State Actions Connecting People to Care
Balancing the high, upfront costs of providing curative treatment for people with hepatitis C against the long-term costs of treating chronic HCV infection is a challenge for states. Many states have taken innovative approaches to increasing access to this lifesaving treatment.
Maryland, for instance, has partnered with Medicare in a unique program to help cover DAA treatment for Medicaid beneficiaries. Because many of the costs associated with chronic hepatitis C infection occur later in life when patients transition to Medicare, that program could see cost savings by investing in treatment now before more costly complications occur. The Maryland model gives Medicare the option of crediting Medicaid for spending money today that it will save on health care costs in the future. A University of Southern California study found that this approach would save $158 to $178 in annual treatment costs per patient or a potential savings of $1.4 billion over 25 years.
Another approach taken by states to improve access to DAAs is removing prior authorization requirements from Medicaid. Prior authorization is a requirement in which physicians and other health care providers must obtain advance approval from a health plan before a physician can deliver a specific service. Prior authorization can delay treatment for four to six weeks and is an intensive process for health care providers. Prior authorization is required for most patients to receive DAA treatment. However, according to the Hepatitis C: State of Medicaid Access project, 21 states have removed prior authorization for DAA treatment in Medicaid. This includes Arizona, Colorado, Oregon and Texas.
For states that have not removed the prior authorization requirement for DAAs, sobriety and fibrosis restrictions may also limit patients’ access to DAA treatment. Some restrictions related to substance use require complete abstinence from drug and alcohol use for a specified timeframe before treatment can be initiated. At least 42 states have removed sobriety restrictions. Fibrosis restrictions require patients to wait until hepatitis C damages their liver before receiving treatment. Liver damage is measured with a “fibrosis score” that must be sufficiently high before a doctor can initiate treatment. As of January 2024, all 50 states (most recently, Arkansas and South Dakota) and the District of Columbia have eliminated their fibrosis restrictions. According to a recent “Dear Colleague” letter authored by the Department of Justice, Department of Health and Human Services and the Centers for Medicare and Medicaid Services, say Medicaid programs that do not ensure access to DAA treatment for people with substance use disorders may be running afoul of ADA requirements.
Two states, Louisiana and Washington, have implemented “subscription” models to address the high cost associated with DAA treatment. Under this model, both states have unrestricted access to curative medication for a single set price. Both Louisiana and Washington have used the model to provide access to Medicaid participants and incarcerated populations. Both states have also emphasized identifying and screening for people with HCV recognizing that treating and curing people with existing infections means those individuals cannot transmit the disease to anyone else, effectively preventing new infections. Evaluations of these models also underscore the value of screening for hepatitis C infection to identify treatment needs.
Other State Actions
Given the continued lack of HCV infection awareness among the U.S. population, states are also working to test and identify people with the disease to help facilitate earlier linkage to curative treatment. Kentucky requires providers to test pregnant women for hepatitis C. California requires adult patients receiving primary care services in specified settings be offered a screening test for hepatitis B and hepatitis C.
Harm reduction strategies allow people who use drugs to reduce the associated negative consequences, such as overdose deaths and transmission of infectious diseases like hepatitis C. Most new HCV infections are due to injection drug use. One harm reduction strategy provides sterile injection equipment to reduce the transmission of these infections. Locally led harm reduction efforts such as syringe programs offer a range of services, including linkages to care and treatment. People who use syringe programs are five times more likely to enter drug treatment and three times more likely to stop using drugs.
Examples of how states have supported harm reduction include New Jersey, which enacted a bill permitting the establishment of harm reduction services, including distribution of sterile syringes and fentanyl testing equipment, to reduce disease transmission related to personal drug use. Arizona enacted a measure allowing local governments or nongovernmental organizations to provide and safely dispose of supplies such as needles and syringes. New Mexico enacted legislation that expands sterile equipment and substance testing supplies available at harm reduction centers. North Dakota exempted syringes and other sterile equipment provided by syringe service programs from their drug paraphernalia laws.