Iowa is considered one of the most restrictive states when it comes to treatment of the blood-borne hepatitis C Virus, or HCV, under state Medicaid programs. The state recieved a 'D' grade in a nationwide analysis conducted by the Center for Health Law and Policy Innovation of Harvard Law School and the National Viral Hepatitis Roundtable.
But Iowa Medicaid officials are expanding care to some HCV patients with less severe stages of liver disease, as defined by their fibrosis score. The metric measures liver scarring and ranges from F0, signifying no signs of liver scarring, to F4, signifying cirrhosis and permanent liver damage.
Previously, only Iowans with more advanced liver disease, a fibrosis score of F3 or above, would qualify for treatment. As of January 1, 2019, those with a score of F2 and above can request the treatment from their doctor through a process known as prior authorization, which requires they meet certain criteria beyond their need for the treatment.
A spokesman for the state Department of Human Services, which oversees Iowa Medicaid, says the agency will continue to review the requirements it places on hepatitis C patients.
"Iowa Medicaid requires prior authorization for hepatitis C treatments to ensure the most cost effective, clinically appropriate regimen is used," Matt Highland wrote. "The Department will continue to monitor treatment developments in consultation with its stakeholders and will continue to reevaluate the prior authorization criteria as appropriate."
But Iowans in the earlier stages of the disease still have to wait, all patients have to pass drug and alcohol sobriety screenings, and only certain physicians can prescribe the drugs. Doctors and advocates argue these restrictions on treating the potentially deadly condition are immoral. Michael Voigt is a liver transplant and liver failure specialist at the University of Iowa, and says the state still lags "very, very far behind."
“It’s completely ethically indefensible in my opinion that we are not treating everybody," Voigt said. “There’s public health as well as mental health as well as physical health issues that are associated with having hep C and not treating it.”
Voigt and other advocates for HCV patients argue Iowa Medicaid's restrictions flout federal law. The Iowa Harm Reduction Coalition is one such group, while working to improve health outcomes for Iowans who use drugs and match them to treatment and services. The virus often spreads among those using dirty needles to inject drugs.
"Iowa Medicaid's failure to provide treatment to people with hepatitis C is illegal," a statement on the IHRC website reads.
The group cites 2015 guidance from the Centers for Medicare and Medicaid Services directing states to only restrict access to HCV drugs "if the prescibed use is not for a medically accepted indication."
Unless critics sue Iowa Medicaid, as patients have done in other states, Voigt says the restrictions will likely remain. In the meantime, the incidence of the potentially deadly disease is increasingly rapidly among Iowans aged 30 and under, according to the state Department of Public Health.
With new drugs the potentially deadly disease is largely curable. But the treatment is incredibly expensive in the United States, often costing $100,000 for a course of pills over a few months.
Limiting who can access the drugs can lead to worse outcomes for individual patients, who may ultimately need liver transplants, as well as those who interact with them, who may be at a greater risk of contracting the disease. Putting off treatment can also lead to a cascade of related health issues that further burden the patient and the overall healthcare system.
“It’s not just a disease of the liver. It increases the rate of coronary artery disease. It increases the rate of certain cancers. It increases the rate of diabetes. It increases the rate of certain kinds of arthritis," Voigt said. "So it actually causes a pretty severe global reduction in the overall health of these people.”
Iowa Medicaid officials have said they're hesitant to expand access to HCV drugs in part out of concern for rising costs to the overall program. At a public health conference in Iowa City last September, Iowa Medicaid Director Michael Randol said he's trying to keep the agency on budget.
“I don’t wake up every morning thinking about the money. I think about 676,000 Iowans that I have to provide services for," Randol said. "We have to have a sustainable program three, five, seven years from now.”
Randol has requested more funds from state lawmakers to help pay for the drugs. But doctors say putting off preventative and largely curative treatments will only cost more down the road, leading to more expensive interventions and more deaths.