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State prison systems say they can’t afford to cure everyone with hepatitis C. The drug, even after a dramatic price drop, is still expensive.

But several states have recently figured out how to make the math work.

When Gilead launched Sovaldi, the first-ever cure for hepatitis C, in late 2013, it charged $84,000 for a course of treatment. Today, a version of Gilead’s most popular hepatitis C drug, Epclusa, retails for $24,000, less than a third of that price.

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Now, prisons in states including Washington, Michigan, and Virginia are cutting deals with Gilead and makers of competing drugs to further reduce how much they spend on the medicines. Louisiana, which has one of the lowest corrections budgets per capita, has treated more than 1,600 people for the virus since signing a deal with Gilead in 2019. Other prisons have forged creative partnerships with hospitals and health departments to bring the costs down, too.

The recent progress demonstrates that the future of hepatitis C care in prisons doesn’t have to look like the early years after these drugs first launched, when more than 1,000 incarcerated people died from hepatitis C-related complications.

There’s no denying it: The drugs remain pricey, and treating everyone infected with the virus would eat up a big chunk of the prison medical budget in some states. In Oklahoma, for example, there were 2,119 people with hepatitis C in 2021. At $24,000 per course of treatment, the medicine would cost the state $50.9 million. That year, Oklahoma’s entire correctional health care budget was $85.7 million.

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In Maine, the state with the third smallest prison population in the country, the Department of Corrections needed the legislature to greenlight an infusion of $5.5 million when it had to expand its hepatitis C treatment program after settling a prisoner-led lawsuit.

“Although funding is difficult to come by, it was very difficult for anybody to argue for a better use of money,” said Ryan Thornell, the deputy commissioner of Maine’s department of corrections.

Further headway will depend on prison doctors, administrators, legislatures, and governors agreeing that it’s worth investing millions of dollars into hepatitis C treatment for incarcerated people, and looking for deals and appropriations to help make it happen.

“These correctional facilities and their administrators … they need to see value in the public health intervention,” said Erin Fratto, a consultant who helps states craft hep C pricing deals. “They need to see value in the incarcerated individuals’ lives.”

In many ways, state prisons must contend with the same high drug prices that eight in 10 Americans deem “unreasonable.” Though they have some power to negotiate a discount, they are excluded from the lower rates that federal agencies, like the Bureau of Prisons, command. Same as everywhere else in the U.S, drugmakers themselves set the price for their products.

Gilead, the company behind most of the successful hepatitis C treatments, has made billions off of these pills — pulling in $2.27 billion from Sovaldi in the first three months after it launched alone. Epclusa has garnered Gilead more than 12.5 billion in global sales since the drug launched in 2016.

The company has defended its prices as “fair and reasonable,” and “in line with the previous standards of care.” A statement to STAT highlighted that 95% of patients who get the drugs are cured.

“We are committed to helping make these medicines accessible to those who need them, including incarcerated individuals, and exploring innovative approaches that address access gaps in today’s healthcare system,” the company said. “Ensuring all patients have access to this highly effective and valuable treatment is a priority.”

Still, most states have set up systems to ration access to hepatitis C medicines because they say they’re too costly to give to everyone with the condition.

There is some truth to their argument, that not everyone needs immediate treatment with the medicines. About 30% of cases clear up on their own. And the disease is often very slow-moving; it’s estimated that roughly 15% to 30% of those with long-term infections will develop severe liver damage, known as cirrhosis, in 20 years.

Treatment for the virus also doesn’t prevent people from getting infected again, if they go back to risky behaviors like prison tattooing. That means prisons could be on the hook for multiple courses of treatment for a single person.

But public health experts say prisons’ focus on the sticker shock of these drugs is shortsighted. The top organization that addresses liver disease in the United States recommends that prisons treat people for the virus as soon as they’re diagnosed. That’s because getting cured of hepatitis C early not only prevents cirrhosis, it reduces the risk of other illnesses like liver cancer. Those with hepatitis C are also at higher risk for a number of other conditions that can seem totally unrelated to liver disease, like type 2 diabetes and coronary artery disease.

Ramping up treatment for hepatitis C also would dramatically reduce the prevalence of the disease in prisons over time, because those who are cured are no longer infectious and cannot spread the virus to other incarcerated people.

Jagpreet Chhatwal, an expert on the cost effectiveness of hepatitis C drugs and a Harvard professor, argues that the medicine’s price is now at the point that the health care system overall would save money over the long term to pay for these treatments now.

“We are preventing all those future complications of hepatitis C that are expensive,” he said, estimating that a national effort to eliminate the disease — inside and outside of prisons — would cost between $8 billion and $10 billion, but would save the health care system $26 billion.

So how does an underfunded prison make the math work to get these drugs?

A number of prison systems have turned to a federal drug discount program known as 340B to buy hepatitis C medicines. To do this, corrections departments partner with a public health department or another player in the health care supply chain, such as a hospital, that is eligible to receive the discounts, which are only available to certain entities that treat the poor. Texas, Alaska, and Utah have all used this approach.

Other correctional systems have hammered out deals directly with drugmakers. States including Louisiana and Washington have devised so-called subscription deals that give the states access to an unlimited supply of these drugs for a set overall price. Others, like Virginia, have negotiated discounts with Gilead in exchange for preferring their drugs over their competitors.

“It really was a very, very easy process,” said Jamie Smith, the chief pharmacist for the Virginia prison system, regarding the state’s contract with the drugmaker.

Even so, Virginia spent a total of $29.3 million on hepatitis C drugs in fiscal years 2019, 2020, and 2021, according to Trey Fuller, assistant director of health services at the Virginia Department of Corrections. It treated nearly 2,300 incarcerated people during that time, according to records obtained by STAT.

For every state that’s cutting a deal, there’s another that isn’t.

In 2020, Florida’s Republican Gov. Ron DeSantis vetoed a $28 million funding increase for hepatitis C treatment in the state’s prisons. In Oklahoma, legislators have repeatedly rejected the state’s requests for significant spending increases for this population. Wyoming’s Republican Gov. Mark Gordon lobbied the state legislature to reject a modest $4 million bump requested by his own corrections department. DeSantis and Oklahoma’s top appropriator didn’t respond to requests for comment. A spokesperson for Gordon said that the governor believed that the department of corrections could cover the cost of hepatitis C medicines with their existing budget.

“Not everybody agrees that the corrections population should be treated medically in the same manner, for all the same issues, that the general population in the community is,” said Thornell, the Maine corrections official.

Jeff Keller, the president-elect of the American College of Correctional Physicians, put it even more starkly: “We physicians in the system are trying to do the best we can. The issue is that the legislators in the states [that don’t treat hepatitis C] don’t care … it doesn’t play well politically.”

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