug at no cost, charging them only when the drug is used. The drug costs $48,000 for a full round of treatment. MacLaughlin said the company will provide the drug free if someone doesn’t have insurance.

DeLeon will soon head to South Florida for rehab, and doctors are optimistic he’ll make a full recovery.

But in North Carolina, an 18-year-old Ohio woman died from the amoeba in mid-June, stoking fear in the community. She had been rafting at the U.S. National Whitewater Center in Charlotte, which is among a handful of facilities in the country that have man-made rapids coursing through concrete channels. Its CEO, Jeff Wise, pointed out the lower part of the channel in mid-July.

“This is the bottom pond,” he said, “where all of the water in our essentially 12 million-gallon system rests while it’s ready to be pumped back up into the top pond, where it’ll float back down through the channels.”

But there was no whitewater between late June and Aug. 10, because CDC tests found the amoeba after the woman died.

Mecklenburg County Health Director Dr. Marcus Plescia encouraged people to keep perspective.

“This organism, Naegleria fowleri, is actually quite a prevalent or commonly occurring organism in open bodies of water,” he said. “We find it in lakes. We find it in ponds. It’s very common for people to come into contact with, but it’s very uncommon for people to develop this kind of infection with it.”

It’s harmless if swallowed, because stomach acid kills it. But if it’s in water forced up the nose, it can cause the brain infection, which is difficult to diagnose and treat.

The Whitewater Center uses city water that it treats with UV radiation, a filtration system and some chlorine. Still, it’s a large, open body of water, and exists in a regulatory no-man’s land because it’s neither swimming pool nor local river or lake.

North Carolina Gov. Pat McCrory said the state should reexamine whether the center should be treated like a swimming pool. But testing for the amoeba is not part of swimming pool regulations, because chlorine used in pools is effective at killing it. And the county and the state don’t have the ability to test for it. It’s usually up to the CDC.

As part of its lease agreement with the county, the center does weekly tests for common contaminants such as fecal coliform bacteria.

County health leaders point out that people are much more likely to die from drowning or boating accidents in area lakes and rivers than they are from Naegleria fowleri. In fact, there have already been at least eight of those deaths in the greater Charlotte area this summer.

But people just don’t get as worked up about those. , a risk management consultant in Concord, Mass., explains why.

“We worry about things not only based on the likelihood of them happening but the nature of the experience itself,” Ropeik said. “The odds may be low of brain-eating amoeba eating your brain, but the nature of a brain-eating amoeba eating your brain sounds pretty scary, doesn’t it?”

Ropeik is the author of “How Risky Is It, Really?” He says the media coverage of rare risks is part of the problem.

“Anything that makes a risk feel scarier like, ‘This is the zombie amoeba!’ is going to subconsciously interest journalists as something that will get people’s attention,” he said. “Because the viewer, reader, listener is likely to pay attention to a story that could portend their death.”

Dr. Jennifer Cope, an infectious disease epidemiologist at the CDC, said 11 out of 11 tests for the amoeba were positive at the rafting center, which does sound alarming. She called that significant but noted this is the first time the CDC has encountered the amoeba in this type of setting.

Whitewater Center CEO Wise says roughly 1.5 million people have rafted there over the past decade, and this is the first health issue it has had tied to what’s in the water.

The CDC says there are ways to make the water less conducive to the amoeba’s growth, including bulking up the amount of chlorine. The Whitewater Center worked with consultants to figure out a more effective way of doing that, and it reopened this month with a revamped chlorination system. So far, county health leaders say it is working the way it is supposed to.

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“It takes her two hours to get here,” said Katherine Wilkin, a University of North Carolina at Charlotte master’s student, translating for Becerril. “She takes two buses, so coming here, she’s definitely devoted to getting this treatment. She comes every time.”

Wilkin is also Becerril’s mental health counselor, and Becerril says Wilkin has helped her deal with depression.

“With therapy, she’s gotten able to organize her thoughts and feelings, and she feels better, not frustrated, less stress,” Wilkin said.

Becerril initially came to this free clinic for diabetes treatment. Director Wendy Pascual said primary care is often the starting point for patients here, most of whom are immigrants.

He and Pascual set up a partnership last year, and now about eight students provide treatment. They’re unpaid — it’s part of their training. Some speak Spanish, some use an interpreter.

Gutierrez said they see a variety of issues.

“The big three we keep finding are depression, high levels of anxiety and then high levels of trauma,” he said. “At one point, about 85 percent of the folks were experiencing some level of some of that.”

