with Alexandra Ellerbeck

One corner of the health-care industry seems to be thriving amid the coronavirus pandemic: The Affordable Care Act’s individual insurance marketplaces.

Within days, President Biden could infuse marketplace plans with more generous federal subsidies with a stroke of his pen. Plans are enrolling hundreds of thousands more consumers during a special, pandemic-related sign-up period, which lasts until mid-May. And several major insurers who previously fled the marketplaces during hard times have announced they’re returning.

It’s a turn of events for the marketplaces.

The state-based marketplaces, which cover around 11.5 million Americans who don’t have workplace coverage, were plagued by skyrocketing premiums and insurer exits during their first few years under the Obama administration.

They stabilized somewhat during the Trump administration, even as enrollment trended down. But now, actions by the Biden administration are raising hopes that millions more Americans will buy plans, in a rush of new enrollment that could ultimately help lower premiums and boost plan options — and make the marketplaces a better place to buy coverage into the future. So far, around 200,000 people have bought plans on HealthCare.gov during a special enrollment period that started Feb. 15 and lasts for three months.

Larry Levitt, a senior vice president at the Kaiser Family Foundation:

Subsidy enhancements lasting two years are embedded within the massive coronavirus relief bill Biden is expected to sign this week (assuming the House passes it) — a measure which includes a number of provisions aimed at both expanding coverage and making plans more affordable for people who already have it. 

“House lawmakers are set to vote as soon as Tuesday on a roughly $1.9 trillion coronavirus relief package, putting President Biden on track to sign his first major legislative accomplishment into law by the end of the week,” our colleagues Tony Romm and Jeff Stein report.

The new subsidy thresholds would allow people earning up to 150 percent of the federal poverty level (around $19,000 for an individual) to purchase a plan with the premiums fully subsidized by the federal government. The provision also removes a cap on subsidies for people earning 400 percent or more of the federal poverty level. These individuals or families would be expected to pay no more than 8.5 percent of their income in monthly premiums.

This means a few things. First, zero premium plans will become much more common for people at the lower end of the income thresholds. And most people earning over 250 percent of the federal poverty level will be able to find at least one bronze-rated plan at zero cost to them, according to David Anderson, a researcher at Duke University’s Margolis Center for Health Policy.

Insurers, who for years have been asking Congress to boost the subsidies, are pleased, to say the least.

“I think the availability of the increased subsidies will change the equation for people who are looking for coverage,” said Jeanette Thornton, a senior vice president for American’s Health Insurance Plans, the national association for health insurers.

If and when Biden signs the bill, there will be a mad scramble to update HealthCare.gov.

Web developers will need to modify the back ends of the federal website and the state-run marketplaces to reflect the new subsidy schedule, so that consumers see an accurate calculation of the federal assistance they’re eligible for while shopping for plans.

That’s likely to take at least a few days. But ultimately, everyone who has bought a 2021 marketplace plan should receive subsidies calculated under the new thresholds — including people who purchased plans during the regular enrollment period at the end of 2020 and have been paying premiums in January, February and March based on the old calculations.

ACA analyst Charles Gaba:

Because the coronavirus relief bill doesn’t spell out the details of how all this might work, it will be up to the Biden administration to explain the mechanics. 

For people enrolled since the beginning of the year, the government will need to reconcile the difference between what they paid in premiums under the old premium schedule with what they're expected to pay under the new premium schedule.

Ultimately, however, any missteps in properly calculating someone’s subsidy should be rectified when they file taxes next year, Anderson said. That’s because the Internal Revenue Service is required to reconcile the marketplace subsidies people received with what they’re eligible for.

Thornton said she doesn’t yet have any information on when the websites might be updated to reflect the expanded subsidies, although she said those conversations are occurring.

People who already bought 2021 marketplace plans will be able to change plans if they want to.

It’s possible to imagine that some people might want to switch to more generous coverage if they’re receiving more subsidies to help pay for it. 

The Biden administration has already said people who enrolled in coverage at the end of last year may use the special enrollment period to switch plans. The administration — and many states — opened the marketplaces for enrollment from Feb. 15 through May 15, in order to maximize opportunities for people to get covered during the pandemic.

