Why Texas Needs Stronger Hepatitis C Policies in State Prisons

Executive Summary

Hepatitis C (HepC) is an infectious disease that causes chronic liver disorders. It disproportionately affects individuals in correctional institutions. Direct-acting antivirals (DAAs) effectively treat HepC and reduce long-term health care costs associated with HepC infections. However, incarcerated individuals face significant barriers in accessing treatment, including high co-pays and restricted access to DAAs. As the incarcerated population ages, their health care costs rise along with their vulnerability to infection. Therefore, addressing HepC becomes essential.

This report examines the obstacles to HepC testing and treatment for incarcerated individuals in Texas and provides options for policy reforms: 

• Expanding access to and clarifying the guidelines for HepC testing and treatment in prisons.
• Requiring HepC testing in county jails.
• Establishing a payer license agreement for the acquisition of DAAs.

Implementing these measures will not only improve health care outcomes for incarcerated individuals but also prevent further spread of HepC in prisons and the community.

Hepatitis C

Hepatitis C (HepC) is an infectious liver disease caused by the Hepatitis C Virus (HCV).^[1] HepC is transmitted through blood-to-blood contact, often as a result of reusing contaminated devices for drug injection or tattooing.^[2] However, HepC can also spread through unprotected sex, accidental needle sticks or cuts, and transmission from mother to child during childbirth and pregnancy.

HepC has two stages: the initial acute stage and the chronic stage. Upon infection with HepC, patients are often asymptomatic, experiencing no obvious signs of disease. After six months, 50% to 70% of patients infected with HCV develop chronic HepC.^[3] Over time, chronic HepC causes persistent liver inflammation, which can lead to liver disease and failure. If left untreated, 10% to 20% of patients will experience liver failure after 20 to 30 years.^[4] As a result, HepC is a leading cause of liver-related morbidity and mortality in the United States.^[5]

In 2014, the first treatment for HepC using direct-acting antivirals (DAAs) received approval from the U.S. Food and Drug Administration (FDA). These drugs’ cure rates exceed 90%, and their side effects are well tolerated.^[6] However, the drugs are expensive. Based on 2025 rates, DAAs cost approximately $22,000 per patient for a standard regimen.^[7]

HepC in Texas Prisons and Jails

HepC is the second most prevalent infectious disease in Texas prisons.^[8] Infections occur at a higher frequency in carceral settings due to overcrowding, making prisons hot spots of infectious disease transmission.^[9] While the general Texan population’s HepC prevalence is estimated at 1.8%, approximately 10% of incarcerated individuals in Texas are infected with HepC.^[10] Experts anticipate that these percentages will continue to grow in Texas and nationally, with injection drug use being the primary source of new infections.^[11]

Even though they are short-term facilities, jails are also hot spots of HepC transmission because individuals frequently cycle in and out of the system. Individuals are detained in jails for often unpredictable periods of time, ranging from days to years, after they are arrested and as they await trial. A 2022 study of the Dallas County Jail found an HCV antibody prevalence of 16.7%, which is 10 times the estimated national prevalence.^[12] Considering the initial asymptomatic nature of HepC, many individuals behind bars may be unaware of their infection.

Furthermore, the steadily increasing aging population has intensified both the medical and fiscal burden of HepC on Texas prisons. In 2019, the number of incarcerated individuals aged 55 and older rose by 65%. Although they only represent about 13% of the prison population, they accounted for almost 50% of health care costs in that same year.^[13] Additionally, elderly incarcerated individuals are at an elevated risk for HepC and are more vulnerable to later-stage liver-related morbidity and mortality.

The high prevalence of HepC in Texas correctional settings is a significant public health concern because infected individuals reentering communities may unknowingly spread HepC. Therefore, developing policies that address HepC in correctional settings is essential to treat high-risk incarcerated populations for this curable disease and to prevent spread.

Health Inequities in the Prison System

The incarcerated population disproportionately experiences high rates of substance use disorder (SUD) and mental illness, which are associated with a greater risk of contracting HepC.^[14] These interconnected issues of substance use, mental health, and HepC transmission in the U.S. prison system largely stem from the rise in mass incarceration, which was driven by legal and health policy changes.

