One of my favorite hepatitis C resources is the report tilted, Hepatitis C: State of Medicaid Access. The report measures the state of access to hepatitis C direct-acting antivirals (DAAs) for Medicaid enrollees in the United States, including Washington D.C. and Puerto Rico. It’s the work of the Center for Health Law and Policy Innovation of Harvard Law School (CHLPI) and the National Viral Hepatitis Roundtable (NVHR).
This easy to use site provides information and a grade for each state, ranging from A+ (Connecticut) to F (Arkansas, Louisiana, Montana, and South Dakota). Connecticut stands alone with an A+. It earned its high rating because Connecticut does not impose any liver damage restrictions on people who want hepatitis C treatment. There are no restriction regarding sobriety. Prescribers aren’t restricted in treating people with hep C. (Note: Connecticut should get extra credit for its state’s hepatitis C testing policy, requiring certain health care providers to offer hepatitis C screening tests to people born between 1945 and 1965.)
Contrast this to one of the states with an F. For instance, South Dakota requires a biopsy confirming severe liver damage (F3 or greater) in order to qualify for treatment. Only specialists are allowed to prescribe hepatitis C treatment. The state requires documentation showing six months abstinence from alcohol and substance use prior to allowing treatment.
Eliminating Hepatitis C
Hepatitis C can be eliminated. In the U.S., the steps towards this are clearly laid out in the National Viral Hepatitis Action Plan. However, we can’t achieve elimination if people don’t have access to hepatitis C treatment.
Since 2007, more people have died every year from hepatitis C than from HIV, and it’s getting worse. From 2004 to 2014, the incidence of new hepatitis C infections increased more than 2-fold. That is an increase of 133%. (Increases in Acute Hepatitis C Virus Infection Related to a Growing Opioid Epidemic and Associated Injection Drug Use, United States, 2004 to 2014—Jon E. Zibbell, PhD, American Journal of Public Health, February 1, 2018) Obviously, if we don’t deal with the opioid crisis, the incidence of viral hepatitis will continue to increase.
State Medicaid programs argue that the cost of hepatitis C treatment prevents treating everyone. Trying to manage these costs, states have severely restricted access to treatment.
This means that although we can cure hepatitis C, we aren’t. Under many state and private insurance plans, patients have to prove that they have cirrhosis, or nearly have it. In short, treatment is approved when liver damage has progressed to its worst stage. It is like refusing to pay for diabetes drugs until the patient is blind or minus a few toes.
In addition to proof of cirrhosis, insurers create hurdles that require mountains of paperwork and patience. Some require documentation that patients have abstained from alcohol and drugs for six months to a year prior to treatment. If substance use is recent, patients must be actively participating in substance use treatment. This practice is not required for cancer or diabetes patients. Imagine if your doctor said to you, “We can cure your cancer, but your insurance won’t pay for treatment because alcohol or marijuana showed up on your tox screen.”
Eliminating hepatitis C is not only compassionate and right, it is cost effective. Treatment restrictions ignore the fact that those with hepatitis C are at increased risk of dying from multiple medical problems, including, lymphoma, cerebrovascular conditions, cancer, and kidney diseases. On average, patients with viral hepatitis die around two decades earlier than those who aren’t infected. Hepatitis C is a risk factor for liver cancer, which has the second highest mortality rate, just behind pancreatic.
How do we explain these restrictive policies to a young woman with minimal liver damage, but wants to be free of hep C prior to starting a family? Do we tell her, “Take a chance, maybe your baby won’t get hepatitis C. We can always treat you and your baby when you each develop cirrhosis.”
Access to hepatitis C treatment affects everyone. If we ration health care for this disease, it is just a matter of time before we ration coverage for other diseases.
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