Veterans are still waiting to see a doctor. Two years ago, vets were waiting a long time for care at Veterans Affairs clinics. At one facility in Phoenix, for example, veterans waited on average 115 days for an appointment. Adding insult to injury, some VA schedulers were told to falsify data to make it looks like the waits weren’t that bad. The whole scandal ended up forcing the resignation of the VA secretary at the time, Eric Shinseki.
Congress and the VA came up with a fix: Veterans Choice, 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.This story is part of a partnership that includes Montana Public Radio, WFAE, NPR and Kaiser Health News. It can be republished for free. (details)
It sounds like a simple idea but it’s not working. Wait times have gotten worse. There are 50,000 more vets waiting at least a month for an appointment than there were at this time last year.
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 Sen. Jon Tester 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.
Hundreds of thousands of bright pink, white or blue tablets and capsules in all colors of the rainbow drop into bottles on sleek conveyors every hour in a sprawling building — somewhere. Each batch of pills may take a month or more to make.
But now, in a lab near Kendall Square, a team of MIT researchers can turn out 1,000 pills in 24 hours in a device the size of your kitchen refrigerator. It’s a whole new way of making drugs.
“We’re giving them an alternative to traditional plants, and we’re reducing the time it takes to manufacture a drug,” said Allan Myerson, professor of chemical engineering at MIT.
The Defense Department is funding this project for use in various places like field hospitals serving troops, jungles to help combat a disease outbreak, and strategic spots throughout the U.S.
“These are portable units so you can put them on the back of a truck and take them anywhere,” Myerson said. “If there was an emergency, you could have these little plants located all over. You just turn them on and you start turning out different pharmaceuticals that are needed.”
Sound simple? It’s not. This mini plant represents a sea of change in both size and operation.
Each tiny pump and chemical reactor in the unit is made or modified to order. “You can’t just go out and buy these components,” said Klavs Jensen, professor of chemical engineering and materials science at MIT, who is working with Myerson and Tim Jamison, chairman of the chemistry department, on the project.
On the operation side, the device produces medications in a flow or continuous process, which is fundamentally different from the way chemistry has been done for a long time.
“For roughly two centuries, to be honest,” Jamison said. “The way that we tend to do chemistry is in flasks and beakers and that sort of thing, and we call that batch chemistry — one batch at a time.”
That’s the way virtually all pharmaceuticals are made. You synthesize big batches of chemicals, wait for them to cool down, synthesize again to create new compounds, wait for the compounds to crystalize, filter and dry. Then you add powders to make a tablet or capsule, steps that can take months.
To shift from the batch to a continuous process, “we had to figure out new ways to make molecules and new ways to think about making molecules,” Jamison said. “But from my perspective that has also provided us with a lot of opportunities that are very powerful.”
The device could increase production of orphan drugs that prevent or treat rare diseases. Some pharmaceutical firms say they can’t afford to develop or make small batches of these medications. And all patients might benefit if these devices wind up in hospitals and pharmacies that then make their own pills as needed.
“If it can be done at a lower cost, well now here’s one way at least that we could reduce the exorbitant cost of medications and that could be a social good as well as an economic good for the people who manage to pull this off,” said James McQuivey, an analyst at Forrester Research, and the author of “Digital Disruption: Unleashing the Next Wave of Innovation.”
The device might make drugs more efficiently than a traditional plant, but most of the cost of an expensive drug is not the materials or manufacturing or transportation, it’s in the drug makers monopoly control, McQuivey said.
“If we can distribute the manufacturing of anything, pharmaceuticals included, so that more people have the opportunity to manufacture it, well, now there will be competition among those manufacturers,” McQuivey continued.
Drug makers have at least two big concerns about the widespread use of this device.
“Intellectual property, that’s first and foremost,” said Dr. Paul Beninger, vice president for pharmacovigilance at Sanofi Genzyme.
Pharmaceutical manufacturers own exclusive rights to produce the drugs they develop for a period of time. His other worry: safety. Who would monitor all of these machines to make sure they are making the medication as directed, with no contamination?