Historically, the beginning of America’s war on drugs in the 1970s signified a movement by the U.S. government to curb drug abuse, trafficking, and manufacturing. Across the subsequent decades, Congress and state legislatures passed legislation and promoted rigid mandatory minimum sentencing laws and more expansive policing.^[15] The increase in drug policies coincided with the deinstitutionalization of state psychiatric asylums, which was not accompanied by investment in community mental health care structures. As a result, individuals with SUDs and mental illnesses, who garnered attention from law enforcement, were largely placed into correctional facilities rather than health institutions. Mass incarceration was borne from these punitive drug policies, and today, the Texas prison population is nearly 150,000.^[16] This high rate of HepC in the Texas incarcerated population is a direct consequence of the imprisonment of people with SUDs.^[17]

In response to the growing prison population toward the end of the 20th century, the Texas Department of Criminal Justice (TDCJ) implemented an academic medicine model of correctional health care delivery through the Correctional Managed Health Care Program (CMHCP). TDCJ partners with the University of Texas Medical Branch (UTMD) and Texas Tech University Health Sciences Center (TTUHSC). Together, they provide comprehensive health care services to individuals in Texas prisons. The coordination and supervision of the CMHCP is managed by the Correctional Managed Health Care Committee (CMHCC).^[18]

Although the establishment of the CMHCP streamlined health care provisioning in Texas prisons, incarcerated individuals still face many barriers to accessing health care. First, correctional officers often act as gatekeepers to health care authorities, as they can dismiss or approve an incarcerated individual’s request to see a physician and receive medical care.^[19] Despite the fact that correctional officers are not health care professionals, they evaluate the validity of an incarcerated individual’s medical needs. If the officer decides to approve the request, a nurse oversees the case before it is transferred to a physician.

The hierarchical nature of correctional institutions compounds the difficulties of accessing health care. The prison environment is similar to that of the military, where there are strict order and control.^[20] As incarcerated individuals are often viewed as dangerous, deceitful, and prone to violence — no matter the offense — the prison system’s authoritative approach often leads to limits on an individual’s access to care. Communication breakdowns also ensue, as incarcerated individuals may not trust the medical system and the treatment they would receive in the prison environment.

HepC infection also carries considerable stigma. Its transmission is frequently linked with the use of unsterile needles and, therefore, illegal substance abuse.^[21] Moreover, a lack of awareness of HepC and recent advances in treatment is prevalent among both the public and health care professionals. Incarcerated individuals may fear discrimination and isolation from prison staff, peers, and providers alike.^[22] Outside the prison system, individuals may hold beliefs tying HepC to moral perceptions of drug use and personal culpability.

In the end, the weight of social stigmatization decreases the likelihood of incarcerated individuals’ pursuit of HepC care, leading to under-testing and nonadherence to treatment protocols. The lasting effects are the transmission and spread of HepC, and the declining quality of life and health care outcomes for incarcerated individuals.

Health Care Costs in Texas Prisons

When individuals are imprisoned in Texas, their access to private health care insurance is terminated, and their access to public insurance is suspended.^[23] This means that the health care costs fall to the TDCJ. TDCJ’s budget in fiscal year 2024 (FY24), from September 2023 to August 2024, was more than $4.3 billion.^[24] Of that amount, more than $767 million was allocated for health care. This value includes the following budget sections: “Unit & Psychiatric Care,” “Hospital & Clinical Care,” “Managed Health Care — Pharmacy,” and “Health Services.”^[25] However, the actual health care costs exceeded the amount budgeted for FY24, as the TDCJ paid almost a billion dollars for the categories listed above.^[26]

The U.S. Supreme Court ruled in Estelle v. Gamble (1976) that incarcerated individuals have a constitutional right to health care and that deliberately withholding health care violates the Eighth Amendment prohibition on cruel and unusual punishment.^[27] However, the decision does not specify the quality or accessibility of care, allowing health inequities to persist. For instance, medical co-pays have become great barriers for incarcerated individuals.^[28] Co-pays are directly connected to the exorbitant costs of the carceral state in health care spending. In Texas, these co-pays are called “health care fees,” and an inmate’s account is charged $13.55 for each health care visit. The amount billed to incarcerated individuals accumulates in their accounts, to a maximum of $100 per fiscal year.^[29] However, in most cases, it is very difficult for incarcerated individuals to pay this amount. In Texas, prisons are not required to pay inmates for their mandatory jobs, and as such, many incarcerated individuals rely on money deposits from family members.^[30]

