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Prisoners With Hep C Get Cured In Some States But Not Others

Editor’s Note (Oct. 17, 6:30 p.m.): The Pennsylvania Department of Corrections has updated its treatment policy since the survey described in this article was taken. It reports having treated nearly 100 inmates with the new class of hepatitis C medications; it is not the case that none of the nearly 7,000 inmates with hepatitis C in the state’s prisons have been treated. The article has been updated to reflect the change in treatment. FiveThirtyEight should have contacted state officials prior to publication to learn of the department’s current policy.


Salvatore Chimenti already had advanced liver damage from the hepatitis C virus when he filed a lawsuit against the Pennsylvania Department of Corrections in the summer of 2015. He wanted access to new and expensive drugs that cure the virus in 90 percent or more of people who take them. Because he is an inmate, when the DOC denied him the medication, the only way Chimenti could potentially get it was to sue. “When you’re in prison, you have no other option, this is your only medical provider. You cannot get a second opinion; you can’t pay for it yourself. You are completely under the control of the Department of Corrections and their medical provider,” said Su Ming Yeh, an attorney with the Pennsylvania Institutional Law Project who is representing Chimenti in a class-action lawsuit.

Chimenti’s health has deteriorated since last year, Yeh said. “Since we even filed the lawsuit, he has progressively gotten worse in terms of his symptoms, and a mass in his liver has appeared.” Depriving prisoners of treatment is considered cruel and unusual punishment, a violation of the Eighth Amendment to the Constitution, which is why inmates are the only people in the country with a constitutional right to health care. She believes the DOC’s denial of medicines to Chimenti and hundreds of other Pennsylvania inmates with hepatitis C is unconstitutional, and though a Pennsylvania judge denied treatment to a prisoner in a different case earlier this year, he came to the same conclusion as Yeh.

As these new and expensive drugs become the norm for treatment, it’s relatively certain that state prison systems will be on the hook to provide them to at least some inmates. But how many, and how much it will cost, appears to vary dramatically, according to data from a study released last week. And even at discounted prices, most states will spend millions of dollars a year just treating the worst cases of hepatitis C among inmates.

The Federal Bureau of Prisons has guidelines for treating prisoners that include providing the new drugs. But the vast majority of U.S. prisoners are held in state facilities; about 1.4 million people are in state prisons, compared with about 191,000 in federal prisons. In their study, researchers from Yale and the Association of State Correctional Administrators sent two surveys to every state prison system. The first looked at care across states — who was getting treatment, and what kind — and the second focused on how much corrections departments were paying for the new drugs, specifically Sovaldi, which was approved for use in 2013, and Harvoni, which hit the market in 2014 (there have since been several others). They found that less than 1 percent of state inmates with hepatitis C1 had received these medications in prison as of Jan. 15, 2015. Although the data isn’t current — the first survey captures the scale of treatment as of Jan. 15, 2015, and the second looked at prices paid for treatment as of Sept. 15, 20152 — it provides a snapshot of both the difference in the number of inmates with hepatitis C among states and how hard it is to negotiate drug prices.

Pennsylvania, where Chimenti is an inmate, reported that 14 percent of its inmates had the virus, 6,976 people at the time of the survey. None was receiving treatment. (Pennsylvania updated its hepatitis C protocol in 2015, DOC spokeswoman Amy Worden said in an email. The state said it has treated nearly 100 inmates with the new class of drugs.)

STATE SHARE OF INMATES WITH HEP C OPT-OUT TESTING?
New Mexico 40%
New Hampshire 33
Alaska 30
Montana 25
Indiana 20
Washington 18
Arizona 16
Wisconsin 16
Missouri 15
Tennessee 15
Pennsylvania 14
North Dakota 14
Utah 14
Massachusetts 14
Wyoming 13
Kentucky 13
Colorado 13
Oregon 13
Vermont 12
West Virginia 12
Louisiana 11
Texas 11
Iowa 10
Alabama 10
Illinois 10
Michigan 10
Nebraska 10
Arkansas 10
Delaware 9
Maryland 9
Oklahoma 8
Ohio 8
Rhode Island 8
Kansas 8
New York 8
New Jersey 7
Florida 6
South Carolina 3
Mississippi 1
North Carolina 1
Rate of hepatitis C among state prison inmates by state, 2015

Opt-out states screen all inmates unless they choose not to be tested (though they may have different methods for screening). Other states use various criteria to determine who will be tested. Ten states either didn’t respond to the survey or
did not provide a rate.

Source: Health Affairs

There are some significant caveats to these numbers, because states track the virus differently. Some states screen everyone who comes into prison, and others simply ask inmates whether they’ve ever been told they have hepatitis C. Some don’t keep track at all. Still, it’s the first time in 15 years that a study has tried to show the number of people getting treatment in each state system.

COST FOR COURSE OF TREATMENT WITH DRUG
STATE HARVONI SOVALDI
Michigan $94,500 $84,000
Idaho 93,000 82,000
Oklahoma 89,777 80,600
Rhode Island 64,260 77,280
Delaware 64,260 77,280
Florida 64,161 76,869
Colorado 63,510 76,089
New York 63,510 76,089
Iowa 63,507 76,086
South Dakota 92,064 76,083
Minnesota 62,844 75,580
Tennessee 62,245 74,573
Washington 89,451 73,106
Louisiana 52,284 68,781
Virginia 47,250 62,160
Nevada 44,421 58,422
Alabama 62,975 56,000
Connecticut 45,856 43,419
State prisons pay very different prices for the same drugs

Data as of September 2015

Source: Health Affairs

In September 2015, Michigan was paying more for a course of treatment than any other state that answered the Yale survey. It treated roughly 100 inmates at the full list price for the first two drugs that hit the market, $84,000 per course of Sovaldi and $94,500 for Harvoni, according to Chris Gautz, a spokesperson for the Michigan Department of Corrections. The state has since negotiated discounts of 60 percent to 65 percent off.

