Value-Based Care and Behavioral Health Treatment

For value-based care to provide truly holistic, coordinated care to patients, it must incorporate behavioral health treatment. This can result in improving the quality of health care for your employees, especially those with chronic medical conditions. Despite the benefits of integrating behavioral health treatment into value-based care, physical and behavioral medicine too often remain siloed in our health care systems — even under value-based care arrangements.

The Need for Inclusive Treatment

Comprehensive primary care has begun to seek ways to integrate behavioral health treatment to improve outcomes and cost-effectiveness. Behavioral health conditions frequently co-occur with chronic diseases, but these symptoms may be overlooked. Depression symptoms, for example, may be masked by other medical conditions. Patients with diabetes often receive mental health education along with diabetes education, since anxiety and depression are frequently associated with this diagnosis. If left untreated or overlooked, people with behavioral health issues can end up in the ER or experience increased physical complications.

Many mental health conditions can affect a person’s overall quality of life, including their ability to maintain employment. And a behavioral health diagnosis can still carry a stigma. Your employees may be uncomfortable with or even unaware of their need for mental health treatment. This may be why 74% of patients go to their primary care doctor first to seek help for depression, according to Mental Health America. But primary care physicians may not be able to address mental health issues due to time constraints, limited knowledge or discomfort discussing behavioral health, and a diagnosis of depression is missed 50% of the time in the primary care setting. Warning signs may go unnoticed or be mistaken for a normal response when a patient is struggling with a serious health condition.

Value-Based Care and Behavioral Health Challenges

Value-based care encourages provider collaboration; taking advantage of this momentum to incorporate behavioral health providers within patients’ provider networks could improve the overall quality of care. A multidisciplinary solution may help determine whether anxiety and depression could be contributing to pain, for example, or help the patient prepare for their procedure and recovery. A behavioral health evaluation may even determine that a different treatment is more appropriate.

The 2017 Centers for Medicare and Medicaid Services Medicare Physician Fee Scale added codes supporting the integration of behavioral health care. But incorporating behavioral health care in value-based care can be difficult. Value-based care focuses on measuring outcomes and quality through the evaluation of standardized data, and the implementation of standardized data and opportunities for cost savings are not as well-established for behavioral health as they are for other medical conditions. Behavioral health professionals may not have access to these tools, or they may utilize different sets of data that make it difficult to share data between providers. If the impact of mental health and its outcomes on chronic conditions are better recognized, it may reduce the separation of mental health treatment from overall care.

Working Toward Changes to Behavioral Health Care

Comprehensive primary care has begun to address behavioral health issues. Some providers will evaluate for mental health and substance use disorders or psychological symptoms, including screening for depression with the Patient Health Questionnaire (PHQ-9). This integration is beneficial, although appropriate mental health care often requires the expertise of behavioral health professionals who aren’t always part of the primary care network.

The coordination of care with behavioral health professionals can assist with directing treatment and improving outcomes. The psychiatric Collaborative Care Model has begun to demonstrate how more effective care integration can help control costs and increase patient satisfaction.

Integrating behavioral health into value-based care may be beneficial for providing more holistic care for your employees. This process has faced some challenges, but ongoing changes in implementing behavioral health treatment are improving the quality of health care.

When it comes to small business health insurance plans , it’s important to do your homework. They could be a good option for certain businesses and self-employed individuals, but be sure to consider both the plans’ advantages and disadvantages before making a decision.

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Are Your Employees Underinsured?

Just because someone has health insurance doesn’t guarantee that they can handle all their medical expenses. In fact, roughly 28 percent of workers with employer-sponsored coverage are underinsured and inadequately protected against health care costs.

Here’s a closer look at this issue and advice for how to assist your employees.

What Does It Mean to Be Underinsured?

Underinsurance is when someone has a health insurance plan but the out-of-pocket costs are high relative to their income. This means that if they need medical care, the deductibles, copays and other fees would be difficult — or impossible — to cover. Underinsured employees could go into medical debt or spend down their savings to pay their out-of-pocket share for their care. Worse, they may even skip necessary treatments because they’re worried about the bill.

How can your employees tell if they face underinsurance? The Commonwealth Fund put together a ballpark calculation to measure the risk. For the survey, a lower-income family was in this category if they spend more than 5 percent of their annual income on health care; higher-income families were included if they spend more than 10 percent.

Take, for example, an employee earning $60,000 a year who has a $7,000 deductible on their health insurance plan. They could be in trouble — the deductible is more than 10 percent of their income. If that employee ever needed serious medical care, the out-of-pocket costs could be difficult to manage.

5 Tips for Becoming Adequately Protected

Your employees need a plan to avoid these financial issues. Here’s are five ways you can help.