With more generous subsidies under the relief bill, some people might want to switch plans — say, from silver-level coverage to gold-level coverage. However, switching plans also means the annual deductible starts over, Thornton warned.

But the boosted subsidies will likely create the strongest incentives to enrollment for people who had purchased individual plans outside the marketplaces for 2021, according to Linda Blumberg, a health policy fellow at the Urban Institute. That's because they now could receive federal assistance by purchasing a plan on Healthcare.gov or the state-run marketplaces.

“The people most incentivized to change plans would be those who bought outside of the marketplaces because they were ineligible for premium tax credits, but who could now get assistance through a marketplace plan,” Blumberg wrote to me.

Insurers are already viewing the marketplaces as a better place to be.

Both CVS’s Aetna and UnitedHealthcare, which fled the marketplaces several years ago amid heavy losses, are reentering. UnitedHealthcare sold 2021 plans in several states including Maryland and Washington. Aetna announced last month it will reenter the marketplaces.

“We’ve been studying the individual market for a while,” said CVS Health’s CEO Karen Lynch. “Some of the remedies have been put in place. Clearly there’s a big market.”

Shelby Livingston, senior health-care reporter for Business Insider:

Ahh, oof and ouch

AHH: Vaccinated grandparents can now safely visit their grandkids, the Centers for Disease Control and Prevention says.

“Federal health officials released guidance Monday that gives fully vaccinated Americans more freedom to socialize and engage in routine daily activities, providing a pandemic-weary nation a first glimpse of what a new normal may look like in the months ahead,” The Washington Post’s Lena H. Sun and Lenny Bernstein report.

The guidance says that vaccinated people who are two weeks past their final shot can visit with unvaccinated members of a single household where the members are at low risk of disease. That means many grandparents will be able to visit grandchildren indoors and without masks, although the health agency is still discouraging traveling to visit family. But vaccinated people should still meet outdoors and don masks when meeting with unvaccinated people who are at higher risk for severe disease, the agency said.

Fully vaccinated people can still transmit the virus to others, although a growing body of evidence suggests that vaccines lower the risk of asymptomatic infections and transmission of the virus.

At least 60 million people have received one or both doses of the vaccine, with about half that number fully vaccinated, as of Monday. Biden has said that the United States will have enough doses for every eligible adult by the end of May.

OOF: Public health groups and GOP strategists are teaming up to promote coronavirus shots to vaccine-hesitant Republicans.

A Kaiser Family Foundation poll released last month found that almost a third of Republicans said they would “definitely not” get vaccinated, and another 18 percent said they would “wait and see” before getting a shot. 

“As a result, millions of Republicans could remain unvaccinated, a potential roadblock to efforts to achieve the high levels of immunity needed to stop the virus in the United States — an irony that isn’t lost on Trump officials who worked to end the pandemic,” The Post’s Dan Diamond reports. 

Efforts to combat vaccine skepticism among Republicans have so far received little attention, but that could change. The de Beaumont Foundation, a public health group, has teamed up with longtime GOP political strategist Frank Luntz to win over vaccine skeptics. Luntz told The Post he plans to conduct a focus group this Saturday to workshop outreach messages targeting holdout Republicans.

Meanwhile, a senior official in the Biden administration, speaking on the condition of anonymity to discuss in-progress efforts, told The Post that they are also working on outreach to Republicans and that Biden officials will appear on conservative networks, like Fox News. But those efforts may require finding a credible messenger that can appeal to conservatives.

OUCH: U.K. viewers were surprised by pharmaceutical ads during Oprah’s interview with Harry and Meghan,

The two-hour interview with the Duke and Duchess of Sussex contained a surprising revelation for many viewers in Britain. "U.S. television broadcasts are punctuated by a continual barrage of pharmaceutical ads that would be illegal almost anywhere else,” The Post’s Antonia Noori Farzan reports.