“There are some really significant issues that this MIT project has to deal with if they’re going to try and make this a successful venture,” Beninger said.
Jensen said continuous monitoring could be built into the manufacturing process with data reviewed at a central location.
The FDA’s Emerging Technologies team has already developed new criteria for things like a 3-D-printed pill.
“I’m confident that this FDA innovative program could do the same with this micro-manufacturing technology,” said Lawrence Yu, FDA deputy director of pharmaceutical quality.
On the exclusivity concern, MIT developers are avoiding it for now by producing generic drugs — seven so far, including generic versions of Benadryl, the numbing agent Lidocaine, Valium, Prozac and a common antibiotic. Jensen said pharmacies or hospitals might license the right to produce new drugs using the device in the future.
Myerson, Jamison and Jensen said they expect to seek FDA approval in two years or so for their pharmaceuticals-on-demand unit. By then, it may be even smaller, the size of dorm fridge, and be tuned to produce even more complex drugs.
References to the Affordable Care Act — sometimes called Obamacare — have been a regular feature of the current presidential campaign season.
For months, Republican candidates have pledged to repeal it, while Democrat Hillary Clinton wants to build on it and Democrat Bernie Sanders wants to replace it with a government-funded “Medicare for All” program.
But much of the policy discussion stops there. Yet the nation in the next few years faces many important decisions about health care — most of which have little to do with the controversial federal health law. Here are five issues candidates should be discussing, but largely are not:
1. Out-of-pocket spending: Millions more people — roughly 20 million, at last count — now have health insurance, thanks to the new coverage options created by the ACA. But most people are also paying more of their own medical bills than ever before. And they are noticing. A recent Gallup survey found health costs to be the top financial problem faced by adults in the United States, outpacing low wages and housing costs.
Employers, who still provide coverage to the majority of those with insurance, are also battling rising costs. They have been passing at least part of that along by raising workers’ share of costs — including premiums, deductibles and the portions of medical bills they must pay — far faster than wages have been rising.This KHN story also ran in USA Today. It can be republished for free (details).
Meanwhile, even in the most generous plans offered to those who buy their own coverage through the ACA’s marketplaces, the portion of health care costs borne by consumers has left many unable to afford care.
As insurers have shortened their lists of “in network” doctors and hospitals, another out-of-pocket spending problem is becoming more common: The “surprise medical bill.” Those are bills for services provided outside a patient’s insurance network that the patient did not know was out-of-network when he or she sought care.
Some of the candidates — notably Clinton and Sanders — have talked about the issue. But serious discussion about ways to ensure health care services remain broadly affordable have been overshadowed by the fight over the fate of the federal health law.
2. Drugs — more than prices: Rising drug prices at the pharmacy counter have also proved problematic for patients. And both Republican and Democratic candidates have discussed proposals to address the cost of prescription drugs.
But there is more involved in this issue than the prices paid by patients.
Drugmakers point out their industry is a risky one, and the big rewards on breakthrough drugs offset the losses for those that never make it to the pharmacy. But at what point does the cost to society for a drug, like new treatments for hepatitis C that tally more than $80,000 for a course of treatment, become prohibitive?More On The 2016 Election VIDEO: Sounds Like A Good Idea? Selling Insurance Across State Lines
Meanwhile, scientists are rapidly approaching the point of being able to develop specific drugs for specific individuals, a trend known as “personalized medicine” or “precision medicine.” But even if everyone could be screened so that they would only get the expensive drugs that will help them specifically, how could those costs be spread over society as a whole?
And how fast should promising drugs be brought to market? Some decry the lengthy testing required for Food and Drug Administration approval. They say people are dying who could potentially be helped. But others are equally concerned that putting a drug on the market too soon poses risks to the public.
It’s not cheap. The annual cost of these services can range from approximately $46,000 for a home health aide to $80,000 or more for a bed in a nursing home.