That’s of everyone coming to the clinic for any kind of health care.

Its focus on the immigrant community means treating many people who are uninsured and often here illegally.

“Latinos, although they’re experiencing a lot of these mental health concerns, they are among the least likely to be able to get services,” he said.

Universities in many parts of the country are recognizing that reality. Virginia Commonwealth University, the University of Georgia and the University of Denver all have similar partnerships.

Texas has several, including between that state’s flagship university and .

“The need is enormous,” said Kathleen Casey of the Austin-based partnership.

“We know that there’s great health disparities, lots of stigma overall and other types of cultural barriers that make it incumbent upon us to do our very best for outreach and engagement to that population,” Casey said.

Latino counselors say the stigma around mental health can be particularly strong in that community. There’s also the language barrier. And the actual border crossing can be traumatic, especially for those who cross illegally.

, a clinical supervisor for practicum students at the Pacific University Psychology Clinic, said some immigrants she treats suffer from post-traumatic stress disorder.

“There are stories of sexual assaults and rapes that happen during border crossings,” she said. “And then there’s more cumulative experiences of growing up in poverty or dealing with drug cartels or gangs or some people have difficult experiences in their country of origin.”

Pacific, based in Oregon, has around 20 master’s and Ph.D. students providing counseling at any given time. Even with that, she said Latinos face waiting lists for treatment.

Back in Charlotte, people lined up outside Bethesda in the rain recently. It was the one day a week Ana Farrera signs up new patients.

“The thing is that rain must have scared them away today,” she said, “because … last week we had 10 people, so I had to turn five away.”

Farrera said there have been some mornings when 20 people line up before she opens the door. They’re mostly waiting for primary care, but Farrera said many will get referred to the UNC Charlotte students for counseling.

Clinic leaders say the students are making a big difference at the clinic. Student Katherine Wilkin said it works the other way, too.

“For me it’s been good,” Wilkin said, because the experience has exposed her to more than “just the easiest client I can think of that we read about in textbooks,” Wilkin said. She feels “very comfortable building up from this.”

So do UNC Charlotte professors. The university plans to scale up the partnership with Bethesda.

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Congress and the VA came up with a fix: , a $10 billion program. Veterans received a card that was supposed to allow them to see a non-VA doctor if they were either more than 40 miles away from a VA facility or they were going to have to wait longer than 30 days for a VA provider to see them.

The problem was, Congress gave them only 90 days to set up the system. Facing that deadline, the VA turned to two private companies to administer the program — helping veterans get an appointment with a doctor and then working with the VA to pay that doctor.

The VA claims there has been a massive increase in demand for care, but the problem has more to do with the way Veterans Choice was set up. It is confusing and complicated. Vets don’t understand it, doctors don’t understand it and even VA administrators admit they can’t always figure it out.

Veterans Face Delays And Worry

This is playing out in a big way in Montana. That state has more veterans per capita than any state besides Alaska. This winter Montana sent his staff to meet with veterans across the state. Bobby Wilson showed up to a meeting in Superior. He’s a Navy vet who served in Vietnam and is trying to get his hearing aids fixed. Wilson is mired in bureaucracy.

“The VA can’t do it in seven months, eight months? Something’s wrong,” he said. “Three hours on the phone,” trying to make an appointment. “Not waiting,” he said, “talking for three hours trying to get this thing set up for my new hearing aids.”

Tony Lapinski, a former aircraft mechanic, has also spent his time on the phone, with Health Net, one of the two contractors the VA selected to help Veterans Choice patients.

“You guys all know the Health Net piano?” he said. “They haven’t changed the damn elevator music in over a year!” That elicits knowing chuckles from the audience. Later during an interview, he said when he gets through to a person, “They are the nicest boiler room telemarketers you have ever spoken to. But that doesn’t get your medical procedure taken care of.”

Lapinski has an undiagnosed spinal growth and he’s worried. “Some days I wake up and go, ‘Am I wasting time, when I could be on chemotherapy or getting a surgery?’ ” he said. “Or six months from now when I still haven’t gotten it looked at and I start having weird symptoms and they say, ‘Boy, that’s cancer! If you had come in here six months ago, we probably could have done something for ya, but it’s too late now!’ ”

Lapinski finally got to a neurosurgeon, but he didn’t exactly feel like his Choice card was carte blanche. Doctors, it turns out, are waiting, too — for payment, he said.

“You get your procedure done, and you find out that two months later the people haven’t been paid. They have got $10 billion that they have to spend, and they are stiffing doctors for 90 days, 180 days, maybe a year!” said Lapinski. “No wonder I can’t get anyone to take me seriously on this program.”

