Not All Californians Can Get Life-Saving Hepatitis C Treatment. Governor’s Budget Aims to Fix.

Originally published by The Sacramento Bee on June 27, 2018. Written by Hannah Holzer.

Brad Sims, 67, lived with chronic hepatitis C until, two years after a liver transplant in 1991, he went through a multi-week specialized treatment covered by his insurance. Now, he is considered cured. “Anybody who’s ill should be treated,” he said. But not everyone is able to access medications because of barriers in health plans and the high price of treatment.

Thanks to FDA-approved breakthrough medicines, modern treatments for hepatitis C are able to virtually cure the infection in nearly 100 percent of cases. Over the past decade, the effectiveness of treatment has drastically increased and, at the same time, there has been a significant decrease in related side effects, according to Dr. Robert Malmstrom, a pharmacoeconomics pharmacist at Northern California Veterans Affairs. In 2011, treatments on the market were 50 to 60 percent effective, Malmstrom said. Three years later, in 2014, with the FDA approval of the drug Harvoni, effectiveness reached 90 percent. “Compared to a decade ago, this is a miracle,” Malmstrom said. 

Nowadays, the treatment period for hepatitis C programs is typically eight to 12 weeks and existing drugs have a 95 to 98 percent success rate in curing the infection, according to several Sacramento-area medical professionals. However, access to treatment is limited for low-income patients covered by Medi-Cal and for state prison inmates. This is why the revised California budget, which Gov. Jerry Brown is expected to approve this week, plans to allocate an additional $176 million to expand hepatitis C treatment for these populations.

The bulk of these funds will be allocated toward the treatment of the estimated 22,000 inmates living with hepatitis C. Just under $106 million will treat all state prisoners living with any stage of the viral infection in light of a protocol from last December, said California Finance Department spokesman H.D. Palmer.

The U.S. Centers for Disease Control and Prevention reported in 2016 that hepatitis C is the deadliest infectious disease. In 2010, the CDC reported there were 3.5 million people living with the viral infection in the United States. Reported cases of hepatitis C almost tripled from 2010 to 2015.

But rates of infection are dramatically higher in prisons because of the high rate of incarceration of IV drug users, according to a study from the National Center for Biotechnology Information. “Treatment within facilities has the potential to reduce HCV (hepatitis C virus) incidence and disease burden in the community,” the study states. “The extraordinarily high cost of HCV treatment regimens and lack of political will are the main barriers to treatment expansion.”

Hepatitis C is spread when the blood of an infected person enters the body of another individual. In 70 to 80 percent of cases, this occurs from the use of IV drugs, says Dr. Robert Gish, a hepatologist at Stanford Health. The governor’s revised budget acknowledges the CDC’s promotion of treatment for hepatitis C due to the link between the infection and the opioid crisis. But hepatitis C should not be stigmatized as an infection only for drug users, Gish said. It can also be spread from mother to child, transmitted sexually or spread through razors or nonsterile tattooing needles.

Although hepatitis C infects as many as 1 in 7 state inmates, according to The New York Times, prisons cannot or are unwilling to pay for the cost of treatment, which can be thousands of dollars. In 2015, 41 states reported that around 10 percent of inmates had hepatitis C, but less than 1 percent of these inmates received treatment, a study from Health Affairs found.

Of the estimated 22,000 inmates with hepatitis C in California state prisons, $60 million of existing funds will treat approximately 2,300 inmates for hepatitis C this year. The projected $105.8 million addition will go toward the treatment of the remaining infected prison population over the next three years. The other $70.4 million in the overall $176 million increase for treatment would allow those with hepatitis C who are at least over the age of 13 and have a life expectancy of more than one year access to treatment.

“Currently, Medi-Cal authorizes treatment for individuals with stage two or above liver fibrosis, or at any stage if they have a qualifying co-morbid condition,” according to the revised budget posted online. Medi-Cal, the state version of the federal Medicaid program, is administered through health plans, Gish said, and within these health plans there are barriers to access treatment. Barriers might take the form of requirements, such as a minimum age requirement. There may be as many as 12 different requirements to get treatment. Additional funding from the state will remove some of these barriers. “Money equals access, access means less rules,” Gish said. He estimates that the average cost for a 12-week treatment is $30,000. At Stanford Health, where Gish works, Medi-Cal covers the eight-to-12-week treatment program for those who qualify.

Based on restrictions to hepatitis C treatment under Medicaid programs, report cards were issued to every state by the National Viral Hepatitis Roundtable in collaboration with the Center for Health Law and Policy Innovation of Harvard Law School. Whereas states like South Dakota, Arkansas and Montana received F grades, California was issued a B-plus.

“California moderately restricts access to hepatitis C medications,” the report states.

Although California does not have any provider or sobriety restrictions, according to the report, individuals under Medi-Cal must have moderate liver damage to qualify for treatment. Other requirements are related to age and the quantity of medication prescribed.

“A beneficiary must be evaluated for readiness to initiate treatment and must be able and willing to strictly adhere to prescribed treatment protocols,” the report states. “Beneficiaries must be 18 years or older to qualify for treatment. California imposes quantity limits; a prescription is dispensed in quantities of 28 days at a time.”

With the projected increase in state funds, Palmer said, an additional 2,090 individuals covered by Medi-Cal will be able to receive treatment. At the Northern California VA, which is federally funded, 2,000 patients have been treated since 2014. The VA has made it clear that providers cannot restrict care for those who qualify for treatment at the VA, Malmstrom said. “Thus far, for Northern California, we’ve cured 30 and we’ve failed to cure zero for fiscal year 2018,” he said.

Dr. Souvik Sarkar, a gastroenterologist at UC Davis Health, said there is no need to find new treatments given the high effectiveness of drugs on the market, so the current focus is on the eradication of hepatitis C. In the Sacramento region, he said, there is a great need for treatment. In fact, Sacramento County has had higher rates of hepatitis C than statewide rates. “In Sacramento County, the rate of chronic hepatitis C cases increased by 8 percent between 2012 and 2016,” according to a hepatitis fact sheet from Sacramento County for 2012-16. “County rates were generally higher than State rates throughout this five year period, with an annual average rate of 108.1 per 100,000 population at the County level compared to 79.1 per 100,000 population at the State level.”

The sheet further explains that the increase in hepatitis C cases among people age 20-29 are consistent with both state and national data primarily due to “a rise in injection drug use associated with the growing opioid epidemic.” Those born between 1945 and 1965, however, are “six times more likely to be infected with hepatitis C than those in other age groups,” the CDC reports.

In Placer County, there are relatively low hepatitis C rates as compared to statewide averages, said Katie Combs Prichard, a spokesperson with Placer County Health and Human Services. “In 2015, we had 61.5 cases per 100,000 residents compared to the state at 86.4,” Combs Prichard said. “The numbers are somewhat variable year-to-year, but we are consistently lower than the state average.”

Dr. Robert Oldham, the Placer County Health Officer, emphasized the potential benefit of the additional funds from the state. “Hepatitis C has potentially serious health consequences if left untreated,” Oldham said. “We are encouraged to hear that our Medi-Cal recipients will have more options covered for them when it comes to treatment. We hope more folks will be treated sooner and that it’ll help improve their lives and fight the spread of this serious disease.”