# Less Restrictive Medicaid Policies for Direct‐Acting Antiviral Access Are Associated With Greater Declines in Hepatocellular Carcinoma Deaths

## TL;DR

States with easier Medicaid access to hepatitis C treatments saw bigger drops in liver cancer deaths.

## Contribution

This study links less restrictive Medicaid policies for hepatitis C drugs to reduced hepatocellular carcinoma mortality rates.

## Key findings

- States with less restrictive Medicaid DAA policies had declining HCC death rates after 2017.
- Improved DAA access is associated with lower HCC mortality and better HCV treatment outcomes.
- HCC death rates continued to rise in states with stricter Medicaid DAA policies.

## Abstract

In the United States (US), chronic hepatitis C virus (HCV) is the leading cause of hepatocellular carcinoma (HCC). Direct‐acting antivirals (DAAs) cure HCV and reduce HCC risk, but Medicaid DAA coverage varies across states.

We assessed whether Medicaid DAA access was associated with trends in HCC‐related deaths.

We analyzed CDC WONDER death certificate data (1999–2023) to assess HCC‐related mortality. US states were grouped based on Medicaid DAA prior authorization restrictions using the Hepatitis C: State of Medicaid Access scoring system: A+/A (n = 28), B (n = 11), and C/D (n = 12). We used NCI Joinpoint software to calculate the annual percentage change (APC) and average annual percent change (AAPC) in age‐adjusted death rate. State‐specific HCC crude death rates were analyzed before and after 2014, alongside changes in Medicaid DAA policies from 2014 to 2024.

Before 2017, HCC‐related death rates were positive in group A + /A (APC 2.01, 1999–2017), group B (APC 3.40, 1999–2009), and group C/D (APC 2.04, 1999–2023). Age‐adjusted death rates became negative in group A+/A states (APC −0.19, 2017–2023), while death rates continued to be positive for group B states (APC 1.49, 2009–2023) and group C/D states (APC 2.04, 2017–2023). The AAPC (1999–2023) was lowest in group A + /A (1.46), followed by group B (2.28) and C/D (2.04). From 2014 to 2024 accessibility to DAAs improved.

Increased DAA access was associated with reduced HCC‐related death rates. Improved HCV treatment could contribute to decreased HCC incidence and recurrence, enhance linkage to subspecialty care, and prevent liver‐related decompensation.

US states with less Medicaid restrictions for direct‐acting antivirals (DAAs) were associated with a greater decline in hepatocellular carcinoma (HCC) deaths. Policy to promote access to hepatitis C virus (HCV) treatment can improve death rates from HCC.