He said he gets it. He used to do part-time work fixing cars, and he would still take jobs from people who had taken more than 90 days to pay him or bounced a check. But he did so reluctantly.

“I had a list of slow-pay customers,” he said. “I might work for them again, but everybody else came before them. So why would it be any different with these health care professionals?”

Hospitals, clinics and doctors across the country have complained about not getting paid, or only paid very slowly. Some have just stopped taking Veterans Choice patients altogether, and Montana’s largest health care network, Billings Clinic, doesn’t accept any VA Choice patients.

Not cool, said Montana Sen. Jon Tester, of Health Net and other contractors.

“The payment to the providers is just laziness,” Tester said. “I’m telling you, it’s just flat laziness. These folks turn in their bills, and if they’re not paid in a timely manner, that’s a business model that’ll cause you to go broke pretty quick.”

The VA now admits the rushed timeframe led to decisions that resulted in a nightmare for some patients.

Health Net declined to be interviewed for this story. But in a statement, the company said that VA has recently made some beneficial changes that are helping streamline Veterans Choice. For example, the VA no longer demands a patient’s medical records be returned to VA before they pay.

Meanwhile, though, veterans continue to wait. “If I knew half of what I knew now back then when I was just a kid, I would’ve never went in the military,” said Bobby Wilson. “I see how they treat their veterans when they come home.”

Scheduling Lags Also Irk The Doctors’ Offices And The VA

And there’s another whole side to the coin. Doctors are frustrated in dealing with another government health care bureaucracy.

In Gastonia, North Carolina, Kelly Coward dials yet another veteran with bad news.

“I’m just calling to let you know that I still have not received your authorization for Health Net federal. As soon as I get it, I will give you a call and let you know that we have it and we can go over some surgery dates,” she told a veteran.

Coward works at Carolina Orthopaedic & Sports Medicine Center, a practice that sees about 200 veterans. Dealing with Health Net has become a consuming part of her job.

“I have to fax and re-fax, and call and re-call. And they tell us that they don’t receive the notes. And that’s just every day. And I’m not the only one here that deals with it,” she said.

Carolina Orthopaedic’s business operations manager, Toscha Willis, is used to administrative headaches — that’s part of the deal with health care — but she’s never seen something like this.

She said it takes, “multiple phone calls, multiple re-faxing of documentation, being on hold one to two hours at a time to be told we don’t have anything on file. But the last time we called about it they had it, but it was in review. You know, that’s the frustration.”

It can take three to four months just to line up an office visit.

The delays have become a frustration within the VA, too. Tymalyn James is a nurse care manager at the VA clinic in Wilmington, North Carolina. She said Choice has made the original problem worse. When she and her colleagues are swamped and refer someone outside the VA, it’s supposed to help the veteran get care more quickly. But James said the opposite is happening.

“The fact is that people are waiting months and months, and it’s like a, we call it the black hole,” she said. “As long as the Choice program has gone on, we’ve had progressively longer and longer wait times for Choice to provide the service, and we’ve had progressively less and less follow through on the Choice end with what was supposed to be their managing of the steps.”

The follow-through is lacking in two ways. The first is the lengthy delay in approving care. And after that’s finally resolved, there’s a long delay in getting paid for the care.

At least 30 doctors’ offices across North Carolina are dealing with payment problems, some that have lasted more than a year.

Carolina Orthopaedic’s CEO Chad Ghorley said his practice is getting paid after it provides the care. It’s the lengthy delay on the front end that burdens his staff and, he worries, puts veterans at risk. He’s a veteran himself.

“The federal government has put the Band-Aid on it when there’s such a public outcry to how the veterans are taking care of, all right?” he said. “Well, they’ve got the Band-Aid on it to get the national media off their backs. But the wound is still open, the wound is still there.”

Those experiences for both veterans and providers are typical. Congress is now working on a solution to the original solution, a bill is expected to clear Congress by the end of the month.

This story is part of a partnership that includes , , NPR’s Back at Base project and Kaiser Health News.

CORRECTION: A previous version of this story misstated how many veterans were waiting at least a month for an appointment this year. The 70,000 figure applies to the number of appointments in which it took vets at least a month to be seen. The story has been corrected to reflect this difference.

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How do these firms do it? With “bundled payments,” a way of paying that’s gaining steam across the health care industry, and that Medicare is now for hip and knee replacements in 67 metropolitan areas, including New York, Miami and Denver.