Medical Testing in the Texas Prison System

In contrast to HepC, a human immunodeficiency virus (HIV)/AIDS screening framework has already been established in the Texas prison system. According to Sec. 501.054(i) of the Texas Government Code, the TDCJ is required to test each incarcerated individual for HIV during the intake process if there is no record of previous positive results and before they are released.^[31] The CMHCC’s HIV policy manual reinforces this testing requirement to align with the legal code.^[32]

HIV testing is mandatory at release; therefore, implementing HepC testing at the same time is structurally feasible. Additionally, an individual may request HIV testing, but the TDCJ is only required to provide that test once every six months. For inmates who request HIV testing, there is also no co-pay since the TDCJ aims to encourage HIV screening.^[33] Yet, the same does not apply to HepC screenings.

The Texas prison system also has health standards in place for the management of tuberculosis (TB) that far exceed those for HepC screenings. According to Sec.89.051 of the Texas Health and Safety Code, each inmate is required to undergo a TB screening test if the inmate is expected to be confined for more than seven days, with religious and medical exemptions accepted.^[34] Additionally, Sec.89.054 of the same code states that a copy of the inmate’s medical records or documentation of TB screenings or any TB treatment received during confinement are to be readily available for review if the inmate is transferred.^[35]

Synthesizing these baselines for TB tracking, the Texas Administrative Code requires Chapter 89 facilities — meaning either jails with at least 100 beds, jails that receive inmates from another county with a jail of that size, or jails that house inmates transferred from another state — to complete and submit the Correctional Tuberculosis Screening Plan annually.^[36] To support Chapter 89 facilities, the Correctional TB Program of Texas’ Department of State Health Services (DSHS) provides technical assistance, consults with jails to manage TB outbreaks and facilitates continuity of care upon an inmate’s release or transfer. Downstream, the Texas Commission on Jail Standards (TCJS) supervises all county and privately-operated jails to enforce compliance with state laws and standards of operation.

In contrast to HIV and TB, the TDCJ has no testing policy in place for HepC — opt-out, mandatory, requested, or otherwise — for individuals during the intake process nor for scheduled releases. The TDCJ offers inmates testing for HepC at intake, but the CMHC’s Infection Control Policy Manual does not make it mandatory.^[37] However, inmates who have been previously diagnosed with chronic HepC or HIV must be tested for HepC. The TDCJ also offers testing during each pregnancy and specifies that inmates with persistent abnormal alanine aminotransferase levels in blood test results and inmates known to have been exposed to HepC should be tested. Notably, the policy does not include information related to the definition and duration of HepC’s persistence that would then necessitate testing. Other individuals may request a HepC screening once a year, without having to disclose any high-risk behavior to qualify. However, the inmate may be required to pay a co-pay, if the test is not initiated by health care staff, posing a financial barrier.

Additionally, the TDCJ uses a liver score known as the aspartate transaminase-to-platelet ratio index (APRI) to help determine which individuals should be referred to a designated HepC clinic or provider to be evaluated for possible treatment. An APRI score greater than 0.5 indicates an increased risk of liver fibrosis, and these patients should be referred. Patients with an APRI score less than or equal to 0.5 generally do not require evaluation for possible treatment, unless a provider specifies otherwise.

The disease management guidelines that the TDCJ follows details several factors to consider when determining if a patient would qualify for HepC treatment.^[38] First, the patient should have no contraindications to therapy. Since HepC treatment usually spans two to three months, the patient would need to have sufficient time left in the system to complete workup, treatment, and follow-up evaluation. Additionally, their life expectancy should not be less than or equal to 12 months, and they cannot be pregnant. As the treatment is expensive, there should be no evidence of ongoing participation in any high-risk behavior associated with the transmission of HepC. Finally, the patient should demonstrate a willingness to complete therapy and compliance with pretreatment workup.