1. Train employees. Go over the concept of underinsurance and use the calculation above to show when an employee might be at risk. Point out the dangers of underinsurance as well: 52 percent of people who are underinsured end up in financial trouble with medical bills, according to the Commonwealth Fund. This is also a good time to review your own small business health insurance with employees and discuss how they can save money on their health care costs by only seeing in-network providers, using generic medications whenever possible and calling the free nursing hotline first before going to the doctor or hospital.
2. Explain the relationship between premiums and deductibles. If you offer multiple health insurance plans and group health plan, explain why automatically picking the one with the lowest monthly premium might not always be the most affordable option in the long run. Chances are, that plan will have a higher deductible and other out-of-pocket expenses. Employees may end up paying more by the year’s end with this type of coverage, especially if it puts them in the underinsurance range. They could be safer by paying a higher premium in exchange for fewer out-of-pocket costs, especially if they already have some medical conditions that require frequent care. While you should stop short of giving employees advice during open enrollment, you can help them understand the potential consequences of choosing different options by guiding them to the right questions to ask about each plan.
3. Offer an HDHP with an HSA. A high-deductible health plan (HDHP) is one where the deductible is at least $1,350 for an individual and $2,700 for a family plan. When a plan’s deductible is this high, it could put enrolled employees in the risky range. Luckily, they have options to protect themselves — employees with an HDHP are eligible to also open a health savings account (HSA). With these accounts, employees can save money from their paychecks and receive a tax deduction for their contributions. They can invest that money over time, and when they spend it on health care, the withdrawals are also tax free. These tax breaks may motivate your employees to put money aside so they have extra cash to manage the any potential costs that would normally put them in debt.
4. Offer critical illness coverage. Critical illness plans are another way your employees can prepare for the high cost of medical care. These policies are not standalone health insurance, and they don’t directly pay any medical bills. Instead, if an employee develops one of the covered conditions, like cancer, a stroke or a heart attack, the policy will pay them a lump sum amount, which could mean an amount like $50,000 drops into their hands at just the right moment. The employee can use this both for their out-of-pocket expenses and to cover their other bills while they’re recovering and out of work. Related plans include accident insurance and hospital indemnity insurance.
5. Encourage emergency funds. Vanguard notes that the typical person should have at least three to six months of living expenses saved in an emergency fund. Encourage employees to work toward this goal. If employees pick a plan with a lower premium but higher out-of-pocket costs, suggest that they put their premium savings in the bank. That way they’ll have extra cash on hand in case they do run into unexpectedly high medical bills.

Don’t wait until your employees meet financial trouble by being underinsured. Teach them these concepts and give them tips for saving now and you’ll be doing your part to keep them healthy.

How to Help Retirees Manage Health Care

A 65-year-old couple retiring this year will need $280,000 to cover their health care costs in retirement — and that number doesn’t include the cost of over-the-counter medicine, dental services or long-term care. This means that a good health care plan is an essential part of retirement financial planning.

Worries about medical emergencies and the costs that come with treating them can take a toll on employees who are nearing retirement age. But whether or not they have the budget to offer full retirement benefits, employers can help alleviate those fears. Here’s what you need to know.

Is It Worth Investing in Retirement?

If you can afford to offer health care retirement benefits to your employees, it can be a worthwhile investment. Stress is a productivity killer, and without having to take on the emotional burden of financial worries as they near retirement, your staff will have fewer distractions from their work. Plus, you shouldn’t underestimate the value of the loyalty good retirement benefits can bring you. A retirement package could help you attract and retain talent, even if you can’t meet the same salary that bigger businesses are offering.

Of course, not every organization can offer full retirement benefits. There’s no doubt they can be expensive, and they can be twice as costly if people retire before the age of 65. It’s understandable that some employers avoid offering them altogether. But even if you can’t offer full retirement benefits, you have other opportunities to help your employees with retirement.

5 Resources That Can Help Employees Plan for Retirement

Here are five resources that can help your employees as they consider how to approach health care in their retirement years.

