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Recent advances in hepatitis C virus (HCV) treatment could be described as revolutionary: for uncomplicated patients, treatment is nearly 100% effective, oral only, has a low pill burden, minimal side effects, and results in a cure.1 Comparisons we have heard from clinicians are that HCV is now easier to treat than either diabetes or hypertension. Unfortunately for many patients, their state of residence is the decisive factor for whether they will receive lifesaving treatment. As part of a tribal telehealth network for HCV, we support several rural clinics successfully treating HCV and see this dilemma all too frequently.
Consider a patient with chronic HCV infection who presents with a recent history of marijuana use and has been late picking up hypertension medication. The patient has cirrhosis and is at high risk of HCV-related mortality. He is enrolled in state Medicaid and highly motivated for treatment. What is the treatment plan? It depends on the state. A resident of New Mexico can start treatment without delay. If instead the patient lives in Montana, a state that determines treatment eligibility based on advanced liver fibrosis, documented sobriety, and compliance with existing medications, the consultation is effectively moot; treatment will be denied. Montana is far from alone in its HCV treatment restrictions. Patients in South Dakota, Nebraska, and several other states we serve face similar hurdles (see Figure).2, 3, 4
These delays matter because prompt treatment saves lives. The number of deaths from HCV outnumber those caused by human immunodeficiency virus, tuberculosis, and pneumococcal disease combined.5 Successful treatment of HCV has been documented to reduce liver failure by 90%, liver cancer by 70%, and all-cause mortality by 50%.6, 7, 8 Patients with HCV-related cirrhosis who are cured can have a full life expectancy.9
In spite of the clinical importance of treatment, a recent study inclusive of 45 states found that about one-third of persons with HCV were denied treatment by public or private insurance.10 Patients with private insurers fared even worse than Medicaid; in the same study, over 50% were denied treatment. The paradox for patients residing in states with restrictive treatment criteria is that the intended safety net of public insurance leads instead to long delays that end in denials, and the surest route to treatment is to have no insurance and be ineligible for Medicaid, a profile that qualifies for drug assistance from manufacturers.
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-Jorge Mera, MDa, Brigg Reilley, MPHb,, Jessica Leston, MPHb, David Stephens, RNb
This article originally appeared in the May 2019 issue of The American Journal of Medicine.