Yet Medicare, the health program for the elderly and some disabled, does not pay for most long-term care services. Medicare has both nursing home and home care benefits, but they are temporary and limited to those with specific medical needs. Most people who need long-term care don’t need special medical interventions, just help with “activities of daily living.”
By contrast, Medicaid, the joint state-federal health program for people with low incomes, paid just over half of the nation’s estimated $310 billion tab for long-term care in 2013, the most recent year for which this information is available. But you either have to be very poor, or spend nearly all of your savings, in order to qualify.
Private insurance for long-term care exists, but it is expensive, and remains uncommon — paying for just 8 percent of the 2013 bill. And private insurance for long-term care has been getting more difficult to purchase as insurers pull back from the products because of rising costs as people, especially women, live longer.
4. Medicare: Speaking of seniors, Medicare, which provides health insurance to an estimated 55 million people — 46 million older than age 65 and another 9 million with disabilities, is also in a financial bind.
Medicare accounts for 14 percent of all federal spending, and that is expected to grow rapidly as those boomers reach their highest health-spending years. The program already accounts for one of every five dollars spent on health care in the U.S.
Interestingly, Medicare spending has slowed dramatically in recent years. That has prompted a lively debate among health policy experts: How much is the slowdown due to the deep recession that caused spending to fall in all sectors of the economy, and how much to other factors that could continue even with stronger economic growth?
The Obama administration contends that changing the way Medicare pays health care providers, as begun in the ACA, has helped put the program on more sustainable footing.
But even smaller changes can kick up big political pushback from those who rely on Medicare for their livelihoods. A recent Obama administration proposal to change the way the program pays for expensive drugs administered in doctors’ offices or clinics has brought cries of complaint from both Democrats and Republicans.
5. Dental care: In 2007, a Maryland 12-year-old named Deamonte Driver died from a tooth infection that spread to his brain. That cast a harsh spotlight on the difficulty low-income Americans — even those with insurance through the Medicaid program — have getting dental care.
Yet research has shown repeatedly that care for the mouth and teeth is inextricably linked to the rest of the body. Oral problems have been linked to conditions as diverse as heart disease, diabetes and Alzheimer’s disease.
Lack of dental care is particularly significant for children. Dental problems are common in youngsters, and in addition to discomfort, lead to school absences and poorer academic performance.
Findings like that are one reason the federal health law made pediatric dental care an “essential benefit” for most insurance plans. But for complicated reasons, including the fact that dental insurance has traditionally been sold separately from other health coverage, many children insured under the law are not getting dental coverage.
Coverage for adults remains spotty as well. According to the Centers for Disease Control and Prevention, one in every three adults has untreated tooth decay. More than 100 million Americans do not have dental insurance, the government reports. And more than a third (38 percent) of adults aged 18-64 reported no dental visits in 2014.
It’s midafternoon and I’m fighting to keep my eyes open. It’s a matter of life and death. That’s because I’m northbound on I-93, going 65 miles an hour — with many cars passing me.
Once or twice on the monotonous two-hour drive, a jolt of adrenaline surges through my bloodstream as I suddenly realize I’ve actually drifted off for a micromoment. Thankfully I get home without killing myself or anybody else.
If you say you haven’t had the same experience behind the wheel, I don’t believe you.
The National Highway Transportation Safety Administration (NHTSA) says there were more than 72,000 documented accidents involving drowsy drivers between 2009 and 2013. But that’s just from official police reports, so experts say it’s a gross under-estimate.
After all, there’s no sleep-a-lyzer test for drowsiness like the blood alcohol-level test for drunk drivers. And it’s harder for a cop to spot a drowsy driver than one distracted by a smart phone.
“Twenty to twenty-five percent of all crashes could be fatigue-related — drowsy drivers,” says Dr. Mark Rosekind, the NHTSA administrator. “We could be looking at over a million crashes and potentially up to 8,000 lives lost.”
Rosekind made those remarks during a webcast this week sponsored by the Harvard T. H. Chan School of Public Health and The Huffington Post. The discussion included HuffPost editor-in-chief Arianna Huffington, Harvard sleep expert Charles Czeisler, and Jay Winsten, associate dean for health communication at the Harvard Chan School.
