Months before Gilead Sciences’ breakthrough hepatitis C treatment hit the market, Oregon Medicaid official Tom Burns started worrying about how the state could afford to cover every enrollee infected with the disease. He figured the cost might even reach $36,000 per patient.
Then the price for the drug was released last December: $84,000 for a 12-week treatment course. At that price, the state would have to spend $360 million to provide its Medicaid beneficiaries with the drug called Sovaldi, just slightly less than the $377 million the Medicaid program spent on all prescription drugs for about 600,000 members in 2013. It potentially would be a backbreaker.
Faced with those steep costs, Oregon and several other states are looking to limit who has access to the drug that nearly everyone acknowledges is a revolutionary treatment for the disease affecting more than 3 million Americans.
Expensive specialty drugs aren’t new to health care. But Sovaldi stands out because it is aimed at helping millions of Americans who carry hepatitis C, and a large share of those infected are low-income and qualify for government coverage. Its arrival also coincides with the aggressive expansion of Medicaid under the Affordable Care Act, whose purpose was to extend health care to tens of millions Americans who previously couldn’t afford it.
Sovaldi has prompted fears among insurers and state officials that the breakthrough drug, despite its benefits, could explode their budgets. And that has sparked an urgent and highly sensitive debate in Medicaid offices across the country: How far should society go to make sure the poor get the best available treatments?
“The purpose of health care and the purpose of the Affordable Care Act was supposed to provide — and now mandates — access to quality and affordable treatment,” said Ryan Clary, executive director of the National Viral Hepatitis Roundtable, a patient group partly sponsored by drugmakers. “They’re now finding that they’re not able to get cured for the condition that’d been keeping them from being in the health care system.”
The Centers for Disease Control and Prevention estimates about 3.2 million people in the country are infected with the chronic liver disease hepatitis C, which kills about 15,000 Americans each year.