The long-term health prospects for thousands of Massachusetts residents are about to improve. As of Monday, MassHealth will require private insurers that manage coverage for two-thirds of the state Medicaid plan’s members to loosen rules that cruelly prevent people infected with hepatitis C from receiving drugs that cure the disease. Until now, these low-income patients have been forced to wait until they are suffering from potentially deadly symptoms before getting a prescription for one of a new generation of medicines that kills the liver-ravaging virus in as little as eight weeks.
The insurance company restrictions were a misguided reaction to the cost of the breakthrough treatments for hepatitis C, a disease which previously could only be kept in check — but not cured — by drugs that came with terrible side effects. When Gilead Sciences Inc.’s Sovaldi became the first of the more effective medicines to hit the market, in 2013, its $84,000 list price — $1,000 a pill — caused sticker shock for payers nationwide. Fearing their budgets would be drained by a rush of people who wanted to get well instead of living with uncertainty, many insurers limited access to Sovaldi. Even from a cold-blooded accountant’s perspective, it was a foolish policy — providing months or years of medical care for someone suffering from cirrhosis costs much more.
Since Sovaldi’s introduction, several similar drugs have been approved by the Food and Drug Administration. MassHealth, like other Medicaid programs, receives built-in discounts on prescription medicines of this type; the Sovaldi competition has helped it negotiate even deeper cuts. A threat by Attorney General Maura Healey to take legal action against Gilead over its pricing practices also helped make drugmakers see the light and lower prices. The total savings have been kept secret, but they are enough for about 3,400 more people to receive hepatitis C treatment without MassHealth increasing its $200 million annual budget for the drugs.
Another longstanding roadblock to treatment for MassHealth patients — insurers’ requirement that they first abstain from alcohol and recreational drugs for a period of time — also will be eliminated starting Monday. That’s important because the disease usually is transmitted through the injection of drugs with dirty needles. Preventing addicts from being cured increases the chances that the virus will be spread.
Massachusetts’ limits on hepatitis C medicines have been at odds with US Centers for Medicare and Medicaid Services’ policy, which mandates that Medicaid insurance plans cover the new drugs. MassHealth also has faced scrutiny from health care advocates, who note that the disease is especially prevalent among lower-income residents who don’t have other treatment options, or who are reluctant to seek preventive medical care. “We’re dealing with a population that has a history of exclusion and distrust of the health care system,” says Robert Greenwald, director of Harvard Law School’s Center for Health Law and Policy Innovation, and a prominent critic of limits on hepatitis C coverage.