Originally published on February 9, 2020 by Bozeman Daily Chronicle. Written by Katheryn Houghton.
Since a steady cure for hepatitis C has existed, Montana denied people on Medicaid access to treatment until the disease severely damaged their liver. This week, the state lifted that restriction among others citing lower prices for the care.
Health providers and advocates celebrated the change that went in place Feb. 3, though they say it came late.
“Montana’s discriminatory restrictions were standing in the way of eliminating hepatitis C,” said Robert Greenwald, a professor at Harvard Law School and the director of the Center For Health Law and Policy Innovation.
Before this week, Medicaid participants had three rules to get past before getting treatment: patients had to demonstrate severe liver damage, had to be sober from alcohol and drugs for six months and needed a specialist.
Montana had a heftier list of restrictions than most states. It was one of four that required patients to develop an active lung disease before getting care.
Because of its rules, last year the state’s Medicaid program denied treatment to 362 Montanans diagnosed with hepatitis C.
From 2017 through 2019, the state turned down 887 requests for the cure.
The overwhelming majority were denied because they weren’t deemed sick enough, said Marie Matthews, the branch manager for Montana’s Medicaid and Health Services
The restrictions came down to money.
“It was the cost of drugs,” Matthews said. “We’ve been talking to health care providers across the state for a long time about what could we do to make this benefit better. Thankfully, we are in a position this year to be able to afford changing the whole layout of the landscape.”
For a long time, people diagnosed with hepatitis C weren’t guaranteed a cure. In 2013, medication came on the market that meant a pill a day for 12 weeks could rid someone of the disease.
But it was expensive.
The initial sale price was roughly $90,000. Today, treatment costs closer to $24,000.
Because of the drop in price, Department of Health and Human Service spokesperson Jon Ebelt said, the department will be able to treat three-to-four times the number of people for the same cost compared to three years ago.
The argument of cost never lined up for some.
Organizations like National Viral Hepatitis Roundtable cite the price of caring for someone with the disease over a lifetime as medical bills stack up compared to 12 weeks of medication.
Greenwald, with Harvard Law School, is among those who called Montana’s old rules illegal, citing the treatment as essential medical care.
“We don’t deny access to health care for a person with diabetes because they don’t have a healthy lifestyle,” Greenwald said. “We don’t restrict treatment to cancer.”
In 2015, the Centers for Medicare and Medicaid notified states that restrictions like those found in Montana seemed to contradict federal coverage requirements.
The next year, Washington state was sued for rules that mirrored Montana’s. That came after a patient’s disease progressed past being able to get treatment as they waited to meet the state’s threshold for care.
A federal judge required the state to drop those restrictions, saying Washington needed to line up with national medical standards.
The Montana Department of Health and Human Services declined to comment on whether the restrictions had been illegal. Matthews said the state found money in its Medicaid budget to drop its rules as soon as possible.
“The disease is terrible,” she said. “We have drugs available to cure it and there are clearly better benefit plan designs than Montana had. All of these things helped raise this particular ask to the top.”
Dr. Ray Geyer, an infectious disease specialist based in Great Falls who advocated dropping the restrictions for years, said doctors were watching the debate over treatment access play out.
“We realized other state Medicaid programs had been sued by patient advocacy groups that resulted in a win, but did we want to do that in Montana? We kept adding pressure with that as a last resort and I think the state got it,” Geyer said.
People with low incomes are disproportionately affected by the disease. Geyer said more than 80% of his patients diagnosed with hepatitis C were covered through Medicaid.
He said at times he was able to find a loophole to get patients care by recording two state denials before taking that paperwork to a pharmaceutical company to try and get the medication for free.
But Geyer said last year the companies announced that would no longer be an option as the majority of state Medicaid programs operated without restrictions.
“I often had to explain to people, ‘You will get through this, it’s a 100% cure rate,’” Geyer said. “‘The only obstacle is the cost of your medication and who is going to pay for it.’ That gets people’s attention.”
Dr. Mark Winton, a Bozeman Health Deaconess Hospital infectious disease specialist, said the state’s 2016 Medicaid expansion meant the hospital saw an influx of patients testing positive for the disease as more people tapped into care.
Since it’s a slow-moving illness, he said some patients had to return for tests each year to see if their liver was damaged enough to begin care.
Meanwhile, the state estimates roughly 1,000 Montanans are diagnosed with hepatitis C a year. Winton said with the restrictions gone, Montana has a chance to chip at that statistic.
However, providers and advocates say Montana’s delay points to a bigger question: As medicine evolves, will governments and health care coverage continue to leave some behind.
“That’s part of the equation that we talk about all the time,” Winton said. “There’s no good answer yet.”
As of Friday, 38 Medicaid members in Montana had requested hepatitis C treatment since Feb. 3.