Inmates in Oklahoma prisons must have advanced liver disease before becoming eligible for treatment of hepatitis C, a potentially deadly and growing disease.
The situation in prisons pits the enormous cost of treatment against the public health gains of curing one of the populations most at risk for the viral infection.
The Oklahoma Department of Corrections reports that more than 2,700 inmates have hepatitis C. But in response to queries from Oklahoma Watch, the agency said that since July 1 it has treated just five inmates with life-saving antiviral drugs, which cure more than 90 percent of patients. Those inmates reached a level of liver scarring that met criteria for treatment; others may not reach that stage for years.
Public health advocates and experts say much more effort is needed to treat inmates infected with hepatitis C before their conditions worsen or they are released and put others at risk. The disease is spread through intravenous drug abuse and sexual contact.
A cost of $29,161 per inmate is the obstacle to comprehensive treatment. The Corrections Department is asking for $79.4 million in fiscal year 2019 to treat all 2,724 inmates diagnosed with hepatitis C. The big-ticket item is part of Corrections Director Joe Allbaugh’s request for an additional $1 billion next year.
The price tag for treatment drugs dwarfs the department’s current spending on them. It has spent $86,408 on hepatitis C antiviral drugs so far this fiscal year, department data shows.
The request for hepatitis C treatment drugs is nearly five times the $17 million the department expects to spend this year for all pharmaceuticals to treat all medical conditions.
By not treating more inmates, the department also is taking a risk that it will be sued.
That has happened in other states, including Missouri, Colorado, Tennessee, Pennsylvania and Florida.
In Florida, a federal judge in November ordered treatment of thousands of inmates with hepatitis C and sharply criticized the state’s corrections system for inaction. Just seven inmates out of about 20,000 with hepatitis C were getting treatment when the lawsuit was filed.
“The judge ordered them to begin immediately staging and treatment of inmates,” said Randall Berg, an attorney with the Florida Justice Institute, which represents the inmates. “He wants the ones that are sickest to be given direct-acting antivirals first.”
In Oklahoma, the prospects of getting additional funding from the Legislature to treat all inmates now is slim.
Lawmakers face a $600 million-plus budget hole and must balance the department’s request with those of other agencies for education, health and highways.
A legislator and anesthesiologist, Sen. Ervin Yen, said the right thing to do is fund the treatments. But he said it will be a tough call in a troubled budget cycle.
“I’m not saying we shouldn’t spend all that money on those folks, but … that’s big bucks,” said the Oklahoma City Republican. “I certainly don’t have a magic answer to that question.”
More Inmates with Hepatitis C
Hepatitis C takes different forms. In the acute stage, which occurs within the first six months of being exposed, the disease can clear on its own. The majority of acute cases become chronic hepatitis C, which can stay with a person for life unless treated and lead to liver cancer or cirrhosis. It can take years for symptoms of hepatitis C to appear and lead to a diagnosis. Symptoms of the liver inflammation include abdominal pain, jaundice and loss of appetite.
Oklahoma had the highest estimated rate of hepatitis C infection in the nation, according to a 2017 study from Emory University and the U.S. Centers for Disease Control and Prevention. The study estimated Oklahoma had about 94,200 residents with hepatitis C in 2010, or about 2.5 percent of the population. The rate of new infections slowed in 2014 and 2015, but the CDC warned that the opioid addiction crisis, which is severe in Oklahoma, is helping drive hepatitis C infections. More than 19,600 Americans died of the disease in 2015, although deaths and infections are undercounted.
The illness is more prevalent among inmates.
The percentage of prison inmates diagnosed with the disease has risen from 6 percent in 2013 to nearly 10 percent in late 2017, corrections data shows. The Corrections Department attributes at least some of this increase to better screening of inmates during the intake process.
Some data from recent years point to rare or nonexistent treatment. The state’s corrections system was only treating one inmate with hepatitis C on July 1, 2016, according to data compiled by the Council of State Governments, which surveys state correctional systems. The Corrections Department doesn’t dispute the figure but notes it is a point-in-time snapshot of how many inmates were undergoing treatment on that day, not for the entire year.
Low figures emerge in other years, too. The department reported that it treated no inmates on July 1, 2015, and three inmates on July 1, 2014.
Separately, a national point-in-time survey by the journal Health Affairs found that Oklahoma was one of four states that reported none of its diagnosed inmates was in a hepatitis C treatment program on Jan. 1, 2015. The highest treatment rate was 5.9 percent in New York.