While the guidelines note that patients who meet the criteria should be prioritized for treatment, there is no specific guidance as to which physical conditions or criteria would prioritize a patient for HepC treatment. As a result, HepC positive individuals remain uncertain about when and if they can receive treatment. Without these recommendations, doctors are forced into the position of deciding which patients to prioritize for treatment. Furthermore, it is unclear what the HepC treatment schedules and expectations are. One individual reported that he was told by doctors that he was at “the top” of the treatment list for more than six years but still did not receive treatment.^[39]

Cost of HepC Treatments in Texas Prisons

Current HepC Treatment Costs and Commitments

Drug costs constitute a significant portion of the TDJC’s health care expenditures, totaling $63 million in FY24. Medications to treat HepC comprise almost 25% of this cost, totaling slightly over $16 million.^[40] Based on 2025 rates, the cost for HepC DDAs is approximately $278 per tablet or $22,000 per person for a 12-week standard regimen.^[41] Moreover, the treatment costs have increased since 2020. There is an opportunity to reduce TDCJ’s overall pharmaceutical costs by negotiating with suppliers to reduce the cost of DAAs.^[42]

In February 2021, the TDCJ settled a federal lawsuit by several inmates, agreeing to provide DAA treatment to incarcerated individuals diagnosed with HepC.^[43] The TDCJ also committed to treating at least 1,200 inmates each year through Jan. 1, 2028. The settlement class included HepC-positive individuals in custody of the TDCJ who were diagnosed as of Sept. 3, 2020, and those who are diagnosed with HepC following this date are eligible for treatment based on certain criteria. However, once the TDCJ finishes treating HepC-positive individuals based on the settlements’ stipulations, it is unclear how HepC-positive individuals will be prioritized for treatment in 2028 and onward.

Novel Purchasing Agreements To Reduce Drug Costs

To reduce the high costs associated with DAAs, some experts have proposed a subscription-based payment model.^[44] The key benefit of these models for purchasers is that the total expenditure on DAAs becomes capped. The mechanisms of this price cap can vary between agreements. For instance, the TDCJ could agree to pay a fixed price in exchange for access to an unlimited number of DAA doses per year. In exchange, the supplier has exclusive rights to provide DAA drugs to Texas’ prisons. Thus, one supplier would receive the entire revenue from this agreement, enabling the supplier to offer a discounted rate on their DAAs and still earn a profit.

Economic modeling suggests that subscription-based payment models have several benefits over standard purchasing agreements for large purchasers. For example, they reduce total costs for health care payers and remove incremental costs, which would then incentivize increased screening and treatment of chronic HepC.^[45] To implement a subscription-based payment model, states must obtain a waiver from the Centers for Medicare and Medicaid Services (CMS). 

Implementations of subscription models have already shown success in other states, such as Louisiana and Washington. Louisiana and Washington obtained CMS waivers in June 2019.^[46] Louisiana launched its five-year subscription model with Asegua Therapeutics. They secured unlimited access to an authorized generic DAA treatment for HepC. In the negotiated agreement, Louisiana agreed to purchase the DAA until the annual expenditure reached $30 million for the state Medicaid program. A cap of $5 million was also negotiated for Louisiana’s State Department of Corrections. These caps were set at the 2018 levels spent on DAA medications.^[47]

In October 2025, the Louisiana Department of Health reported that more than 18,600 people have been treated with DAAs for HepC since July 2019.^[48] This corresponds to a monthly average of approximately 300 individuals. This is more than triple the number treated — roughly 100 people per month in 2018 — prior to implementing the subscription model, and the cost of DAAs remained at the 2018 level due to the subscription agreement.^[49] Louisiana’s program demonstrates how subscription-based payment models can be a powerful tool to increase the cost-effectiveness of treating HepC while expanding the accessibility of this life-saving treatment.

Recommendations

Timely diagnosis and treatment are necessary to prevent the spread of HepC in prisons and the broader Texas population. Improving the diagnostic process and accessibility of DAAs will lead to long-term reduced costs on both Texas’ prison and overall health care system. The authors of this report propose three recommendations to address the prevalence and cost burden of HepC in the Texas prison population:

1. Expanding access to and clarifying the guidelines for HepC testing and treatment.
2. Mandating HepC testing in county jails.
3. Implementing a subscription-based payment model for DAAs.