• COBRA. If employees want to stay on your health care plan after they retire, they might be able to continue using their employee health benefits through the Consolidated Omnibus Budget Reconciliation Act. This option can be expensive for the employee, and it only lasts for a limited time, but it’s a good temporary solution for employees who are about to retire and still want full coverage.
• Medicare Advantage. Employees can purchase Medicare Advantage plans directly from private insurance carriers. The plans cover everything Medicare does, plus extra benefits like dental work, glasses, hearing aids and gym memberships, depending on the specific plan. Medicare Advantage plans will soon include more options, according to the New York Times, including health-related adult day care programs, home aides and home safety devices. As an employer, you can contact the Centers for Medicare and Medicaid Services or a private insurance carrier to offer a group Medicare Advantage plan through your business.
• Long-term or in-home care insurance. Discounted long-term or in-home care insurance can be a huge help to retired employees. However, employees might not think about purchasing health care for retirees until they actually need long-term or in-home care. That’s a big mistake — the average age for purchasing this insurance is 57. Older employees may face higher premiums or need to get a smaller plan that fills in some gaps but has a lower daily benefit.
• HSAs or HRAs. Health savings accounts (HSAs) provide a way for employees to save funds for medical expenses after they retire. You can offer HSAs with certain high-deductible health care plans, and you or your employees can put away a total of up to $3,450 pretax a year into an individual HSA — plus an additional $1,000 if the employee’s over 55. Balances accrue from year to year, and the money taken out is tax-free if used for qualified medical expenses. Another option is a health reimbursement account (HRA). These accounts are funded solely by the employer, with funds covering qualified medical expenses once employees have retired and meet other requirements.
• Supplemental gap plans. These plans are secondary to Medicare, only kicking in after Medicare covers its share of medical costs. Much less expensive than a full health care plan, supplemental gap plans are a more approachable way for you to help out with retirement health care.

Just because you can’t offer all of your employees full retirement benefits doesn’t mean you can’t make their retirement financial planning easier. Offering help with medical costs through one of these five tools could make all the difference — a difference your staff will know who to thank for.

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In California, a ‘Surprise’ Billing Law Is Protecting Patients and Angering Doctors

The state’s closely watched law is similar to an approach Congress is considering nationally.

Three years ago, California passed one of the strongest laws in the country to outlaw surprise medical billing. That legislation made sure that when patients went to a hospital covered by their insurance, doctors couldn’t later ambush them with unexpected bills.

Now lawmakers who want to ban surprise bills nationally are gravitating toward a California-style approach, making the California experience a key exhibit in the debate.

“Every single office I’d go into, I would start talking about our experience in California,” said Anthony Wright, executive director of the California patient advocate group Health Access, who spent part of this summer lobbying members of Congress on the issue. “And they would stop me and say, yeah, you’re the fifth person who has come in to talk to us about that.”

The parties who have watched California’s performance disagree, sometimes vehemently, on whether the prospect is rosy or grim. Doctor groups, particularly those representing specialties like anesthesia and emergency medicine, argue that a national version of a law like California’s would disrupt medical care so much that patients would have difficulty finding a doctor.

But two new reports — an analysis of state data and a study of insurer claims — found no such warning signs in the state. Those studies, both published this week, suggest the bill has more or less worked as planned.

California’s surprise billing law limited the payments for out-of-network doctors to a formula based on what other doctors were being paid. Bipartisan bills passed by committees in both the U.S. House and Senate this summer use a roughly similar approach, often described as benchmarking.

The legislation, which has yet to advance to the floor of either the House or the Senate, has enemies. One dramatic television advertisement, run by a dark money group called Doctor Patient Unity, shows an ambulance pull up to an abandoned emergency room, warning that benchmarking could mean closed hospitals. The group, which is funded by two large private equity-backed physician staffing firms, has spent more than $28 million to oppose the bills.

A letter to Congress from the California Medical Association described the California law as “failing,” and provided four pages of examples of insurance companies dropping doctors from their networks or demanding substantial payment cuts. “The California law is reducing access for patients to in-network physicians and jeopardizing access to on-call physician specialists needed in medical emergencies,” the letter says.

But new data from California state regulators and other sources suggest that the situation isn’t as dire as the doctors’ groups describe. Since the California law took effect in 2017, there has been little evidence that patients’ access to health care has suffered.

In other words: Some doctors may be hurting from a pay cut, but that doesn’t seem to be hurting patients.

“It is possible that there are cases where they are receiving less money for in-network and out-of-network services,” said Erin Duffy, an adjunct policy researcher at the RAND Corporation who has studied California’s surprise billing law. “They may be experiencing marginal losses and, while loss aversion is real, I don’t think providers are going to be exiting the practice of medicine over this.”

A new analysis, from researchers at the U.S.C.-Brookings Schaeffer Initiative for Health Policy, examined a large sample of insurance claims data from the company FAIR Health to see whether the law had caused insurers to drop doctors from their networks. In contrast with the claims from the California Medical Association, that study found the opposite had occurred: Compared with the period before the law was enacted, the percentage of anesthesiologists, pathologists, assistant surgeons, radiologists and neonatologists whose work was covered by insurance increased by an average of 17 percent. The research team included Ms. Duffy.

A study published by the insurance industry last month in the American Journal of Managed Care also found that the number of California doctors in their networks had increased, not declined, since the law kicked in.

