Less than 1% of prisoners with hepatitis C in state correctional facilities in the United States are receiving treatment according to a new study in the October issue of Health Affairs conducted by the Association of State Correctional Administrators in collaboration with the Yale Global Health Justice Partnership. The study found that the main barriers to increasing access to care are the high price of the medications, the few policy options available for reducing drug costs for state correctional facilities and the lack of funding for state correctional health services to meet the needs of incarcerated patients.
Caught between costly hepatitis C medications and an enormous need for treatment, prison officials are forced to make difficult decisions about who to treat, explained A.T. Wall ’80, the Director of the Rhode Island Department of Corrections and a co-author of the study. “Patients and prison officials alike want to cure hepatitis C infections. That requires financial resources and discounts we don’t have. What we desperately need are less costly drugs and more funding.”
Hepatitis C, a liver disease that can lead to severe illness and death, affects 3 million adults in the United States, according to the Center for Disease Control and Prevention (CDC). About one-third of those people spend at least part of the year in correctional facilities. Two new hepatitis C medications, Sovaldi (sofosbuvir) and Harvoni (sofosvubir/ledipasvir), cure the vast majority of patients. However, they are extremely expensive, with list prices of $84,000 and $94,500 for a 12-week course of treatment of each drug respectively.
The study is the first peer-reviewed analysis in over a decade examining the scope of hepatitis C medical care in state prisons. The research examined testing, treatment, and drug spending. It was performed by a coalition of prison officials, doctors, and researchers using data provided by 49 of the 50 directors of state departments of corrections.
While many federal agencies get discounts on new hepatitis C medications, state prisons are among few government institutions that do not get those rebates, the study found. The federal prison system gets at least 24% off, a U.S. Senate Committee on Finance 2015 report observed. And the Department of Veterans Affairs may have a discount of 50% or more. Yet numerous state prison systems see discounts of only 10% or less. One prison system received no discount at all, paying the full $84,000 for Sovaldi and $94,500 for Harvoni.
“Gilead is turning a blind eye. State prisons don’t get an automatic discount by law, and they don’t have much bargaining power. Instead of offering lower drug prices, Gilead is just letting these patients get sicker,” said senior author Gregg Gonsalves, a lecturer at the Yale Law School and a director of GHJP. “If Gilead won’t cut the prices for state prisons, other steps may need to be taken.”
“When left untreated, hepatitis C leads to expensive health problems. Some patients ultimately require a liver transplant, which costs hundreds of thousands of dollars. And taxpayers foot that bill for patients in Medicaid, Medicare, or correctional facilities,” said Adam Beckman, the study’s lead author and a former GHJP Student Director. “Treating people now and paying upfront for healthier lives will reduce our spending down the road on disease complications.”
“If we want to slow the nationwide hepatitis C epidemic, then providing treatment for prisoners is a must,” added Dr. Doug Bruce, Chief of Medicine at Cornell-Scott Hill Medical Center, Associate Clinical Professor at the Yale School of Medicine, and a co-author. “Many inmates with hepatitis C have injected drugs, and sharing needles spreads the infection. If we treat patients, then they don’t pass along hepatitis C to someone else.”
“Prisoners are among the only people in the United States with a legal right to adequate medical care,” said Amy Kapczynski ’03, a Yale Law School professor and director of GHJP.
The study calls on state governments to allocate more prison funding for treating hepatitis C. “Treating inmates is expensive upfront, but research suggests that it’s a smart investment,” explained Beckman.
The report suggests ways state prisons may achieve lower drug prices. State prisons can collaborate with other agencies, giving them greater bargaining power, or partner with qualified health facilities to obtain discounts via a special federal program (340B Drug Pricing).
The authors also outline other steps that can help address the situation. They recommend that state prisons increase programs to reduce drug injection among inmates, since only 14 state prison systems reported having substance use and medication-assisted treatment programs. They also encourage state prisons to implement routine hepatitis C testing, given that only 17 state prison systems reported offering a test to every inmate.
“It’s not unreasonable to consider very large-scale efforts. We could extend Medicaid coverage to inmates, thereby expanding access to treatment. The disease takes enough lives that we may want the federal government to launch an initiative for eradicating hepatitis C nationally,” said Dr. Bruce.
“We have cures for hepatitis C. If we give them to prisoners, we save lives and do so cost-effectively. The law may even require us to do so,” said Mr. Gonsalves. “Bottom line: The status quo of the high cost of drugs preventing treatment needs to change.”
George Camp, Co-executive director of ASCA, former Director of Corrections in Missouri, and a co-author of the study noted, “The numbers were staggering in most states. We have to improve the situation.”
Other study authors are Alyssa Bilinski, Ryan Boyko, Joseph K. Lim, and Emily Wang.
The Association of State Correctional Administrators (ASCA) is the only national organization of persons directly responsible for the administration of correctional systems and includes the heads of each state’s corrections agencies, as well as the Federal Bureau of Prisons, the District of Columbia, New York City, Philadelphia and Los Angeles County.
The Global Health Justice Partnership (GHJP), hosted by Yale Law School (YLS) and Yale School of Public Health (YSPH), was established in 2012 to promote interdisciplinary, innovative, and effective responses to global health disparities. It is a transformative collaboration that integrates different fields in order to make critical policy interventions. Building on Yale’s institutional assets, the GHJP trains students in law, public health, global affairs, and other fields to undertake collaborative, real-world research and advocacy to promote health justice. It also organizes path-breaking conferences and events, builds partnerships with local NGOs around the world to move research into action, and nurtures a truly interdisciplinary brain trust dedicated to effecting social change.