At The Crossroads, Part 7: Behind bars, Hep C takes a toll on inmates and budgets

Rhode Island’s prisons are grappling with a dilemma. Hundreds of inmates have hepatitis C. New drugs can cure it. But they’re so expensive the department of corrections can’t afford them for every inmate who’s sick.

In this next part of our series “At the Crossroads,” a look at how prison officials decide who gets treated first.

Patients crowd the waiting room in this busy clinic. Down the hallway, the doctor’s office is prepped, clean and bright. Fresh white paper lines the exam table. Inside, the doctor and nurse are going over patient records before the first appointment of the day. It’s like any other medical clinic, except the patients here wear khaki uniforms. And guards with chirping walkie-talkies pace the halls. We’re in the medium security state prison in Cranston. Every week Dr. Michael Poshkus sees patients with hepatitis C here. And this morning he’s got good news for one of them, Ed, who’s just hopped up on the exam table. Ed doesn’t want to use his last name because of the stigma he might face for doing time, and having hepatitis C. Wait– scratch that… having had hepatitis C.

“So at this point we want to repeat the blood test and we anticipate that we won’t see any virus in your system at this point, after just one month.”

Just one month of taking a new medication called Sovaldi, and Ed may well be cured of hepatitis C. He’s one of a handful of inmates in Rhode Island approved to take this new drug. It’s so expensive the prison can’t afford to give it to every prisoner who might benefit. And there are hundreds. A recent study estimated that hepatitis C affects about a quarter of Rhode Island’s more than 3000 inmates.

“And so do you have any questions?” asked Poshkus.

“No, all I can say is I’m glad I’m on this new medication,” said Ed. “I’m on this new medication, I’ve been hearing about it for like a year now, and I’m just glad I’m on this. Two months ago I was jaundiced…. I just want to thank you for this medication.”

Poshkus finishes up his exam and tells Ed he’ll follow up in two months. Down the hall from the exam room, Ed pulls up a chair in an empty holding cell to tell his story. He says he probably got hepatitis C from sharing needles.

“I’ve been a heroin addict, I’ve been shooting drugs for over 30 years,” Ed said. “I’m 51 years old. But I don’t know how long I’ve had it. I could have had it for 10, 20 years now.”

He can’t wait to put hepatitis C--and the life he led on drugs –behind him.

“I have a loving fiancé, I got two kids, they always tell me, daddy when you coming home? Daddy will be home soon. I just want to live a normal life. That’s all I want,” said Ed.

Ed knows how much his treatment is costing taxpayers. And that some people might balk at spending so much on inmates.

“I don’t like the thought of people thinking, oh, I’m spending my money on inmates. We’re human beings, you know, like everybody else.”

If that sentiment doesn’t convince you, Ed said, consider this:

“It is a lot of money but, in the long run it’s worth it, because these guys, one day, they’re getting out of here. All of us, one day we’re going to be out on the street, so it’s better treating us now.”

Most inmates will be released at some point, many of them struggling with drug addiction. If they go back to shooting drugs and sharing needles, they risk transmitting hepatitis C to others.

The U.S. constitution guarantees inmates medical care.  And that care must meet the same standards of care out in the community. The community standard of care for hepatitis C changed almost overnight. And it caught Rhode Island Department of Corrections head A.T. Wall off guard.

“The advent of these new treatments for hepatitis C came like a monsoon on a calm summer day,” Wall said. “We didn’t see it coming. So when we submitted our budget for last year and this, the possibilities provided by these new treatments were unknown to us.”

The possibilities for curing most patients, with hardly any side effects. A far cry from the old treatment. Also a far cry from the old treatment? The price. Wall says 12 weeks of treatment with a new drug called Sovaldi, which often has to be taken in combination with another drug, will cost about $150,000 dollars per inmate. And again, hundreds of inmates under his care right now could benefit from the treatment.

“Our entire pharmaceutical budget for this year is about $2.25 million dollars,” Wall said. “It doesn’t take many patients at $150,000 per to eat up the entire pharmaceutical budget. Something’s going to have to give here. And I don’t know how it’s going to play out.”

So Wall says they’ve adopted new guidelines from the federal Bureau of Prisons that prioritize patients for treatment according to how sick they are. Wall says a committee reviews requests for treatment from prison doctors. And medical director Dr. Fred Vohr says inmates whose livers are in the worst shape from hepatitis C go to the top of the list.

“We measure the liver function, we measure what the liver looks like, we measure how it’s working. And then we say, now you’ve got three other guys here, they’re all pretty bad. But this one’s worse than this one. Mind you the end result of liver disease is death, or a liver transplant.”

So asking an inmate to wait for treatment means his liver disease keeps getting worse. But that’s what many inmates will have to do unless the corrections department’s $19 million dollar health care budget gets a boost. Not likely, said Wall, in a state already facing a budget deficit.

“The fact of the matter is this cost is borne entirely by the states,” said Wall. “And that drains money away from education, transportation, economic development, areas that are more attractive to the public and public officials.”

“When people think of prisoners, an image of somebody bad, dangerous, needs to be locked up comes to mind,” said Dr. Jody Rich. “What they don’t realize is that if you look at prisoners and you look at who they are, they’re normal people, people who happen to be stigmatized, who happen to be disadvantaged, who happen to have made some poor decisions.”

Every week for the past 20 years, Rich has peddled to Cranston to see patients behind bars. On this day he’s in his cluttered office in Providence, between meetings and phone calls. Rich advocates for treating hepatitis C behind bars as a way to make a real dent in the epidemic. That’s because the disease is far more prevalent in corrections than in the general population – by some estimates as many as 30 percent of the nation’s prison population has hepatitis C.

“So when we extrapolate that to the 2.2 million people behind bars today,” said Rich, “that’s a large proportion of people with hepatitis C behind bars now.”

Yes, the upfront costs are huge, says Rich. But if we spend the money now to treat people in prison, we not only keep them from spreading the disease after they’re released. We avoid the costs of not treating hepatitis C.

“So those costs are generally borne by the community, not so much by the criminal justice system,” said Rich. “So that means these people are going to get out, they’re going to get sick, they’re going to show up in emergency rooms, they’re going to get hospitalized, they’re going to get tests, they’re going to get liver transplants.”

We can avoid all that, said Rich. We have everything we need to fight this epidemic now: “We know how to do this and we’ve done it with HIV. But a big difference between HIV and hepatitis C at this point, given our newer treatments, is that we can cure hepatitis C in a few months.”

But that will take money. Millions of dollars in Rhode Island, billions nationwide. There’s no ground swell of public opinion for or against finding that money, yet.

At the Rhode Island Dept. of Corrections, medical director Dr. Fred Vohr says that, for now, they’re not denying inmates treatment. But they are prioritizing them. And that’s all he can do unless someone forces them to do more.

“Much of the medical improvements in the correctional world is because of suits generated by the incarcerated community,” Vohr said.

Vohr said that, under certain circumstances, he’d welcome a suit if it got inmates the care they need.

This story originally ran on the Rhode Island Public Radio.