Consumer complaints to the state’s Department of Managed Health Care have been largely flat. A report ordered by the state legislature found that between zero and 20 percent of patients who were treated at an in-network hospital were still receiving out-of-network care, depending on the insurer. Those numbers, which could not be compared with previous rates, were published in March to little fanfare. Only a tiny fraction of doctors have used an appeals process to dispute their benchmark payments. Those state indicators were highlighted in a new white paper from Health Access published Thursday.

“We have not seen evidence indicating negative impacts for consumers’ access to care as a result of this new law,” said Rachel Arrezola, a spokeswoman for the department, in an email.

The California Medical Association noted that the state agency hadn’t examined the full universe of health plans that might have been affected by the law. Around 10 percent of health plans in the state are regulated by a different agency.

There is less data about what doctors are being paid under the new system. The letter from the California Medical Association provides examples of insurers that are demanding rate cuts as high as 40 percent. Blue Shield of California, one of the state’s largest insurers, told Senate staff in a letter that its payment rates had increased since the law went into effect, even as the number of doctors in their network increased. But its experience may not be universal. The Congressional Budget Office estimates that the average affected doctor could end up making between 15 percent and 20 percent less if the bill before the Senate becomes law.

A recent survey from the Kaiser Family Foundation found that 78 percent of adults favor a solution to surprise medical bills. When told this could reduce doctors’ pay, 57 percent still support the idea.

Michael Champeau, the president of the Associated Anesthesiologists Medical Group in Palo Alto, said he was the first physician to try out California’s appeals process. After the law passed, it prompted his practice to try to sign contracts with all the nearby insurance companies, most of which obliged, offering similar prices. Blue Shield, he said, was the exception. “We made several calls to their contracting officer,” he said. “No one ever returned our phone calls. They just refused to acknowledge we existed.”

Matthew Yi, a spokesman for Blue Shield, said the company did respond to Dr. Champeau’s company in the summer of 2016, with a request for materials to begin a contract negotiation. He said the practice did not reply for several months, and then only to update its address.

After his practice treated Blue Cross patients at Stanford Hospital, Dr. Champeau received an automatic payment 35 percent lower than what the other insurers pay him, he said. After a long process, he lost the appeal. “Why on earth would they want to contract with me for the average going rate in my area when they knew they were going to be able to pay me 35 percent less?” he said.

Dr. Champeau, who is now the treasurer for the American Society of Anesthesiologists, has been to Washington and discussed his experience with Anna Eshoo, the chairwoman of the Energy and Commerce Health Subcommittee, and with Speaker Nancy Pelosi.

Ms. Duffy, the RAND researcher, said this was a common refrain from the doctors she interviewed for her study, who lamented that the new law meant they had less leverage in contract negotiations.

“They said the tenor of the conversation had changed,” she said. “It had been made clear to them they were in a weak position. And that was very upsetting to them.”

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For Older Patients, an ‘Afterworld’ of Hospital Care

Long-term care hospitals tend to the sickest of patients, often near the end of their lives. Many will never return home.

The Hospital for Special Care in New Britain, Conn., had 10 patients in its close observation unit on a recent afternoon. Visitors could hear the steady ping of pulse monitors and the hum of ventilators.

The hospital carefully designed these curtained cubicles to include windows, so that patients can distinguish day from night. It also placed soothing artwork — ocean scenes and landscapes — on the ceilings for those who can’t turn over and look outside.

All these patients had undergone a tracheostomy — a surgical opening in the windpipe to accommodate a breathing tube attached to a ventilator — when they arrived from a standard acute-care hospital. Some had since been weaned from the ventilators, at least for part of the day.

The facility is called an L.T.C.H., a long-term care hospital (also known as a long-term acute care hospital). It’s where patients often land when an ordinary hospital is ready to discharge them, often after a stay in intensive care.

But these patients are still too sick to go home, too sick even for most nursing homes.

“It’s truly a hidden segment, even to most people in health care,” said Dr. Anil Makam, a hospitalist and researcher at the University of California, San Francisco.

Take the man in his 60s slowly making his way down the hallway, supported by a large wheeled apparatus that had also lifted him out of bed. Two physical therapists and two aides accompanied him.

He had been in the nonprofit Hospital for Special Care for about a month, on top of 30 days in a standard hospital, trying to recover from a brain hemorrhage and spinal cord injuries after a fall down the stairs in his home.

He had finally come off the ventilator the week before, although he might need it again. “Setbacks are very common,” said Dr. John Votto, a pulmonologist and former chief executive of the hospital, watching the patient’s progress.

