Dr. Michael Fine: What’s Crazy About Hepatitis C, HIV, and Colon Cancer

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Dr Francis Collins, the retired but long-time director of the National Institutes of Health, has been writing and talking recently about the need for the US to spend about $5 billion over five years to eliminate Hepatitis C in the US.  

It’s a great idea, on the face of it.  There are about 2.7 million Americans infected with Hepatitis C, which kills 10-15,000 people a year by causing cirrhosis of the liver, gastrointestinal bleeding, liver failure, and cancer of the liver.  The only good news is that we’ve had a good treatment for Hepatitis C since 2014. (We had some less good but usually effective treatments about ten years before that.)  This treatment is usually easy to tolerate – one pill a day for eight to twelve weeks.  It is a little expensive, though – about $84,000 for one course of treatment.  But the treatment is a cure; it saves lives, and every person treated stops transmitting the virus and infecting others.

So, what’s not to like about this idea?

Two things.

The first is the cost, and the second is that Dr Collins’s plan won’t work to eliminate Hepatitis C in the US.  

So first to cost.  Treating $2.7 million people with a drug that costs $84,000 per treatment would cost $226 billion dollars, which is more than the Gross Domestic Product of all but fifty nations in the world and about twenty states and more than the total state budget of every state except California. (Rhode Island’s GDP is about $74 Billion.  Our state budget is about $15 billion.)  There’s good news, sort of.  There’s a competing drug that only costs $20,000 per treatment, so we might be able to treat 2.7 million people for only $54 billion.  Dr. Collins, to his credit, and others have described a subscription plan, under which Medicaid would buy the drugs from their manufacturers for a fixed price and save the government money.  And get more people treated in the process.  All good.

But.  But.  But.  But.  But.  This proposal might reduce the number of people infected with Hepatitis C.  And it will save lives and even, perhaps, save money, because it may keep more Hepatitis C infected people from dying expensively from cirrhosis and liver cancer.  But as health care writer and policy expert Merrill Goozner points out, we haven’t seen savings from these medications yet, because too few people have been treated, which means the disease is still spreading and the total number of people with it has continued to rise.  With Dr Collins’ ideas about treating more people, we will save some lives and save some money, which is all to the good.

 But this proposal cannot and will not eliminate Hepatitis C in the US.

Why?  

In order to eliminate Hepatitis C, HIV, and colon cancer, all treatable, preventable diseases, and markedly reduce disability and death from diabetes, heart disease and stroke, which are also preventable diseases, we’d need a system that enrolls all Americans, tests all of us for diseases like Hepatitis C, HIV, and colon cancer as well as diabetes, high blood pressure and elevated cholesterol, treats or cures those of us who have those diseases and thus prevents their spread, in the case of Hepatitis C and HIV, or prevents death and disability from those diseases before that disability and death can occur, in the cases of colon cancer, diabetes, heart disease and stroke.

Dr Collin’s idea won’t eliminate Hepatitis C in the US because it doesn’t include a plan or a mechanism to test all Americans.

Creating a system to enroll and test all Americans isn’t difficult or expensive.  All we have to do is to expand access to primary care, make sure all Americans have a primary care clinician, and give all our primary care clinicians the tools they need to test all their patients. That’s what other advanced nations do, nations that have health care that is affordable and effective, which ours is not.  About 43 percent of us already have primary care.  Primary care is inexpensive, compared with other medical treatments, about $500 per person per year.  Which means it would cost another $94 billion dollars a year to provide primary care to all Americans (57 percent of 330 million people = 188 million people x $500/per person per year) – less than the cost of treating just everyone infected with Hepatitis C, if we paid full price.

Even if we could eliminate Hepatitis C in the United States using the Dr Collins’ approach, we’d leave HIV and colon cancer to continue killing Americans.  And diabetes, heart disease and stroke.

But we can markedly reduce or eliminate HIV, colon cancer, diabetes, heart disease and stroke for a price less than the cost of reducing the spread of Hepatitis C alone.  We just need to think a little more broadly and bring primary care to everyone.

We can improve the public’s health in the US and do so affordably. And eliminate Hepatitis C, HIV and colon cancer.  We just need a health care system that provides primary care to all Americans in every American neighborhood and community.

It’s crazy we haven’t provided primary care to all Americans.  And it’s crazy to read plans like Dr Collin’s, which talk about only one disease and don’t focus on what we can and should do together as a nation, which is to provide primary care to all.