While the interview also broadcast on British television, an untold number of Britons found ways to watch it broadcast a day earlier on American television. Many were surprised to see a string of pharmaceutical advertisements narrated with dizzyingly long lists of symptoms and side effects.

One viewer asked, “How are the side effects of the medicine in American ads more lethal than the thing they’re treating???”

The United States and New Zealand are the only two developed nations that allow pharmaceuticals to be advertised directly to consumers. The industry argues that the advertisements lead to more informed consumers, but critics argue that they can lead to higher prices and marketing costs get passed on to patients or taxpayers.

More in coronavirus news

We still don’t know why the coronavirus ravaged some countries but not others.

“The usual trend of death from infectious diseases — malaria, typhoid, diphtheria, H.I.V. — follows a dismal pattern. Lower-income countries are hardest hit, with high-income countries the least affected,” Siddhartha Mukherjee writes in the New Yorker.  “But if you look at the pattern of covid-19 deaths reported per capita — deaths, not infections — Belgium, Italy, Spain, the United States, and the United Kingdom are among the worst off.”

“For many statisticians, virologists, and public-health experts, the regional disparities in covid-19 mortality represent the greatest conundrum of the pandemic,” Mukherjee writes.

When researchers at Imperial College London built coronavirus models that accounted for age, virus contagiousness, interpersonal contact and a range of demographic factors, their predictions were reasonably close to reality when it came to wealthy countries. For poor countries, not so much. “Nigeria was predicted to have between two hundred thousand and four hundred and eighteen thousand covid-19 deaths; the number reported in 2020 was under thirteen hundred,” Mukherjee writes.

Epidemiologists and other experts point to a number of potential variables: systematic underreporting of deaths, demographic factors like age and obesity, more open-air ventilation in warmer parts of the world, partial immunity from exposure to other circulating pathogens, or government response to the pandemic. But most of these explanations are unsatisfying on their own or fail to explain certain outliers. The key to the mystery may be that “here’s no one culprit but many,” Mukherjee writes.

On the Hill

Sen. Joe Manchin III seemed to soften his position on the filibuster.

Manchin, a Democrat from the deep-red state of West Virginia, has long expressed opposition to getting rid of the filibuster — a procedural rule that results in most legislation needed 60-votes in favor to pass through the Senate. But in an interview on Sunday, Manchin seemed to soften his position, expressing that he might be open to reforming the filibuster in a way that would make it harder for Republicans to indefinitely delay or block a vote.

Manchin has been seen as a key obstacle to getting rid of the filibuster — a step that is likely necessary for Democrats to pass some of their most ambitious plans including creating a government-run, “public option” health plan.

But it’s not just Manchin who is opposed to changing the filibuster, The Post’s Philip Bump reports. Democrats are deeply divided on whether to change the filibuster, and how they would go about any potential reform. Biden himself may be opposed to changing the rule. On Monday, White House press secretary Jen Psaki said that the “president’s preference is not to get rid of the filibuster.”

Elsewhere in health care

Advocates are pushing states to pass bills banning discrimination in organ transplants.

“Denying organ transplants to people with intellectual and neurodevelopmental disabilities like Down syndrome or autism is common in the United States, even though it is illegal under the Americans with Disabilities Act,” Kaiser Health News’s Sara Reardon reports.

A report from the National Council on Disabilities found that physicians may worry that individuals with disabilities will have co-occuring conditions that make the transplant more dangerous or that they will be unable to comply with post-transplant requirements. They may also doubt that a transplant will improve the patient’s quality of life. But the NCD report found that none of these concerns is universally true.

One widely cited 2008 study found that 44 percent of organ transplant centers said they would not add a child with some level of neurodevelopmental disability to the organ transplant list. A more recent study found that 71 percent of transplant programs would automatically disqualify an adult with an IQ under 35, which is considered severe intellectual disability.

Advocates in Montana are pushing to change that with a bill that would ban physicians from denying organ transplants based solely on disability. If it passes, Montana will become the 17th state to ban such discrimination. Montana itself does not have any transplant centers, but supporters will help it draw attention to the issue. Seven other states and the federal government have similar bills pending.

Sugar rush