In one cubicle lay a woman with severe emphysema who had endured six hospitalizations in five months. “She’s off the vent, but she’s very tenuous, in and out, in and out,” Dr. Votto said. She hadn’t been home since January.

Close to 400 such hospitals operate around the country, some free-standing, others located within other hospitals, most for-profit. They provide daily physician visits, high nurse-to-patient ratios and intensive therapy.

In 2017, they accounted for about 174,000 hospital stays. Medicare covered about two-thirds of them, at a staggering cost of $4.5 billion, the Medicare Payment Advisory Commission has reported.

Yet the odds look dismal for older adults who enter an L.T.C.H., Dr. Makam and his colleagues reported in a recent study in the Journal of the American Geriatrics Society.

Sampling 5 percent of Medicare data, they identified more than 14,000 patients who had been transferred to such hospitals and tracked them for five years, from 2009 through 2013. Most had not needed mechanical ventilation.

Only 45 percent of Medicare patients were alive a year after admission, the study found; fewer than 1 in 5 survived for five years.

The researchers defined “recovery” as logging 60 consecutive days without entering a hospital or nursing home — “a pretty low bar,” Dr. Makam said. But over five years, more than half of Medicare patients in an L.T.C.H. never reached it.

Moreover, “true recovery rates — getting back to thinking clearly and functioning well — may be lower,” Dr. Makam said.

In fact, despite the prevalence of aggressive, life-prolonging procedures like feeding tubes, ventilators and dialysis, L.T.C.H. patients spent two-thirds of their remaining lives (the median survival period was 8.3 months) in institutions, including hospitals, skilled nursing homes and rehab facilities.

“A little over a third of people never make it home,” Dr. Makam said. “They go back and forth between the L.T.C.H. and hospitals and nursing facilities, and they die in one of them.”

Younger patients in their 60s and those admitted with musculoskeletal diagnoses, like complications from a hip fracture or joint replacement, fared better. But 41 percent of this population was 80 or older, and “the older old do exceptionally poorly,” Dr. Makam said.

A few years back, Dr. Daniela Lamas, a critical care specialist at Brigham and Women’s Hospital in Boston, found herself wondering about what she calls “this afterworld,” one she knew little about.

At an L.T.C.H., she interviewed 50 patients, with an average age of 63, who had undergone tracheostomies, or family surrogates (when patients couldn’t communicate), asking not-very-medical questions about goals, fears and understandings.

Patients described their quality of life as poor, complaining of hunger, thirst, difficulty communicating. “People were bored,” Dr. Lamas said. “They couldn’t move. There was a deeper sense of being alone, feeling trapped.” Their families felt anxious and stressed.

Most patients expressed optimism about returning to their former lives, and hadn’t talked with their L.T.C.H. doctors about what would happen if they encountered setbacks.

But when discharged, only 20 percent went home; most moved to nursing homes or returned to acute-care hospitals. Just 38 percent were at home after a year; 30 percent had died.

“When we put people through things with a goal that’s not achievable, that allows people to suffer without a purpose,” Dr. Lamas said. “There are ways to allow people to keep their hopes but also face reality.”

Once, the L.T.C.H. was among the fastest-growing sectors of the health care industry. Their numbers jumped from 97 hospitals in 1992 to 388 in 2005, “a period of explosive growth spurred by overpayment and inappropriate admissions,” the advisory commission said.

Medicare responded with moratoriums on new facilities and stricter patient criteria for reimbursement. The growth of Medicare Advantage plans, less likely to reimburse for L.T.C.H. care, has also hurt revenues.

As a result, more of these hospitals have shut down than opened in recent years, and the National Association of Long Term Hospitals expects further closings.

Such hospitals cluster in certain states, particularly Texas, Louisiana and Ohio, while other states have none (Maine, New Hampshire, Vermont) or few (New York State has one). That distribution, which largely reflects whether state regulators insist that hospital developers demonstrate the need for new facilities, also affects how likely patients are to enter them.

Now, stricter patient criteria mean that patients in an L.T.C.H. will be sicker still. “They may have even poorer prognoses than the sample we looked at,” Dr. Makam pointed out.

All of which should prompt frank discussions among families, doctors and patients about whether a frail older person leaving an intensive care unit or standard hospital truly wants to spend another month or more in an L.T.C.H. and then move to a nursing home, which is the likely scenario.

“Some people may change directions and choose hospice care instead,” Dr. Makam said. But compared to patients in the general Medicare population, far fewer L.T.C.H. patients enroll in hospice, although many would qualify as terminally ill.

“It’s easy for this move to be like a train you get on until it stops,” Dr. Lamas said of L.T.C.H. stays. “But the doors can open at any point.”