Here’s how it works: Lowe’s and other employers pay one flat rate for a particular procedure from any of a number of hospitals they’ve selected for quality, even if they are a plane ride away. And, under the agreement, the hospital handles all the treatment within a certain time frame — the surgery, the physical therapy and any complications that arise — all for that one price.

It was , senior vice president for compensation and benefits at Lowe’s, who came up with the idea in 2010. When he told managers at other companies about it, he said, “The first question was always, ‘Oh, this is just for executives, right?’ And I said no, absolutely not, this is for any Lowe’s employee in the Lowe’s health care plans.”

The program is optional for employees. They can still use their local surgeon, if they prefer, and pay out-of-pocket whatever their insurance doesn’t cover. But more than 700 Lowe’s employees have taken the company up on its offer, Ihrie said.

It’s a great deal for patients, he said, and for his company.

“We were able to get a bundled price, which actually enables us to save money on every single operation,” Ihrie says.

“We’re seeing savings at the front end,” she said, because Lowe’s pays less for the surgery. And, because the hospital is responsible for all that care, the institution has a strong incentive to be careful and thorough, Ross added.

That means “huge savings on the back end,” she said, “from things like reduced re-admissions, reduced return to the O.R. and lower rates of blood clots. Those are hugely expensive, preventable complications.”

Lowe’s comes out ahead, even after paying for the patient’s travel, Ihrie confirmed.

Participating hospitals win, too, by attracting more patients, said Trisha Frick, who handles such negotiations on behalf of in Baltimore.

“It’s new business for us,” Frick said. “And, for the most part, the reimbursement is acceptable; we believe that we can provide that, within that amount of money.”

Medicare, the health insurance program for people 65 and older, started using bundled rates for hip and knee replacements this month. Medicare had some early evidence from pilot programs that “the model works well,” according to , a health care consultant with The Advisory Board Company.

“Medicare is saving something like $4,000 on orthopedic cases,” he said.

Medicare’s deal is somewhat different than Lowe’s. Patients may pay something out of pocket, depending on the type of Medicare policy that insures them. And while the few hospitals selected in Lowe’s program can bank on increasing their revenue and the number of surgeries they’ll get, the rates established by Medicare’s bundled payment system hold for every hospital in a participating area.

“Entire markets are selected for participating,” Lazerow explains. “If you’re in the San Francisco market or you’re in the New York market, all of the hospitals are actually participating in the program.”

But there are similarities, too, and Medicare may learn some lessons from Lowe’s experience. Lowe’s initially had trouble wrangling all a patient’s medical records from local doctors. And the company found that patients who had questions weeks or months after an operation sometimes had trouble following up with the out-of-town doctor who had performed the surgery.

“You have some setbacks, and things happen, and you just have questions,” Ihrie said. “So what we give every patient now is a little card with the doctor’s name and direct phone line and the nurse’s name and direct phone line. And all of a sudden, things were a lot better.”

Another lesson was startling, Ross said. In addition to cutting the cost of procedures, another chunk of savings to the companies came from avoiding surgeries that probably shouldn’t happen in the first place.

“We’re seeing up to 30 percent — close to 30 percent of cases — who should not be moving forward with the joint replacement,” Ross said.

What typically happens in these cases, she said, is that employees get a recommendation from a local doctor that they should have surgery, only to have physicians at the selected hospitals deem the operation inappropriate.

In some cases that may be because the employee hadn’t first tried less invasive treatments, such as physical therapy, Ross said. Or the employee may need to lose weight first, to make the surgery safer.

Ihrie said what heartens him most about his company’s program is that Lowe’s employees are now taking a more active role in decisions about their care.

“What treatment you receive is not always very black and white,” he said. “The mere fact that people now think about what they’re doing helps us control costs across the board.”

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And yet, sign-ups in North Carolina are on pace to be substantially higher than the two previous years. Roughly 95,000 more North Carolinians selected a plan during the first two months of this enrollment period compared with the last one. Across the country, only two states using the federal exchange saw more sign-ups over the same period: Florida and Texas.

Sue Martin, who’s from the small town of Mebane, North Carolina, about two hours northeast of Charlotte, said, “I hate to sound hyperbolic, but it’s kind of a matter of life and death.” Her experience is a case study of how the health law is playing out in the state and how individuals have navigated surging premiums.

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“Nothing I’ve done really translates over [to civilian jobs] beyond basic EMT,” said Manning, who served 15 years in the Navy and five more in the Army. “Trying to find something in the medical field without any credentials, without any licensure is tough. There’s nothing out there.”