The forum is part of a national campaign against drowsy driving that’s just getting underway.
The idea is to treat drowsy driving as the public health issue that many believe it is and to bring to the campaign the same strategies that stigmatized drunk driving. Winsten master-minded that effort 28 years ago when he coined the term “designated driver” and nagged movie and TV producers to insinuate it into their scripts.
I moderated the online discussion. Here are some highlights:
The Brain Split
Czeisler, who’s the head of the division of sleep and circadian disorders at Brigham and Women’s Hospital, says the sleep-deprived brain can split itself in two. One part goes through the motions of a “highly over-learned task” such as driving. Meanwhile, cognitive centers involuntarily transition from wakefulness to sleep.
“So it’s particularly concerning that 56 million Americans a month admit that they drive when they haven’t gotten enough sleep and they’re exhausted,” Czeisler says. “Eight million of them lose the struggle to stay awake and actually admit to falling asleep at the wheel every month.”
My powerful mid-afternoon drowsiness was typical. “It used to be thought that [drowsiness-related crashes] only happened at night, but that’s because people weren’t looking,” Czeisler says. “Most sleep-deficient driving incidents happen during the daytime because there are so many more drivers on the road.”
And there’s a physiological factor. Mid-afternoon is before the brain’s internal clock “has given us a second wind to help us stay awake in the evening,” he says.
Who Falls Asleep Most?
Three groups are particularly vulnerable to falling asleep at the wheel, Czeisler says: young people, night-shift workers, and the millions of people who suffer from sleep apnea.
“Young people think that because they’re young, they’re fit, they can do anything,” the Harvard sleep researcher says. “But actually, young people are the most vulnerable. More than half of fatigue-related accidents are in people under 25 years of age.”
It’s not because – or not just because – they’re out carousing. There’s a biological reason. As we age, the brain’s “sleep switch” – the cluster of neurons in the hypothalamus that governs the transition from wakefulness to sleep – gets sluggish. That’s why many older people have trouble falling asleep. But young people’s brains have an efficient sleep switch that can “seize control” and cause involuntary sleep in the face of sleep deprivation.
“When we keep an 18-year-old awake all night and compare that to keeping a 70-year-old awake all night, the 18-year-old will have 10 times as many involuntary lapses in attention,” Czeisler says.
Many studies show that the nation’s nearly 10 million night-shift workers, who have disrupted sleep patterns and often suffer from sleep deprivation, are much more likely to crash their cars – especially on their way home after a shift. The Harvard researchers had night-shift workers drive on a test track at the time they’d be commuting home and found nearly 40 percent of them had a near-crash event.
Sleep apnea — pauses in breathing that disrupt deep sleep, often many times a night – afflict one in three men and one in six women. The vast majority don’t know they have it.
Czeisler’s group recently found that truck drivers with sleep apnea are 400 percent more likely to have a serious, preventable crash.
Driverless Cars: A Fix?
One powerful argument for driverless cars is they’ll prevent crashes, especially by drowsy or distracted drivers.
Of course, they’ll have to be perfected first. Then lawmakers and regulators will have to decide whether to allow them on the road. And the public will have to be convinced they’re safe. There are sure to be bumps along that road.
Rosekind, the NHTSA chief, says we can’t wait.
“If you had the perfect self-driving car tomorrow … it takes 20 to 30 years for new technology to fully penetrate our vehicle fleet,” he says. “So you can’t have this tomorrow.”
But technology already exists that could make a big difference. My new Subaru (not a top-of-the-line model) senses traffic flow and keeps me three car lengths behind the next vehicle. It brakes when needed in case I don’t. And it sounds an alarm if I stray outside my lane. (Of course, I still have to stay awake and alert.)
Rosekind says NHTSA has just finalized an agreement with 20 car manufacturers that promises 99 percent of all new vehicles will have automatic braking by 2022. Toyota tells the government its cars will have automatic braking by 2017.