She urged patients and families to arrange for periodic re-evaluations. “At four weeks or eight weeks, where do we hope we are? We can reassess.”

Dr. Votto, also chief medical officer of the industry association, endorsed that idea. “You’re at a level of illness where there’s not a lot of good outcomes, no matter what,” he said.

But, he added, “Most people don’t look at the percentages. They say, ‘Maybe I’ll be one of the 20 percent’” who leave an L.T.C.H. and go home.

Get insured yourself and your whole family by exploring the group health insurance and save yourself from the hospital bills. if you want to know more then please contact us in the comment section.

Is America’s Health Care System a Fixer-Upper or a Teardown?

To understand the competing Democratic health care plans, consider an elaborate home construction metaphor.

Imagine the United States health care system as a sort of weird old house. There are various wings, added at different points in history, featuring different architectural styles.

Maybe you pass through a wardrobe and there’s a surprise bedroom on the other side, if not Narnia. Some parts are really run down. In some places, the roof is leaking or there are some other minor structural flaws. It’s also too small for everyone to live in. But even if architecturally incoherent and a bit leaky, it still works. No one would rather be homeless than live in the house.

In Democratic politics, there is agreement that the old house isn’t good enough, but disagreement about just how possible — or affordable — fixing it will be. The biggest fault line in the debate is between candidates who think our current system can be salvaged with repairs and those who think it should be torn down and built anew. Building a dream house eases the way to simplification, but it increases potential disruption and cost.

The Pelosi plan

The most limited Democratic plan, championed by House Speaker Nancy Pelosi, for example, would deal with the house’s biggest structural issues. It would lower the cost of health insurance for more people and fix some glitches in Obamacare’s design — the home construction equivalent of patching the roof, fixing a saggy porch and repainting. Residents could remain in the house while such minor repairs take place. These changes would not cost a ton of money. The house would still be weird. There would still be some people without a place to live.

The Biden plan

The next tier of health care plans, like the one from Joe Biden, would go further. Mr. Biden, too, would patch the roof and upgrade the windows. But he’d also put on a big new wing: an expansion of the Medicare program that would allow more people to join, sometimes called a public option. Everyone living in the house can stay while the renovations take place, though there might be disruptions. It would cost more, more homeless people would now fit in, and some living in the weirder wings might move into the new addition. People would pay for housing through a mixture of taxes and rent.

There are a bunch of plans in this general category, including proposals from Michael Bennet, Steve Bullock, Pete Buttigieg, John Delaney, Julian Castro, Amy Klobuchar, Beto O’Rourke and Marianne Williamson. They differ, mainly, in how many people in existing wings are allowed to move into the new wing, and how large that wing will be.

The Sanders plan

Bernie Sanders wants to tear down the weird old house entirely and build his dream home. It would be enormous and feature many wonderful amenities. When done, there would be no homeless people at all, and everyone’s bedrooms would look exactly the same. The weirdness would be gone. But the entire old house would be gone, too, which some people might miss, and there could be unanticipated cost overruns in the construction. Some people might not enjoy the aesthetics of a modernist villa. While no one would have to pay rent in exchange for housing there, most people would have to pay more in taxes so the government could maintain the property.

Several candidates have signed on, in whole or part, to the single-payer dream house approach, including Cory Booker, Bill de Blasio, Tulsi Gabbard, Elizabeth Warren and Andrew Yang.

The Harris plan

Kamala Harris also wants to tear down the old weird house. But she doesn’t want to make everyone live in identical bedrooms. Her dream arrangement involves more choices, but most of the basic architectural features would be very similar. She would eliminate nearly every part of the existing health insurance system, and set up a new universal Medicare program that includes options from private insurers. It’s like a housing development with several slightly different model homes. The basic architecture and amenities would all be the same, but families would be able to choose some custom options, like paint color, countertops and bed linens. It would also be expensive, and everyone would still need to move.

The debate

At the debate last week, you heard arguments between the teardown candidates and the fixer-upper candidates about cost — and about change. Tearing down your current house comes with risks that many candidates don’t want to take on.

Although big changes to the health care system often garner strong support in surveys, Americans frequently also tell pollsters that they like their current insurance arrangements, and would dislike giving them up. The authors of some fixer-upper plans assume that only some people are looking for a change, while other candidates assume that, over time, nearly everyone will want to opt into a form of government-run insurance.

You also heard a debate about fairness and choice. Giving all Americans access to the same housing arrangements means that no one will have to live in a cramped attic. But it also means that some family members will have to part with some of their favorite furniture. “Of the 160 million people who like their health care now, they can keep it,” said Mr. Biden, of the virtues of his fixer-upper proposal. “If they don’t like it, they can leave.” By contrast, Ms. Warren emphasized the universal nature of a teardown approach: “We’re going to do this by saying, everyone is covered by Medicare for all; every health care provider is covered.”

