Editorial | Published:

Disparities in Access to Direct Acting Antiviral Regimens for Hepatitis C Virus (HCV): The Impact of Race and Insurance Status

The American Journal of Gastroenterology (2018) | Download Citation



Despite highly effective and well-tolerated regimens for treating hepatitis C virus (HCV), patients face barriers in accessing treatment. In addition to suboptimal HCV screening programs and lack of effective linkage-to-care, other barriers include strict requirements from some payers to cover treatment. This study reports insurance status and Hispanic ethnicity as predictors of not receiving treatment. These barriers occur despite the fact that HCV is the most common indication for liver transplantation and cause of hepatocellular carcinoma in the U.S. Therefore, it is critical that policymakers bring all the stakeholders together and develop a national policy to eradicate HCV infection from the U.S.


Since the discovery of hepatitis C virus (HCV), there has been mounting evidence that HCV infection is a systemic disease with negative impact on clinical, economic, and patient-reported outcomes (PROs). These outcomes are also influenced by a number of socio-demographic factors that can fuel health disparities in the United States. These factors became more prominent after the availability of highly effective treatment regimens for HCV infection [1,2,3,4,5,6,7]. In the current issue of AJG, Wong et al. present an analysis of the barriers to HCV treatment in the United States by using a community sample of 29,544 patients with chronic HCV infection from 2011 to 2017. Although authors report that treatment rates have increased after the introduction of the new direct acting antiviral treatment agents (DAAs), a large proportion of HCV infected patients remain untreated. Furthermore, these data show that the majority of HCV patients who are at risk for more severe liver disease are not being treated. Finally, their multivariate analysis indicated, that in comparison to the non-Hispanic whites, HCV infected patients of Hispanic ethnic background were less likely to be treated. Additionally, compared to those with commercial insurance, those with Medicaid, Medicare, and indigent status were less likely to receive treatment [1].

In addition to this analysis, there is other evidence supporting the disparity of care based on HCV patients’ insurance status. In fact, a recent study using Trio Health’s Innervation Platform reported similar findings [3]. Trio is a unique platform that collects and aggregates real-time data from academic medical centers, community physicians, and speciality pharmacies in the United States [3]. In this study authors reported that 81% of HCV patients with a prescription for treatment did not start for insurance or financial reasons [3]. In fact, in their matched comparison analysis, patients with commercial insurance were 6.5 times more likely to start treatment as compared to HCV patients with Medicaid, despite the fact that the majority of Medicaid patients had advanced fibrosis [3]. Since this analysis, there has been some improvement in the access to care challenges for the Medicaid population with HCV. In fact, recent data suggest that some Medicaid programs have adopted a more liberal policy in providing coverage for treating HCV, though others continue a highly restrictive policy [3]. Unfortunately, these restrictive policies remain in place despite evidence that there are downstream economic benefits for treating HCV patients with Medicaid coverage [4].

It is also important to place these data in the context of the burden of disease and applicable policies for Medicaid. First, the prevalence of HCV infection is disproportionally higher in the Medicaid and uninsured population [5]. Second, it is important to note that recent evidence suggests that both HCV infection and Medicaid coverage in HCV infected patients can increase the likelihood of all-cause mortality [5]. Third, in March of 2015 a policy was established to guide HCV treatment for the Medicaid population in the United States [6]. The purpose of this policy was to guarantee Medicaid beneficiaries have access to HCV drugs according to the established policies [6]. It is also important to recognize that after the passage of the Patient Protection and Affordable Care Act, some of the uninsured patients with HCV became Medicaid eligible as a consequence of the Medicaid expansion policies adopted by some states [7]. Finally, in 2017, the World Health Organization (WHO) declared its goal of HCV elimination by the year 2030 [2]. In the context of these important facts, it is important to recognize the challenges faced by many Medicaid programs in the United States. To deal with the conundrum of HCV infection in the Medicaid and uninsured population, it is important for policymakers to provide Medicaid programs with additional resources in return for requiring all HCV patients be treated.

In addition to the insurance status, the study by Wong et al. reported that being of Hispanic ethnicity was also associated with not receiving treatment [1]. These data are also worrisome because of the recent reports from New York City suggesting the highest HCV mortality was among non-Hispanic blacks or Hispanics [8]. The high burden of HCV infection in the Hispanic population was confirmed by another study using geographic information systems, spatial epidemiology, and statistical modeling [9].

In summary, the study by Wong et al. provides additional evidence about important disparities in providing care for HCV infected patients. In this context, it is important that policymakers in the United States develop a comprehensive national policy to eliminate HCV by 2030. In developing this national policy, they must include all important stakeholders including patients, providers, payers, and pharmaceutical companies. Short of this national policy, the disjointed and disparate approach to identification and treatment of HCV infected patients will continue and the goal of elimination of HCV as set by the WHO will not be realized.


  1. 1.

    Wong RJ, Jain MK, Therapondos G, Shiffman ML, Kshirsagar O, Clark C, et al. Race/ethnicity and insurance status disparities in access to direct acting antivirals for hepatitis C virus treatment. Am J Gastroenterol. 2018. Mar 9. https://doi.org/10.1038/s41395-018-0033-8. [Epub ahead of print].

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    World Health Organization. Eliminate hepatitis: WHO. WHO, Geneva, 2017. http://www.who.int/mediacentre/news/releases/2017/eliminate-hepatitis/en/

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    Younossi ZM, Bacon BR, Dieterich DT, Flamm SL, Kowdley K, Milligan S, et al. Disparate access to treatment regimens in chronic hepatitis C patients: data from the TRIO network. J Viral Hepat. 2016;23:447–54. https://doi.org/10.1111/jvh.12506. Epub 2016 Feb 3.

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    Younossi Z, Gordon SC, Ahmed A, Dieterich D, Saab S, Beckerman R. Treating Medicaid patients with hepatitis C: clinical and economic impact. Am J Manag Care. 2017;23:107–12.

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    Bush H, Paik J, Golabi P, de Avila L, Escheik C, Younossi ZM. Insurance coverage and mortality in patients with hepatitis C virus (HCV) infection in the United States (US). Digestive Disease Week, Washington DC, 2018

  6. 6.

    Department of Health & Human Services. Medicaid drug rebate program notice. Release No. 172. 2015 https://www.medicaid.gov/medicaid-chip-program-information/by-topics/prescription-drugs/downloads/rx-releases/state-releases/state-rel-172.pdf

  7. 7.

    Medicaid Expansion Act of 2009, HR 511, Public Law 110-69.

  8. 8.

    Ford MM, Desai PS, Maduro G, Laraque F. Neighborhood inequalities in hepatitis c mortality: spatial and temporal patterns and associated factors. J Urban Health. 2017;94:746–55.

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    Stopka TJ, Goulart MA, Meyers DJ, Hutcheson M, Barton K, Onofrey S, et al. Identifying and characterizing hepatitis C virus hotspots in Massachusetts: a spatial epidemiological approach. BMC Infect Dis. 2017;17:294.

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  1. Department of Medicine, Center for Liver Diseases, Inova Fairfax Medical Campus, Falls Church, VA, USA

    • Zobair M. Younossi MD, MPH
  2. Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA

    • Zobair M. Younossi MD, MPH


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Conflict of interest

Guarantor of the article: Zobair M. Younossi MD, MPH

Specific author contributions: Zobair M. Younossi MD, MPH

Financial support: None

Potential competing interests: Zobair M. Younossi, MD, MPH, has received research funds or consulting fees from Intercept, BMS, Gilead, NovoNordisk, Shinogi, and Novartis.

Corresponding author

Correspondence to Zobair M. Younossi MD, MPH.

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