The Center for Health Law and Policy Innovation (CHLPI) at Harvard Law School and the National Viral Hepatitis Roundtable (NVHR) today launched the next phase of Hepatitis C: State of Medicaid Access, a project that evaluates hepatitis C virus (HCV) treatment policies across state Medicaid programs and advocates for policy change to connect more people living with HCV with the cure. Since its inception in 2017, Hepatitis C: State of Medicaid Access has evaluated treatment access based on three criteria: fibrosis, substance use, and prescriber limitations. The project now considers an expanded range of barriers to HCV treatment access for Medicaid beneficiaries, as advocacy and litigation have transformed the treatment access landscape over the past several years.

Developed in consultation with hundreds of advocates, public health officials, medical professionals, and people with lived experience, the new phase of the project tracks six categories of restrictions implemented by state Medicaid programs that limit access to HCV treatment for Medicaid beneficiaries:

Prior Authorization (conditions under which physicians or health care providers must obtain advance approval from a health plan in order for a patient to qualify for payment coverage);

  • Fibrosis Restrictions (based on a patient’s disease severity);
  • Substance Use Restrictions (based on a patient’s drug or alcohol use history);
  • Prescriber Restrictions (a requirement where prescriptions must be written by or in consultation with a specialist);
  • Retreatment Restrictions (based on whether a patient has already received prior treatment); and
  • Access in Managed Care (whether there is parity between a state’s fee-for-service program and the state’s contracted managed care organizations).

A seventh category, “Additional Restrictions,” captures individual state restrictions that may be less common but still limit treatment access. The changes reflect a broader understanding of how the changing treatment access landscape impacts patient health and well-being, and an analysis of the policy change necessary to eliminate hepatitis by 2030, a goal set by the World Health Organization (WHO).

As part of the launch, Hepatitis C: State of Medicaid Access released updated grades for all 50 states, Washington, D.C., and Puerto Rico based on their policies that impact HCV treatment access for Medicaid beneficiaries. These grades reflect changes in the national treatment access landscape, and each state evaluation highlights opportunities for action.

Over the past five years, Hepatitis C: State of Medicaid Access has directly led to significant policy change. State Medicaid programs in 14 states have removed prior authorization requirements for most patients entirely. As of the beginning of 2022, Medicaid programs in 33 states have either eliminated or reduced their fibrosis restrictions, 29 have loosened their sobriety restrictions, and 28 have scaled back their prescriber restrictions.

While important progress has been made, there is much work to be done to fully eliminate hepatitis C as a public health threat in the United States. 36% of states still impose some form of substance use restrictions on treatment, and 23% of states require prescription by or in consultation with a specialist. Additional retreatment and managed care restrictions continue to restrict treatment access in numerous states across the country.

“As we see the treatment access and overall healthcare landscape change around us, it’s important that Hepatitis C: State of Medicaid Access reflects those changes and incorporates a holistic approach to achieving the goal of eliminating hepatitis C by 2030,” said Robert Greenwald, JD, Faculty Director of CHLPI. “Many states have taken incremental steps towards lifting barriers to HCV treatment access, which has unquestionably led to thousands of Medicaid beneficiaries receiving the treatment they need. It’s time for state Medicaid programs to take the next step to be able to eliminate viral hepatitis – the new phase of Hepatitis C: State of Medicaid Access can guide officials in making that change.”

Hepatitis C is the deadliest bloodborne infectious disease in the U.S., and disproportionately impacts communities of color, people who use drugs, people who are incarcerated, and others who have historically faced inequities in access to healthcare. National trends indicate a rise in hepatitis C case incidence due in part to the ongoing opioid crisis. However, treatment levels for hepatitis C declined between 2014 and 2020, according to recently published data from the Centers for Disease Control and Prevention (CDC). Fortunately, direct acting antivirals (DAAs) offer a near-100 percent cure rate. Yet barriers to this treatment persist across the country.

“Hepatitis C: State of Medicaid Access underscores the gravity of addressing health inequities rooted in racism and stigma to realize viral hepatitis elimination,” said Adrienne Simmons, Director of Programs, NVHR. “People of color tend to experience worse health outcomes when infected with HCV, including worse HCV-related morbidity and mortality. State Medicaid programs must continue to increase access to life-saving treatment for vulnerable populations beyond incremental steps, including lifting all prior authorization requirements for hepatitis C treatment.”

“Hepatitis C elimination requires investment in harm reduction strategies that lead to better outcomes for the most vulnerable populations, including people who inject drugs (PWID), who currently make up 80% of new HCV infections,” said Daniel Raymond, Director of Policy at NVHR. “Hepatitis C: State of Medicaid Access will now recognize previously missed opportunities to treat, care for, and cure people living with hepatitis C tied to drug use as the opioid and stimulus use epidemic spikes across the country. This also includes recognizing the exacerbation of the hepatitis C and opioid use syndemic driven by the ongoing COVID-19 pandemic.”

To read more about the next phase of the project or learn more information about hepatitis C treatment access barriers across the country, please visit www.stateofhepc.org.