Like ‘Coming To Work Drunk’
Our panelists — admittedly a missionary group — were unanimous in urging immediate action to minimize drowsy driving, not remote technofixes. And that requires changing cultural attitudes about sleep.
Case in point: During a recent NPR interview, Sen. Jon Tester, of Montana, mentioned he’d gotten only two hours of sleep the night before. “That’s plenty,” he told Morning Edition host David Greene. “Sleep is totally overrated.”
That sends Arianna Huffington up the wall. “We have a lot of examples of … bragging about sleep deprivation and congratulating employees for working 24/7,” she says. “It’s the cognitive equivalent of coming to work drunk. And you wouldn’t tell someone, ‘Hey … great, you’ve just had five shots and now you’re at work! Good for you!’ But it’s the same thing.”
But Huffington perceives change. She says business leaders are beginning to recognize the importance of adequate sleep. For instance, the global consulting firm McKinsey & Company, recently published a widely read paper on “The Organizational Cost of Insufficient Sleep.” Aetna, the nation’s third-largest health insurer, is paying employees a bonus if their company-provided Fit Bit shows they’re getting enough sleep.
What To Do Now
The panelists had a wide range of strategies to reduce drowsy driving, such as:
–Require education about drowsy driving on licensure tests, as only two states (New Jersey and Arizona) do now.
–Screen truck drivers and other professional (e.g., bus drivers, train engineers, airline pilots) for sleep apnea and, if positive, require them to comply with treatment.
–Change laws to reflect new scientific consensus that driving with less than two hours of sleep in the previous 24 hours constitutes negligence.
–Incorporate rumble strips on highways to warn drivers who stray out-of-lane.
–Make it OK to take naps.
On that last point, Rosekind notes there’s solid evidence that naps work. When he was at NASA, he did a study that showed a 26-minute nap boosted pilots’ performance by 34 percent and alertness by 54 percent. “A nap is one of the most powerful strategies you can have to boost your performance,” he says.
And what about caffeine? “If you use caffeine correctly – not all the time, but strategically – you can get over a 30 percent boost,” Rosekind says. But don’t rely on super-caffeinated energy drinks to substitute for sleep.
“You can’t paper over this problem with caffeine,” Czeisler says. “The problem is it pushes people to be even more sleep-deprived, and it also interferes with the restorative value of sleep once they do get to sleep because caffeine has a six- to nine-hour half-life.”Related:
Delve lets you easily find your co-workers and learn more about what they're working on. Skype for Business helps you connect and collaborate with other people in real time using instant messaging, audio and video conferencing, and screen sharing. SharePoint Online and OneDrive allow several people to simultaneously edit a single file.
This week at CBPP, we focused on health care, family income support, housing, food assistance, state budgets and taxes, and the economy.
The 20th anniversary of Temporary Assistance for Needy Families (TANF) this year is an opportune time to improve the program, but the four bills the House Ways and Means Committee passed this week don’t address TANF’s key weaknesses.
The National Archives is just a short walk down Capitol Hill and across the National Mall from the Library of Congress. Currently, if you live in Washington, D.C. or are visiting, there is a very interesting exhibit titled Amending America.
Each time I visit the National Archives I learn more about the great institution and new projects they are working on. The Innovation Hub, for example, provides a space for the public to scan and transcribe documents. Since my work here at the Library of Congress involves legislative materials, I enjoy browsing the records of the Center for Legislative Archives. If you are new to researching their collection, they have a helpful Getting Started With Your Research page.
If you happen to be a Member of Congress (thank you for reading In Custodia Legis), they have a page with services specifically for you.
Conservative health care proposals commonly allow insurers to offer health plans to people or small businesses in other states, even if the plans don’t comply with the other states’ requirements — and the health proposal that House GOP are crafting may do the same. Selling health insurance “across state lines,” supporters say, would reduce premiums and give consumers substantially more options. The handful of states that tried to open their markets to out-of-state insurers before health reform, however, had little to show for it.