A report from this month’s Liver Meeting revealed that in some states, Medicaid has refused payment for antivirals to 50 percent of hep C patients. Often patients are told that their fibrosis is not advanced enough to warrant treatment.

In many cases, fibrosis becomes advanced after people reach age 65, when they are eligible for Medicare. The program for older Americans is federally funded. It more likely than cash-strapped states to pay for the drugs, Matt Salo, executive director of the National Association of Medicaid Directors, told Medscape this week.

The Department of Health and Human Services is set to debate this and other drug-cost issues tomorrow. The forum on Innovation, Access, Affordability and Better Health can be viewed in a live webcast at 9 a.m. EST, Friday, Nov. 20. http://ow.ly/URrJX

The TPP (Trans Pacific Partnership) recently negotiated among the United States, Canada, Mexico, and eight South American and Asian countries, may help keep the high cost of hepatitis C drugs high.

Until now, most countries (notably excluding the United States) were able to negotiate costs with drug manufacturers. For example, Egypt procured Solvaldi for its citizens for a total treatment cost of about $900.

Parties to the TPP have agreed to “promote transparency and procedural fairness” in dealing with pharmaceuticals. Yet transparency is the last thing a good negotiator wants to use in bargaining down the cost of a product. Expert negotiators say you should never reveal your maximum purchase price to the seller. Concealment of your budget isn’t transparent, yet being upfront about the maximum price you might pay tends to make the negotiated price rise to that max.

Solvaldi, Harvoni, and Viekira Pak have already been through the negotiation roundtable. But with new hep C drugs arising to treat difficult genotypes, the future remains precarious under this trade deal.

China has just rejected one of Gilead’s patents for Sovaldi.  Patient advocacy groups had challenged the patent, saying it wasn’t inventive enough. Tahir Amin, intellectual property director for one of the groups, said this could begin a shift toward lower-priced, generic hep C drugs in China and other countries.

The patent is also being challenged in in Ukraine, Russia, Argentina and Brazil.

In the U.S. today, ProPublica and the Washington Post have jointly reported that the cost to treat hepatitis C for Medicare patients soared 15-fold last year, from 2013.

In 2014 Medicare spent $4.5 billion on hep C drugs. This doesn’t include deductibles that Medicare patients pay. Medicare is available to U.S. citizens and permanent residents over 65.

Solvadi, Olysio (Galexos in Canada), and Harvoni account for most of the programs’ spending. Medicaid, the U.S. program that funds health care for the poor, spent $1.2 billion on the drugs in the first nine months of 2014.

Given that many people were still getting interferon treatment through much of 2014, the 2015 costs could climb much higher. Competition, rationing, or compassion from drug companies could lower the costs, of course.

It was great to learn today that accessing two of the new hepatitis drugs has become easier in British Columbia. Pharmacare has just approved Solvaldi and Harvoni, both Gilead products. Many extended health plans pay for only Pharmacare-approved drugs.

In France the charity Medicins du Monde has just challenged Gilead’s patent on Sovaldi, because of the exorbitant of the drug. Meanwhile in the United States, the Southeastern Pennsylvania Transportation Authority is suing Gilead over the drug’s $84,000 price tag. In India, where the patent office rejected Sovaldi because of its similarity to another compound, Gilead is the plaintiff in an appeal of that decision.

Meanwhile, other drugs are set to compete in the hep cure marketplace. One to keep an eye on is Achillion’s NS5A inhibitor. Combined with Sovaldi in a small trial last year, it cured 100% of patients in six weeks. The company is now looking at a 4-week trial. Granted, Gilead is still involved, but other competition from AbbVie, Bristol-Meyers Squibb, Johnson & Johnson, and Merck portend a very different playing field. There’s lots and lots more to come on this.