Altogether, these efforts will reduce the transmission and impact of HepC in Texas’ incarcerated population.

Recommendation 1: The Texas Department of Criminal Justice (TDCJ) should expand testing and provide transparent guidelines for the diagnostic and treatment processes for HepC for incarcerated individuals in state prisons. With the high prevalence of HepC among the incarcerated population in Texas, identifying Hep C-positive individuals is essential to prevent the spread of infection both within and beyond the prison system.

• Action 1a: The TDCJ should provide mandatory testing for HepC at release. Requiring that every individual committed to a state prison and scheduled for release be tested for HepC will identify individuals who acquired HepC during their time in prison. As previously mentioned, HIV testing at release is currently mandated to prevent the further spread of infection. Thus, Texas already has a structure and policy in place in TDCJ prisons to provide HIV testing. Inmates can be exempt due to religious or medical contraindications confirmed by a physician. Since these individuals are scheduled to be released, the cost of treatment would not fall on the TDCJ system, as the test would identify HepC-positive individuals before they enter the general population and allow them to take necessary precautions for mitigating transmission to others.
   
• Action 1b: The TDCJ should publish transparent guidelines for HepC treatment prioritization. No guidelines or references are currently in place to direct how medical test results or physical conditions would prioritize an individual for DAA treatment. Creating a written policy that better defines these guidelines would provide clarity to HepC-positive individuals and treating physicians.
   
• Action 1c: The TDCJ should amend the Correctional Managed Health Care Committee (CMHCC)’s HepC policy manual to state that individual-requested HepC testing, with a limit of once per fiscal year, should not be subject to a co-pay. Since the HepC prevalence rate is significantly higher in prisons, HepC-negative individuals are at an increased risk. Removing co-pays will mitigate financial barriers to HepC testing and empower individuals to recognize HepC symptoms and request testing.

Recommendation 2: The Texas Commission on Jail Standards (TCJS) should mandate HepC testing for incarcerated individuals in county jails. County jails are high-trafficking sites where individuals are frequently exposed to HepC. Due to the high incidence, prevalence, and transmission of HepC in such correctional settings, jails are a crucial site for HepC screening and diagnosis. The TCJS should mandate routine opt-out HepC testing for incarcerated individuals who are expected to be confined for more than seven days.

To facilitate enforcement of this policy, the Texas Administrative Code should require Chapter 89 facilities to submit a Correctional HepC Screening Plan and to obtain approval from the HIV/STD Branch of the Texas Department of State Health Services (DSHS). The DSHS should establish HepC screening and treatment standards to guide these practices for the TCJS. Finally, TCJS’ authority should be expanded by amending Sec. 511 of the Texas Government Code to require the TCJS to inspect jails annually for compliance with HepC screening and treatment protocols.

Recommendation 3: The University of Texas Medical Branch (UTMB), in conjunction with the TDCJ, should implement a subscription-based payment model for the acquisition of DAA drugs. Per the recent litigation, until 2028, the TDCJ will be required to treat patients who had been diagnosed with chronic HepC as of September 2020 with DAAs, regardless of liver fibrosis scores. Many more patients will need to be treated with DAAs in the coming years. This situation will likely lead to cost overruns to the TDCJ, and subsequently Texas taxpayers.

To prevent this, the CMHCC, in conjunction with the TDCJ and UTMB, should solicit and implement a subscription-based payment model with a pharmaceutical manufacturer to acquire DAAs at a reduced or leveled cost. The CMHCC should coordinate with the TDCJ, UTMB, and Texas Medicaid to request a waiver from CMS to develop solicitation for offers to acquire DAAs through a subscription model. The model should be modeled after Louisiana’s program.^[50] As a starting point, this expenditure cap could be set at $16 million, which is the amount of funds that UTMB spent on DAAs in FY24.^[51]

Conclusion

The current health care landscape in Texas prisons and jails presents significant challenges in managing the incarcerated population’s high prevalence of and mitigating the transmission of HepC following individuals’ release. Prisons and jails are revolving doors through which individuals often cycle between the correctional system and their communities. A lack of testing for HepC at release results in many individuals reentering their communities without being aware of their status. Consequently, individuals released from correctional institutions with unknown HepC status can increase the spread of HepC to their communities and beyond. HepC transmission rates are especially concerning given that the incidence rate of HepC in Texas has risen over the past few years, posing greater public health concerns.