Manning is in the inaugural class of a  launched this month by the University of North Carolina at Chapel Hill and geared at recruiting non-traditional students — specifically, veterans, as the country seeks to improve health care by expanding the number of primary care providers. UNC staff worked with Army officials at  to figure out how to translate troops’ medical experience into jobs.

Manning’s story is becoming more common as the U.S. winds down wars in Iraq and Afghanistan, and it’s especially important for North Carolina which is home to eight military bases, including some of the country’s largest installations. Manning has experience that can’t be found in a classroom, and some in the UNC medical community wanted to capitalize on that.

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Since the announcement last month, , a nutrition professor at UNC-Chapel Hill, says he’s heard from a lot of colleagues wondering, “What the heck is going on at UNC?” The clinic in question is actually about 25 miles away, in Raleigh — home to North Carolina State University.

“For them to name it this way — to give advertisement to a very unhealthy food, high in added sugar and unhealthy fats and refined carbs with no nutritional value — was quite surprising to people around the nation,” Popkin says.

“The corporation is definitely not part of the name,” she says. “It’s named for a race! The name of the doughnut happens to be in the name of the race. But at the heart of it, it’s about the race and about these kids.”

°Õ³ó±ðÌý is an annual, 5-mile charity race that student volunteers at NC State University created about a decade ago, initially just for fun, and then to raise money for the hospital. The event, always held in February, has grown in size over the years, and now includes about 8,000 runners.

Chris Cooper, a junior in chemical engineering and economics at NC State, is the current executive director of logistics for the race, which does involve eating doughnuts.

“You run 2.5 miles, starting at the NC State Belltower,” Cooper explains, “and then the challengers eat a dozen doughnuts,” which they pick up mid-way, at stations set up in front of the local Krispy Kreme shop.

But most of the runners raise money without scarfing down fried sweets.

“The casual runners normally just pick their doughnuts up and keep running,” Cooper says. “And then you run 2.5 miles back to the Belltower.” The students got permission from the pastry company to use the Krispy Kreme name — but they pay for the doughnuts.

If all that pastry pounding and distance running sounds kind of sickening, well, Cooper says it can be.

“After Krispy Kreme, when people are running back, there is normally a fair amount of throw-up that happens,” he says. “We have a group of students whose job is to go around and clean up the streets.”

Gross, sure. But the race has raised nearly $1 million for UNC Children’s Hospital and clinics so far, and the student leaders have committed to raising another $1 million.

“Behind all of this is a group that’s committed to making a difference for our patients and families,” says Nelson.

UNC Health Care is now having conversations about whether to go through with the name change, Nelson says. An online petition to scrap it has gathered about 13,000 signatures so far.

, a public health professor at New York University, and former adviser in nutrition policy for the federal government, says public fallout from awkward pairings of corporate brands with health causes has been increasing.

She points to Coca-Cola’s corporate  with the American Academy of Family Physicians as another high-profile example.

“There was a big demonstration in front of a California hospital a few years ago,” Nestle says, “in which physicians burned their membership cards to the academy in protest.”

Last summer, the physician’s group and the soft drink company announced they’re  their deal.

Nestle says that’s certainly not apples to apples with what’s happening at the UNC clinic. But she does think putting Krispy Kreme in the clinic’s name — for whatever reason — sets a bad example for kids.

Race coordinator Chris Cooper says if UNC decides to back off the name change, he’s OK with that.

“I don’t think anyone in the organization was really excited about us having a name on the clinic,” he says. “I think a lot more of it was, ‘How are we going to use this name to help the children’s hospital even more?'”

But, if it isn’t helpful in drawing more people to the race and in raising more money for the good cause, Cooper says, then he has no attachment to the name.

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For many of the Republicans who control the state legislature, the reason for the change is simple: budget predictability.

“For years and years and years, Medicaid has been considered the budget Pac-Man that eats up all the dollars that people in this chamber would like to see spent on many, many other things,” Rep. Bert Jones said during the North Carolina House’s debate of the bill last month. Gov. Pat McCrory signed the overhaul into law on Sept. 23.

The state, which has not expanded Medicaid under the health law, struggled with huge Medicaid cost overruns from 2010 through 2013. That sent lawmakers looking for a better way to manage it, even though a signature part of the program has won national awards for quality and cost.

The lawmakers settled into two camps: One camp wanted to use a managed care model, which basically means paying large insurance companies a specific amount per person covered and relying on the companies to contain costs.

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