On May 9, the Center for Health Law and Policy Innovation (CHLPI) and AIDS Alabama filed an administrative complaint with the United States Department of Justice (DOJ), alleging that Alabama Medicaid is illegally discriminating against people with substance use disorder by obstructing access to treatment for hepatitis C.
Hep C, a curable liver infection that is commonly transmitted through shared needle use, currently affects more than 30,000 people in Alabama. Yet the state “denies [hep C] treatment to otherwise eligible Medicaid enrollees who cannot prove they did not use drugs or alcohol within the last six months.” Prospective patients must also agree to not use drugs, including alcohol, during the treatment. Out of pocket, a standard regimen of hep C medication costs tens of thousands of dollars.
Use of state-banned drugs like heroin, fentanyl, cocaine and methamphetamine does not interfere with the efficacy of the medication. The only substance of concern is alcohol, since hep C affects the liver and the additional strain from alcohol can make it more difficult for the medication to do its job. But the public health-based approach is to not withhold lifesaving treatment just because someone consumes alcohol; rather, patients are advised to abstain for the duration of treatment—typically eight to 12 weeks—if possible, and if not to just reduce their drinking as best they can.
Alabama Medicaid patients found to be using drugs, including alcohol, while taking the medication face their treatment being discontinued. But it is unclear how Alabama Medicaid would monitor this, or whether drug-testing would be involved. Neither Alabama Medicaid nor the DOJ responded to Filter’s request for comment.
The policy could not only prevent some patients from curing their hep c now, but prevent them from ever being cured.
Discontinuing hep C treatment partway through can result in a patient’s system developing a resistance to the medication, meaning that this policy could not only prevent some patients from being cured during the current attempt, but prevent them from ever being cured.
“On an individual level, for a single person seeking hep C treatment, it means the difference between being cured of hepatitis C and continuing to live with this very dangerous illness that, in many cases, can lead to liver scarring, liver cancer and even death,” Suzanne Davies, an attorney and CHLPI clinical fellow, told Filter.
Alabama is not alone in maintaining these prohibitive requirements around hep C medication. “A lot of state Medicaid organizations put a lot of restrictions into their policies,” Davies said, prompted by “what they perceived to be the high cost of treating people.”
If these states “made an effort to do the opposite of what they are doing,” she continued, “then that would have a really big public health impact in not just curing individual people, but helping to make sure that [hep C] doesn’t continue to spread.”
Still, Davies added that Alabama’s sobriety clause is something of a hold-over from an earlier time, as in recent years many states have removed these policies.
While CHLPI and AIDS Alabama could have started a legal case against Alabama Medicaid—and did against Texas Medicaid’s practices in 2021—they decided to go through the DOJ because it is the federal entity tasked with enforcing Title II of the Americans with Disabilities Act, which oversees anti-discrimination among state or local government entities like Medicaid.
“In this case, looking at the past couple of years, we have noticed that the [DOJ] has been involved in several settlements with public entities and private entities involving issues regarding substance use disorder,” Davies said. “People had reported discrimination against them based on their substance use, and the [DOJ] had settled cases with some of those entities.”
Petitioning DOJ to investigate state Medicaid systems can be an effective way of combatting Title II discrimination. In an administrative complaint of this kind, one party submits information about what happened for the DOJ to evaluate, and then decide whether to begin its own investigation into the matter.
DOJ taking up the complaint “would be such a big step in the right direction,” Morgan Farrington, founder of Alabama-based harm reduction organization GoodWorks, told Filter.
But the timeline on which DOJ will respond to the complaint is uncertain. It “could be a fast turnaround,” Davies said, “or it could take years.”
Photograph via Centers for Disease Control and Prevention