‘Major milestone’: Governor’s budget targets hepatitis C epidemic in prisons

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Nearly half of the people in New Mexico’s state prisons are infected with hepatitis C, and for years, the Corrections Department has only purchased enough medicine to treat a fraction of them. But that may be about to change.

The executive budget proposal Gov. Michelle Lujan Grisham released Jan. 6 recommends $30 million in new funding for the Corrections Department for treatment of hepatitis C, with the expectation of curing most inmates by the end of 2024. This parallels an expansion of treatment taking place in other prison systems across the country, and would eliminate a focal point of New Mexico’s epidemic.

It appears the money will pass muster with state lawmakers. Last week, the Legislative Finance Committee recommended a slightly smaller appropriation of $25 million.

Observing that both budget proposals acknowledged the issue, state Sen. John Arthur Smith said it was likely additional funds would be appropriated. “When I say very likely, at this stage, I’m willing to say 100%,” he said. 

Dr. Kimberly Page, a professor at the University of New Mexico School of Medicine and one of the state’s foremost experts on the disease, welcomed the news.

“This would be a major milestone from a population and public health standpoint,” she said.

Hepatitis C is an infectious, blood-borne disease. Left untreated, it causes progressive liver damage that can result in organ failure and cancer. The disease contributed to the deaths of 17,253 people nationwide in 2017, more than died of HIV/AIDS.

The outlook for patients with hepatitis C changed dramatically in 2013 when the first medications were introduced that reliably cured the infection. But drugmakers asked as much as $84,000 per treatment and some insurers balked at paying the high price. Many state Medicaid programs and correctional systems set stringent criteria to limit who was eligible for treatment. 

Over time, competition drove prices down considerably, and in 2018, a generic therapy was introduced with a list price of $24,000. But cost still presents a barrier to access for many. 

The prevalence of hepatitis C in New Mexico is significantly higher than it is nationwide, and the highest concentration is in the state’s prisons: a February 2019 investigation by New Mexico In Depth reported that 44% of inmates were infected, the highest known share of any correctional system in the country. 

Baby boomers, who came of age before the virus had been identified and screened from blood banks, generally have higher rates of the disease, as do people who use injection drugs. 

Whereas the state Medicaid program removed all barriers to treatment in late 2017, the state’s prisons have continued to exclude most inmates from access. According to the New Mexico Corrections Department, of approximately 2,800 state prison inmates diagnosed with hepatitis C, only 123 were treated in 2019. One administrator told NM In Depth last year that eligibility criteria for treatment was a form of rationing because there was not enough funding to treat every inmate in need. 

That meager level of care made the state vulnerable to litigation. In a growing number of states, prison inmates with hepatitis C have filed class-action lawsuits arguing that withholding treatment is cruel and unusual punishment. The Eighth Amendment guarantees prisoners a right to adequate healthcare, and prisons cannot show “deliberate indifference” to their serious medical needs.

Courts have generally ruled in the inmates’ favor. One of the first lawsuits was decided in Florida, where a judge ordered the Corrections Department to expand treatment to all people infected with the virus. Facing the prospect of paying for hundreds of millions of dollars in forgone care, the state is appealing that decision. 

Judges also ordered treatment expanded in Indiana and North Carolina. Facing litigation of their own, Tennessee lawmakers appropriated an additional $25 million for treatment and made all inmates eligible, which a court recently found was sufficient to meet their constitutional obligations. Other state corrections departments agreed to expand drug access to avoid trial.

Lujan Grisham, who once served as state health secretary, voiced concern last year about prisoners’ lack of access to treatment and indicated she might take action. “The proposed increase in funding came about because we recognize the need,” a spokesperson from her office wrote in an email.

“This would be a major milestone from a population and public health standpoint.”

Dr. Kimberly Page, a professor at UNM’s School of Medicine

Rapidly expanding treatment in prison would help reduce the risk that inmates who benefited from the cure would later be reinfected, according to Homie Razavi of the CDA Foundation, a nonprofit that assists governments in eliminating hepatitis. “Treatment in the prison setting is very effective in reducing new infections,” he said.

But he pointed out that unless it was part of a statewide elimination strategy, like those announced recently by New York and Washington State, it would have a limited impact on the overall burden of hepatitis C in New Mexico, where the vast majority of infected people are in the general population. An analysis by the CDA Foundation found that if New Mexico scaled up treatment sufficiently to eliminate the disease statewide by 2030, it would avert 2,400 deaths.

The Health Department confirmed that for the last year it has been planning a strategy for statewide elimination, but said the plan will not be finalized and released before the end of this year’s legislative session.

Nor will the proposed funding increase be sufficient to treat all infected inmates unless the Corrections Department negotiates a lower price for the drugs. In fiscal year 2019, it paid $21,700 per course of treatment, which is higher than some other states.

In Texas, state prison inmates receive care from clinicians at the University of Texas Medical Branch, which is eligible for a 23% discount on drug purchases through a federal program known as 340B. As a result, the state spends less than $13,000 per inmate treated, according to Dr. Owen Murray, vice president of Correctional Managed Care.

New Mexico’s Corrections Department has been exploring a similar arrangement with Christus St. Vincent’s hospital for several years, but has not yet achieved one. The private company that took over operation of the state’s correctional health system in November 2019, Wexford Health Sources, is not 340B eligible. But a spokesperson said that it partners with 340B-eligible entities in its operations in Illinois, Indiana and West Virginia, and was hopeful it could come to a similar arrangement in New Mexico.

Beginning last year, Louisiana dramatically expanded hepatitis C treatment for its Medicaid and prison populations by negotiating a novel agreement with Asegua Pharmaceuticals that entitles the state to unlimited quantities of its hepatitis C drugs while capping costs, an arrangement that has been likened to a Netflix subscription. In its first four months, the agreement enabled the state to treat some 2,500 people, and the state is on track to eliminate the disease entirely by 2025.

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