The Hidden Health Crisis of the Opioid Epidemic

Originally published by Reuters on December 7, 2017. Written by Robert Greenwald, faculty director of the Center for Health Law and Policy Innovation of Harvard Law School and Ryan Clary, executive director of the National Viral Hepatitis Roundtable.

The American epidemic of opioid abuse is finally getting the attention it warrants. While policy solutions continue to be inadequate, the decision by President Trump to declare a national opioid emergency has helped to increase discussion about the problem and how the country can solve it. But the conversation also needs to address a dangerous—and largely ignored—interconnected public health crisis wreaking havoc among young Americans.

The problem is that more Americans than ever are injecting opioids and inadvertently infecting themselves with hepatitis C. Shared needles mean shared blood-borne infections—and that’s how the opioid crisis has created a new generation of hepatitis C patients. The number of reported hepatitis C infections nearly tripled from 2010 to 2015, with the virus is spreading at an unprecedented rate among young people under 30—who are now, for the first time, the most at-risk population for contracting and transmitting hepatitis C.

In the United States, an estimated 3.5 million people, and likely more, are currently living with hepatitis C. The virus kills nearly 20,000 Americans each year—more than HIV and all other infectious diseases combined.

Hepatitis C attacks the liver, causing cirrhosis—or scarring of the liver—and leads to severe liver damage, liver cancer and liver failure. The virus is the leading cause of liver cancer—the fastest-growing cause of cancer mortality in the U.S., which kills twice as many Americans now than it did in the 1980s. Driven by young people who inject drugs, new cases of liver disease have nearly tripled nationwide in just a few years.

Fortunately, we now have an unprecedented chance to eliminate the virus. More and more treatments are available that provide cure rates of over 95 percent, without the debilitating side-effects of older and far less effective hepatitis C therapies. These newer treatments, known as direct-acting antivirals, eliminate the hepatitis C virus from the body, stopping the virus’ attack on the liver and preventing the patient from infecting others.

While some of these treatments made national headlines for their initial $1,000-a-pill sticker prices, that time has passed. Due to increased competition as new treatment options have entered the market over the last three years, the cost of a cure has dropped dramatically. The price will decrease even further as additional alternative cures are approved.

For too many Americans, however, barriers to getting cured remain. While access has increased significantly for the more than 216 million Americans with private insurance and the 53 million who have Medicare, state Medicaid programs are a different story. The more than 70 million low-income Americans covered by Medicaid, including low-income adults, children, pregnant women, seniors, and people with disabilities, continue to face severely limited access to cures for hepatitis C.

Negotiated discounts to Medicaid are proprietary and confidential, but we know that the price to Medicaid for leading hepatitis C medications is now in the $20,000-$30,000 range—far less than the cost of treating the liver damage and cancer caused by hepatitis C. Each year, hepatitis C-positive patients average more than five times the hospitalizations and more than three times the number of emergency room visits as patients without the virus. Hepatitis C is also the underlying cause of approximately 30 percent of all liver transplants performed in the U.S. — an operation which costs an estimated $577,000 and thousands more to maintain ongoing health.

But it’s not just about the cost-effectiveness of the cure. Medicaid is America’s safety-net health care program for low-income individuals, and it is required by law to provide access to medically necessary treatments. As an entitlement program, there is no such thing as a waiting list or set budget in Medicaid. The program is specifically designed to shrink and expand to respond to public health needs, disease outbreaks and treatment advances.

It’s time that all state Medicaid programs start treating hepatitis C as the public health threat that it is, but that’s not what is happening in most states.

In our new report, Hepatitis C: State of Medicaid Access, we graded all 50 state Medicaid programs, as well as the District of Columbia and Puerto Rico, according to access to hepatitis C cures. More than half of Medicaid programs received a “D” or an “F” for withholding a cure based on restrictions related to liver disease progression, sobriety requirements, and limitations on who can prescribe the treatments.

All of these restrictions contradict established treatment recommendationsfrom the American Association for the Study of Liver Diseases and Infectious Disease Society of America. They also run afoul of guidance from the Centers for Medicare & Medicaid Services, which states clearly that some states are limiting access to hepatitis C treatment in violation of federal Medicaid law. The guidance to states puts Medicaid programs on notice that they must comply with the requirement to provide medically necessary treatments, and this obligation has been confirmed by U.S. Federal District Court decisions.

Not only are these restrictions imprudent from a public health, cost-savings, and moral perspective, but they are medically unfounded. A growing body of research shows that drug-users can be cured just as easily as people who don’t use drugs—and that curing the virus in substance users can lead to low re-infection rates.

Current restrictions do nothing but needlessly jeopardize the health and wellbeing of hepatitis C patients and the general public. With opioid addiction at an all-time high, there is no justification for prohibiting drug users—the population most likely to spread this highly communicable disease—from accessing a cure.

States that are still rationing a cure based on outdated cost concerns and imaginary medical concerns are not only allowing the hepatitis C epidemic to spread, they’re exacerbating the lasting aftermath of the opioid crisis. It’s time for them to look at the bigger picture.