The “Medicare for all” system envisioned by Mr. Sanders would cover more benefits than nearly any system in the world, but it would require everyone to have the same type of insurance, with no easy workarounds for patients who aren’t satisfied. Ms. Harris’s plan would allow more choice, allowing private plans to operate alongside the government system. But those tightly regulated products would not be allowed to differ nearly as much as plans that exist in today’s system, and would also amount to a brand-new system.

The candidates also disagree on how people should finance their ambitions. The fixer-upper candidates, for the most part, favor a system in which most Americans would still need to pay some form of rent to live in the house. The teardown candidates think everyone’s housing costs should be financed by taxes instead of direct payments.

A tax-financed system would mean big changes in who pays what for health care, and how. A system that preserves a mix of taxes, premiums and direct payments like deductibles would mean less rearranging of the financing of health care, and would probably require more modest tax increases.

This is only a metaphor, of course. There are many ways the health care system is not like a residence. But if you’ve ever renovated or built a home, you know the emotional and budgetary stakes. The health care system is personal to many Americans, just like their home. It’s no surprise the debate has been so heated.

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Share of Americans With Health Insurance Declined in 2018

The drop, despite a strong economy, was the first since 2009 and at least partly caused by efforts to weaken the Affordable Care Act.

Fewer Americans are living in poverty, but for the first time in years, more of them lack health insurance.

About 27.5 million people, or 8.5 percent of the population, lacked health insurance for all of 2018, up from 7.9 percent the year before, the Census Bureau reported Tuesday. It was the first increase since the Affordable Care Act passed in 2010, and experts said it was at least partly the result of the Trump administration’s efforts to undermine that law.

The growth in the ranks of the uninsured was particularly striking because the economy was doing well. The same report showed the share of Americans living in poverty fell to 11.8 percent, the lowest level since 2001, and household incomes edged up to their highest level on record.

The decline in health coverage reverses improvements since the Affordable Care Act established new insurance markets and financial assistance for millions of Americans who had previously struggled to obtain insurance. Before the passage of the law, more than 15 percent of Americans lacked coverage.

“It’s very frightening in that if this is happening now with unemployment at 3.7 percent, then what’s going to happen when the employer coverage situation gets worse?” said Eliot Fishman, a senior director at the consumer group Families USA and a top Medicaid official in the Obama administration. “There’s a fear we could see really dramatic increases in the uninsured rate if that happens.”

Surveys consistently show that health care is one of the top concerns for voters heading into the 2020 election. And candidates for the Democratic presidential nomination, several of whom have promised to extend health insurance to all Americans, are sure to use Tuesday’s figures as evidence that the current system is not working.

Several of them, including former Vice President Joseph R. Biden Jr., blamed President Trump’s health care policies for the higher uninsured rate on Tuesday.

The Census Bureau report also had good news for the White House. Poorer households experienced the strongest income gains, a significant reversal after decades of rising inequality and a sign that the recovery is at last delivering income gains to middle-class and low-income families.

The report is the latest evidence that the strong job market is creating opportunities for a wide array of workers, said Michael R. Strain, an economist at the conservative American Enterprise Institute.

“You’re seeing improvements in employment outcomes for people with disabilities. You’re seeing improvements in employment outcomes for the formerly incarcerated,” Mr. Strain said. “These workers who are potentially more vulnerable, you’re seeing the recovery reach them.”

Democrats, however, are likely to highlight evidence that income gains have slowed since President Barack Obama’s final years in office. Median income grew 5.1 percent in 2015 and 3.1 percent in 2016, compared with less than 1 percent last year.

And while Tuesday’s report showed the benefits of what now ranks as the longest economic expansion on record, it also highlighted the limitations of that growth. Median household income is only modestly higher now than when the recession began in late 2007 and is essentially unchanged since the dot-com bubble burst in 2000.

David Howell, a professor of economics and public policy at the New School in New York, said economic growth in recent years had helped families recover from recession, but had done little to reverse the longer-run stagnation in middle-class incomes. Democrats and Republicans alike, he said, have tapped into the sense among many voters that the economy is not working for them.

“If you look at the long-run trajectory from 1979, it’s pretty disastrous,” Mr. Howell said.

Health insurance

The drop in insurance coverage in 2018 is relatively small compared with the long-term trend, but it suggests that policy changes under the Trump administration, which has been hostile to the health law, have made a difference.