It’s not easy for state prisons to negotiate drug prices. Three programs regulate how much the federal government pays for drugs, guaranteeing that it receives discounts for Medicaid, Medicare and the Veterans Health Administration. Federal prisons are entitled to discounted prices, but state prisons are excluded from many of the programs. In theory, there are ways for states to hook up with other health care providers to buy drugs at lower prices through a discount program known as 340B, but in practice, it’s a complicated process that isn’t easy to navigate. At the time of the first survey, just 16 states were working on getting discounts through 340B. Twenty-nine said they were trying to negotiate directly with the pharmaceutical companies (and some were doing both).

“The broader issue is that the U.S. has an incredible patchwork of drug pricing regulation, and [state] prisons are left out of it,” said Sean Dickson, a senior manager at the National Alliance of State and Territorial AIDS Directors who previously worked for a law firm that helped a major pharmaceutical company report its drug pricing data.

The Michigan DOC estimates that 10 percent of its inmates — about 4,400 people — have hepatitis C and has taken an aggressive stance on treatment in the past year. The department wants to set its own standards for who can get treatment before a lawsuit decides the standard for it, Gautz said. While some other states aren’t providing the new and expensive drugs to any inmates, the Michigan DOC decided to cover people who could in theory get the drugs from Medicaid if they weren’t incarcerated, which includes anyone with serious liver scarring.3 To date, they’ve treated roughly 400 people at a cost of $26 million, Gautz said. One-time funding from the state legislature is helping to treat the inmates who are currently eligible, about 600 people, but the Michigan DOC estimates that it will need about $7 million a year going forward to treat new inmates and current inmates with the disease whose health deteriorates.

Michigan says it isn’t treating everyone because not everyone with the hepatitis C virus will get sick from it. While 75 percent to 85 percent will develop a chronic infection, only 5 percent to 20 percent will develop severe liver damage, and 1 percent to 5 percent will ultimately die of liver failure or cancer, according to the Centers for Disease Control and Prevention.

Despite the huge price tag, treating nearly everyone with the virus has been deemed cost-effective and is what’s recommended by the American Association for the Study of Liver Diseases. That’s partly because it’s the best way to prevent others from being infected in the future, and, as I wrote last year, providing treatment in prisons is the only way to eliminate or drastically reduce the number of people with hepatitis C because it’s where many of the cases are concentrated. However, it would cost $33 billion just to treat all U.S. inmates with the virus, according to a 2014 estimate. That’s a lot of money that corrections departments don’t have. The study “gets to a moral societal question,” said Adam Beckman, lead author of the Yale paper. “What do we do when something is cost-effective, but we’d have to break our budget to spend on it?”

That question is particularly poignant in New Mexico, where the Corrections Department reported that 40 percent of its inmates had hepatitis C, the highest percentage of any state. Alex Sanchez, the deputy secretary of administration, points to the state’s long history with heroin addiction as the main cause. To date, the state has treated about 75 people, Sanchez said, and there has been a 100 percent cure rate. But by the Corrections Department’s estimates, it spends about $80,000 per week to treat an inmate. That cost includes much more than the drugs — things such as additional security, special meals and treatment for other underlying medical conditions — but from a budgetary standpoint, Sanchez says, those help make up the real cost to cure.

Like in Michigan, officials in New Mexico started treating prisoners before a court told them they had to, so they could do it on their terms. “Our goal is to treat people who need to be treated, but we have to be cognizant that this is taxpayer money. We don’t want to land ourselves in some kind of court decree that leaves taxpayers paying through the nose,” Sanchez said. “We have something like a 50 percent recidivism rate,” she said. “The likelihood that we’re going to treat everyone and be done with it? This is going to go on for a long time here.”

Yeh says the Pennsylvania class-action lawsuit is in the discovery phase until next month. After that, she will swap information with the Pennsylvania DOC, including data on how many inmates have the hepatitis C virus. Even without that information, it’s fairly clear that if Chimenti wins, the state will be on the hook for hundreds of millions of dollars.

Footnotes

  1. This refers to inmates with the hepatitis C virus. Not everyone who has the virus will present with disease, which can be either acute or chronic. Statistics presented throughout refer to people with the virus, not necessarily disease.

  2. In the first survey, 41 states reported data on the number of inmates with hepatitis C infections and the number receiving treatment. While Nevada included the number of its inmates estimated to have hepatitis C, the authors did not include the percentage of inmates that represented, so only 40 states are included in the table below. Thirty-one states completed the second survey, but several did not disclose the prices they paid for drugs and are not included in the tallies here. The researchers also surveyed two smaller systems, Los Angeles County jails and the Philadelphia Prison System.

  3. Eligibility is restricted to people with advanced liver disease, F3 and F4 on the Metavir scale.

Anna Maria Barry-Jester reports on public health, food and culture for FiveThirtyEight.

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