Like much of the country, Alaska is seeing a surge in opioid and heroin addiction. State officials are scrambling to deal with an expanding list of the consequences. One side effect is a massive increase in diseases connected to injecting drugs, particularly Hepatitis C, raising concerns about a potential tidal wave of healthcare costs facing Alaska.
On the wall of his midtown Anchorage office, Jay Butler has a framed picture of a Yup’ik mask made by artist Drew Michel. It’s colored in hot, garish shades of paint representing a face in pain from Hepatitis C.
“That’s certainly how I interpret it,” Butler said.
The piece is fitting, given that Butler is the Chief Medical Officer for the state health department, and has been loosing sleep over Hep C.
“We talk mostly about opioid overdose deaths, but there’s a lot more that happens related to opioid use than just deaths,” Butler said.
Like Hep C infections, which can slowly destroy the liver. As more people inject prescription painkillers and heroin, there is a parallel rise happening in blood-born diseases.
Especially among young people.
“The most concerning trend that we see is an increasing number of diagnoses age 18 to 29,” Butler said.
That’s new. Hep C used to hit Baby Boomers the hardest. The virus wasn’t discovered until 1991, and by then millions had been exposed to it through blood transfusions, tattoo needles, and syringes. Rates fell throughout the 90s and bottomed out in the 2000s. But since then, the number of cases is shooting up.
Reported infections among 18 to 29-year-olds doubled in Alaska during a five-year period from 2011 to 2015, according to the Division of Public Health.
While chronic Hep C is not necessarily a death sentence, it creates a slew of long term problems.
“About one in five people will develop more progressive liver damage with fibrosis,” Butler said, referring to scarring of the liver. It can also cause Cirrhosis to the point where the scarring diminishes liver function. Aside from discomfort, this “slow burn inflammation” can exacerbate other conditions, and in up to five percent of people lead to the kind of full liver failure that requires an organ transplant.
Until recently, the treatment available for the hepatitis C virus was ineffective and fairly toxic. But in 2013 the FDA approved a new class of direct-acting antiviral drugs, which can clear the body of Hep C 90 percent of the time. It is effectively a new cure to a dangerous and widespread chronic condition.
But here is the catch: these medications are extremely expensive.
“The price is the downside and why I usually don’t say it’s a ‘miracle drug,'” Butler explained. “Because miracles don’t come with a price, they’re gifts.”
A course of treatment for Viekira Pak or Harvoni, two common medications, can cost $85,000 to $94,500. When these drugs first hit the market, Butler did a back-of-the-envelope calculation of what it would cost to treat the roughly 3.5 million Americans estimated to be infected with Hep C.
“I was coming up with more than 10 percent of all the medical care in the country,” he said.
In other words, not financially feasible.
It’s especially troubling for a state like Alaska. In rural areas people tend not to have regular access to clean syringes, which drives up the likelihood of re-use or needle sharing, increasing the risk of infections. And while Hep C medications are expensive on the front end, they’re cheaper in the long-term than treating people’s liver damage or paying for transplants.
But that’s putting real stress on a prime source of care: Medicaid.
“We’ve seen definitely an increase in the number of individuals who access these medications,” Erin Narus, the lead pharmacist for the state’s Medicaid program, said. As patients and doctors have grown more familiar with the new anti-viral meds, they’re being prescribed with greater frequency.
In 2015, Alaska’s Medicaid program spent $5.9 million dollars on Hep C treatments, according to Narus. The next year, that more than doubled to $13.6 million. And that money only bought treatment for around 150 people.
Nationwide, Medicaid spent about $2.2 billion on just one Hep C medicine, Harvoni made by Gilead Sciences. That was more than any other single medication. The second most purchased medicine that year was a brand of insulin that cost Medicaid $1.4 billion.
“It appears as if that outpaced the other drugs in that year,” Narus said of Harvoni.
Medicaid is just one of the insurers paying for these medications. Numbers from private providers, the VA and the Indian Health Service are not as public. A report by the McDowell Group calculated that treating just the 1,009 people in Alaska estimated to have been infected with Hep C from injecting drugs in 2015 would cost $90 million.
And even that model probably underestimates that full number of new cases. The areas seeing the steepest growth rates in Hep C infections are Southwest, Northern and Southeast Alaska — rural communities where healthcare, access to clean needles,and testing are spread the most thin. Among young people in southeast, the rate of diagnosis went up 490 percent during five years. Most of the officials interviewed during reporting said that when it comes to Hepatitis C in Alaska, the reality is likely worse than what the data show.
Which is especially bad, because right now the state has no money.
“This is not a time when it is likely that we’ll be able to increase the amount of money being allocated to addiction treatment,” Rep. Ivy Spohnholz (D-Anchorage) said. She chairs the House’s Health and Social Services Committee.
Without more funding for rehab programs or social services, legislators have been focusing on prevention efforts like those in House Bill 159, which limits access to pain pills and boosts reporting protocols to prescription drug data-base.
Gov. Bill Walker also accepted expanded Medicaid under the Affordable Care Act, and lawmakers are now hoping to tweak how the state delivers behavioral healthcare through the program. According to Spohnholz, the Alaska recently requested a 1115 waiver, which could give the state more discretion from federal guidelines when it comes establishing what treatments Medicaid will pay for.
“We need to make sure that (a) person gets addiction treatment, therapy and that they’re getting their basic healthcare needs met,” Spohnholz said. “So we need a lot more flexibility to be creative with that. The 1115 waivers could allow us to do that.”
Right now, the US Senate is revising the Republican bill to replace the Affordable Care Act, which could undermine Alaska’s approach to mitigating the worst effects of opioid abuse. Provisions in the first draft of the bill could end the requirement that private health insurance cover mental health benefits, leaving people without access to addiction treatment. More dramatically, it would make deep cuts to federal Medicaid spending compared to what’s in the ACA, and replace the open-ended system of reimbursements with a capped budget. Which means Alaska and other states would be forced to make more difficult choices about whether they can afford expensive treatments for growing problems like Hepatitis C.