Trends in hepatitis C treatment initiation alongside changes in Medicaid policy requirements: Wisconsin, January 2015-December 2022

BACKGROUND: Treatment is recommended for all persons with hepatitis C virus (HCV) infection, which substantially reduces HCV-associated morbidity and mortality. A US state Medicaid program incrementally removed policies restricting access to direct-acting antiviral (DAA) treatment, including specialist and severity requirements (2017), sobriety (2019), and prior authorization (2020). We evaluated longitudinal trends in hepatitis C treatment initiation alongside the timing of these policy changes. OBJECTIVE: To describe HCV treatment initiation rates concurrently with the removal of restrictive policies among a population of Medicaid recipients with recently diagnosed infection. METHODS: We matched public health surveillance data and Medicaid claims to identify Medicaid recipients with HCV infection during January 2015-December 2022. We defined treatment initiation as at least 1 pharmacy claim for DAAs within 6 months of hepatitis C diagnosis among persons with 6-month continuous Medicaid enrollment. We evaluated longitudinal changes in treatment rates across distinct policy periods using modified Poisson regression models adjusted for sex, race, ethnicity, and birthyear cohort. Adjusted rate ratios and 95% CIs were calculated. RESULTS: Yearly treatment ranged from 1% (among those diagnosed in 2015) to a maximum of 23% (among those diagnosed in 2020). In the multivariable model evaluating trends concurrent with policy changes, treatment initiation was 2.8 times (95% CI = 2.2-3.6) as high as baseline during the period without specialist provider and disease severity restrictions; 3.7 times (95% CI = 2.8-4.8) as high during the period without sobriety restrictions; and 5.6 times (95% CI = 4.4-7.0) as high during the period when all administrative restrictions were absent. CONCLUSIONS: Overall treatment uptake remained low in this population of Medicaid beneficiaries diagnosed with hepatitis C, despite the incremental removal of policy requirements. Although relative treatment rates increased across successive policy periods, initiation peaked at just 23%. These findings suggest that although removing administrative barriers is a necessary baseline step, policy liberalization alone is insufficient to achieve hepatitis C elimination, and additional clinical and structural interventions are needed.