The administration cut back on advertising and enrollment assistance, programs that helped low-income people learn about the new insurance programs, among other changes that may have depressed the number of people signing up for health plans. The government also announced that it might begin counting Medicaid enrollment as a strike against immigrants who are seeking green cards or citizenship — a policy that became final this year. Insurance coverage for Americans of Hispanic origin fell last year, according to the report.

The administration’s decision in 2017 to eliminate a subsidy program contributed to large price increases for health insurance in the Obamacare marketplaces in many parts of the country the next year. Research from the Department of Health and Human Services shows that more than a million Americans who were previously buying their own insurance left the market in 2018.

But the Census Bureau figures show that the main change in the uninsured rate came from declines in Medicaid coverage. Urged by the administration, which expressed concerns about the program’s integrity, several states started asking families to prove their eligibility for Medicaid more often in 2018. The number of Americans covered by Medicaid and the Children’s Health Insurance Program fell by more than 1.6 million last year, according to administrative data.

“If you increase red tape you are going to lose people, many of whom are actually eligible for the coverage,” said Joan Alker, a research professor at Georgetown University. She said she was particularly disheartened to see declines in the number of children with health insurance.

But Brian Blase, a former special assistant to Mr. Trump for health care policy, pointed to a recent study suggesting that some Americans who had enrolled in Medicaid in the early years of Obamacare were not eligible for it.

“My sense is in 2018 states probably started tightening eligibility,” said Mr. Blase, who is now president of the consulting and research firm Blase Policy Strategies.

As part of the 2017 tax law, Congress abolished Obamacare’s so-called individual mandate, which required most Americans to obtain health insurance or pay a fine. Technically, the change did not kick in until this year. But analysts believe publicity about the provision may have led fewer people to seek coverage.

Historically, health coverage has tended to increase when the economy grows, since most Americans get insurance through employers. Indeed, before 2018, the uninsured rate had not risen in any year since 2008.

Income and poverty

Income gains have slowed substantially as the economic expansion has matured. But the tepid progress in top-line numbers hides positive trends under the surface.

“You continue to see some progress for households in 2018, especially in the bottom of the income distribution as they benefited from a tighter economy,” said Jason Furman, who was chairman of Mr. Obama’s Council of Economic Advisers. “But the pace of that progress seems to have slowed relative to past years.”

Median household income, the level at which half of households make more money and half make less, rose to about $63,200 in 2018 from $62,600 the year before. The change was so small that it was not statistically important. The Census Bureau made major tweaks to its methodology in 2013, making comparisons to earlier years difficult; by some estimates, household incomes remain below their 1999 peak.

Some of the pullback in income gains was to be expected. Increases earlier in the recovery were driven by people returning to work; for example, households where only one person worked outside the home might have become two-earner homes.

Now, with the unemployment rate near a five-decade low, household income gains must rely more heavily on raises for existing employees, said Ernie Tedeschi, an economist at Evercore ISI.

At an individual level, pay did climb by some measures. Among full-time, year-round workers, inflation-adjusted earnings rose more than 3 percent for both men and women.

And as some workers take home fatter paychecks, it is helping to even out inequality, if only slightly. Incomes grew more for poorer households last year, adjusted for household size. Poverty fell for households with children headed by women, and the black poverty rate was the lowest ever reported — though it is still more than double the white poverty rate.

There has been a “theme of the recovery finally seeping down to the most marginal workers and families in America,” and “you see that in 2018,” Mr. Tedeschi said.

The report’s income statistics are pretax, so they do not directly reflect Mr. Trump’s tax cut package, which took effect last year. The Tax Foundation has estimated that richer households probably saw the greatest decrease in taxes because of the changes.

A separate report this week, from the Government Accountability Office, found that wealthy Americans were far more likely to live to old age than their poorer neighbors. Other recent research has found that gap has been growing.

Altogether, 38 million people were living in poverty. The poverty rate has fallen relatively steadily since 2010, when it topped 15 percent. Among children, the poverty rate was 16.2 percent, also down from 2017.

The Trump administration applauded that progress.

Pro-worker policies are “unleashing the private sector and achieving historical gains for the most disadvantaged Americans,” Tomas J. Philipson, acting chairman of the White House Council of Economic Advisers, said in a statement.

But a broader measure that is often preferred by economists tells a less positive story. The headline poverty figures count the number of people living in households that earn below a certain threshold: about $20,000 for a family of three in 2018.

A supplementary poverty rate, which takes into account regional differences in the cost of living and government benefits such as housing assistance and the earned-income tax credit, was 13.1 percent in 2018, little changed from 2017. More seniors and fewer children are poor under that measure.

Government programs, particularly Social Security, the earned-income tax credit and the nutrition-assistance program formerly known as food stamps, kept tens of millions of people out of poverty, the report noted.

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