The Corrections Department declined to make its medical director available for an interview, saying he was unavailable.
What Triggers Treatment
Hepatitis C experts and public-health advocates say treating inmates is a common-sense step to keep the disease from spreading after they are released.
“Prisons and jails are ground zero,” said Michael Ninburg, executive director of the Hepatitis Education Project, a Seattle-based advocacy group. “(Halting the disease’s spread) is not going to happen unless we start to treat hepatitis C in the correctional setting. So it’s a way to dramatically reduce the mortality and disease burden.”
Matthew Elliott, spokesman for the Oklahoma Corrections Department, said more states are moving toward testing and treating inmates.
“There is certainly support for this from public health organizations because of the potential to eradicate the disease,” he said in an email.
Oklahoma inmates are screened for evidence of liver disease when inmates enter the prison system – men at the Lexington Assessment and Reception Center and women at the Mabel Bassett Correctional Center in McLoud.
Last year, the department began using a more comprehensive blood test panel to screen new inmates for enzymes that indicate liver disease. If enzymes are detected, a follow-up test is ordered that directly checks for hepatitis C. Inmates are prioritized for treatment based on the extent of liver damage. The department’s policies require evidence of progressive liver damage before inmates become eligible for treatment. Inmates also must be free from alcohol and drugs and not have poorly managed chronic medical conditions or recent tattoos or piercings.
Although only a handful of inmates get the drugs that cure them, the department said it monitors all inmates and treats the symptoms of those who don’t qualify for the drugs.
Elliott said the department’s policy is based on policies of the U.S. Bureau of Prisons, which also prioritizes treatment based on scarring level. Oklahoma’s policy applies to inmates in privately run prisons, too.
Elliott said the $79.4 million budget request would cover treatment and genetic testing for diagnosed inmates. Tests are required to determine the most effective antiviral medication. The average cost of an inmate’s treatment is an estimated $28,861. Genetic testing is another $300.
The request doesn’t cover future needs. Elliott said the funding request wouldn’t pay for testing or treatment of not-yet-diagnosed inmates or new inmates entering the system.
Forty-two states, including Oklahoma, track hepatitis C in corrections systems, a 2017 report by The Pew Charitable Trusts found.
A separate Pew study on pharmaceutical costs in prison health systems found that newer, more effective and expensive drugs for hepatitis C that came out in 2013 and 2014 have elevated the issue of prescription drug costs. In that study, 21 state corrections agencies said the rising cost of hepatitis C drugs is a concern. Since then, drug costs have started to decline.
In response, states have reported prioritizing treatment for the disease based on its stage and using objective criteria, said Maria Schiff, with The Pew Charitable Trusts.
Ninburg, of the Hepatitis Education Project, said the Florida order bodes well for inmates seeking treatment.
“That ruling is likely to be the first of many,” he said.
For now, the cost of drugs combined with the knowledge of how many Oklahoma inmates have the disease creates tough questions. Should treatment be delayed if an inmate will exit the system before there is any liver scarring? Is the state liable for damages if that inmate infects someone else after release from prison?
The practice of prioritizing treatment based on the degree of scarring saves the state tens of millions of dollars a year but also means some inmates deteriorate while awaiting treatment.
Outside prison walls, the medical world views hepatitis C like any other disease: Early treatment offers a better outcome for the patient and saves money in the long run. Antiviral drugs, which typically must be taken two to three months before curing the patient, are better than a liver transplant.
“From the medical point of view, my answer is ‘yes’ because I’m a doctor,” Dr. Harlan Wright, who treats liver conditions at the University of Oklahoma’s Oklahoma Transplant Center, said about early treatment.
The other group that benefits is local communities, Ninburg said.
Most inmates are released and reintegrate into society. Although SoonerCare, the state’s Medicaid program, pays for hepatitis C drugs, many newly released inmates don’t meet the income and other criteria to qualify for SoonerCare. The program doesn’t cover prison inmates.
“By treating them now and curing them now, not only are we preventing an early death, we are also preventing transmission to other community members when the prisoner gets out,” Ninburg said.
“If you are a lock them up and throw away the key type of person, as wrong as that is, what you cannot argue with is the fact that correctional health equals public health.”
Reach reporter Ben Botkin at firstname.lastname@example.org or (702) 418-6089.