Selected and summarized by Ronald O. Valdiserri, MD, MPH, Professor, Department of Epidemiology, Rollins School of Public Health, Emory University, and Co-Chair of HepVu.
Dr. Valdiserri reviews significant articles on prevention, public health, and policy advances in viral hepatitis. This month, he highlights “Medicaid Expansion and Restriction Policies for Hepatitis C Treatment.” Furukawa NW, Ingber SZ, Symum H, Rapposelli KK, Teshale EH, et al. JAMA Network Open 2024, July; 7(7): e2422406 PMID: 39012632
What question(s) does this study address?
Estimates of hepatitis C virus prevalence in the U.S. range from 2.2 million to 4.0 million. One recent analysis estimates that as many as 60% of persons with hepatitis C in the U.S. have public insurance and that 44% have incomes below the poverty level. Medicaid is the primary program in our nation that provides health care coverage to low-income individuals and is jointly financed by both federal and state governments.
Because of the initial high cost of all oral direct acting agents (DAAs), many state Medicaid programs instituted coverage restrictions (e.g., prior authorization, required degree of liver fibrosis, provider requirements, sobriety requirements) as a cost control strategy. Over time, a number of these restrictions have been removed—although some still remain in place. Another aspect of state Medicaid programs that has changed in recent years pertains to if and when states have adopted Medicaid expansion, an important provision of the Affordable Care Act (ACA). The Medicaid expansion provision allows states to extend Medicaid benefits to a larger number of individuals and assures that the federal government will pay for most of the expanded coverage costs.
Furukawa and his colleagues used prescription data from the Centers for Medicare & Medicaid Services (CMS) in this cross-sectional analysis to estimate (across all 50 states and Washington, DC) the association of DAA restrictions and Medicaid expansion with the number of Medicaid recipients with filled prescriptions for DAAs.
What are the major findings of this report/article?
- Between January 1, 2014, and December 31, 2021, a total of 381,373 Medicaid recipients filled prescriptions for DAAs to treat hepatitis C.
- 57.3% of the Medicaid recipients filling DAA prescriptions were aged 45 to 64 years, 58.7% were men, 39.7% were women, and among those with available race/ethnicity (R/E) information, 52.2% were non-Hispanic White, 15.2% were non-Hispanic Black, 10.4% were Hispanic, 1.6% were Asian, and 1.8% were multiracial or other R/E.
- By the end of the study period (12/31/21), many DAA coverage restrictions had been lifted: only 2 of 51 jurisdictions had fibrosis requirements, 27 of 51 had a sobriety restriction, 16 of 51 had a prescriber restriction, and 9 jurisdictions had fully removed prior authorization requirements.
- By the end of the study period (12/31/21), the number of jurisdictions that had expanded Medicaid increased from 27 in 2014 to 38 in 2021.
- In a multivariate analysis, jurisdictions that had not expanded Medicaid, maintained fibrosis restrictions, and kept sobriety restrictions in place had fewer people with filled DAA prescriptions per 100,000 Medicaid recipients per year compared to jurisdictions that had expanded Medicaid, removed fibrosis restrictions, and eliminated sobriety requirements.
What are the implications for the prevention and control of viral hepatitis?
- When DAAs first became available, restriction policies were put in place by Medicaid programs to reduce the short-term costs of hepatitis C treatment. However, these restrictions have hindered progress toward hepatitis C elimination in the U.S. and their removal could improve timely access to hepatitis C treatment.
- A previous analysis of U.S. Medicaid enrollees, looking at data from 2017—2019, found that persons younger than age 30, women, Hispanic and Asian individuals and persons who inject drugs had significantly lower hepatitis C treatment initiation. Fully removing Medicaid hepatitis C treatment restrictions—in addition to expanding Medicaid–could help to ensure health equity by decreasing demographic disparities among those with hepatitis C infection.
- A recent analysis by the Office of the Actuary, Centers for Medicare & Medicaid Services, estimated that the proposed National Hepatitis C Elimination Program would reduce Medicaid spending by $17.02 billion over ten years.
- Although expanding Medicaid and removing DAA restrictions will increase access to hepatitis C treatment, providers and policy makers must keep in mind that other efforts (e.g., overcoming stigma associated with viral hepatitis, increasing harm reduction services for people using drugs, integrating medical and social services, etc.) may be necessary to support and maintain vulnerable populations once they have begun HCV treatment.