The longer Texas waits to effectively screen and treat individuals for HepC, the greater the community infection burden and costs become. Inaction also translates into paying more later through in more treatments, further community health costs, and potential lawsuits. Furthermore, unclear guidelines regarding prioritization of treatment for HepC-positive individuals within prisons result in confusion among patients and leave physicians to make difficult moral decisions on who should access treatment. Additionally, as inmates already face significant financial limitations within prison, requiring a co-pay for a requested HepC test poses a major barrier to health care.

To move beyond these limitations and barriers, the authors urge the TDCJ, CMHCC, and UTMB to recognize the public health implications of the spread of HepC and adopt a comprehensive and proactive approach to HepC management in the Texas prison system. They also recommend a mandated routine HepC testing for incarcerated individuals to identify HepC-positive individuals. Finally, the authors propose that the CMHCC, UTMB and Texas Medicaid request a CMS waiver to enter into a subscription-based payment model with a pharmaceutical manufacturer to acquire and lower the cost of DAAs.

By addressing these challenges and barriers to HepC diagnosis and treatment, Texas can lower the rate of HepC transmission within and beyond the incarceration system. With a massive prison population nearing 150,000 individuals, Texas’ policies for HepC diagnosis and treatment can serve as a model for other states. Collaboration and communication among members of the public including policymakers, health care professionals, and health administrators with the TDCJ, CMHCC, UTMD, and TCJS are paramount to prevent community spread of HepC outside the prison system. Acting sooner rather than later will reduce the long-term financial costs on the TDCJ and the broader health care system in Texas.

Acknowledgements

This report was produced as part of the Rice University course, BIOS 370/670: “Current Biosciences and Health Policy Topics,” in spring 2025. The authors would like to thank the guest lecturers for the class and Baker Institute fellows and staff who provided feedback on the report and its recommendations.

Notes

^[1] Michael P. Manns et al., “Hepatitis C Virus Infection,” Nature Reviews Disease Primers 3 (March 2017): 17006, https://doi.org/10.1038/nrdp.2017.6.

^[2] Maeve McNamara et al., “Advancing Hepatitis C Elimination through Opt-Out Universal Screening and Treatment in Carceral Settings, United States,” Emerging Infectious Diseases Journal 30, no. 13 (2024): 80–7, https://doi.org/10.3201/eid3013.230859.

^[3] Massimo Fasano et al., “Acute Hepatitis C: Current Status and Future Perspectives,” Viruses 16, no. 11 (2024): 1739, https://doi.org/10.3390/v16111739. 

^[4] Rachel U. Westbrook and Geoffrey Dusheiko, “Natural History of Hepatitis C,” Journal of Hepatology 61, no. 1 (2014): S58–68, https://doi.org/10.1016/j.jhep.2014.07.012.

^[5] Catharina J. Alberts et al., “Worldwide Prevalence of Hepatitis B Virus and Hepatitis C Virus among Patients with Cirrhosis at Country, Region, and Global Levels: A Systematic Review,” The Lancet Gastroenterology & Hepatology 7, no. 8 (2022): 724–35, https://doi.org/10.1016/S2468-1253(22)00050-4.

^[6] Philipp Solbach and Heiner Wedemeyer, “The New Era of Interferon-Free Treatment of Chronic Hepatitis C,” Viszeralmedizin 31, no. 4 (2015): 290–6, https://doi.org/10.1159/000433594.

^[7] Sheri Diehl and Trisha McGhee, eds., “CMC Formulary, 31st Edition, Version 1.0,” Health Services Division, Texas Department of Criminal Justice (TDCJ), last modified December 10, 2024, 65, https://www.tdcj.texas.gov/divisions/cmhc/docs/CMC_Formulary_31st_Edition.pdf.

^[8] Jacques Baillargeon et al., “The Infectious Disease Profile of Texas Prison Inmates,” Preventive Medicine 38, no. 5 (2004): 607–12, https://doi.org/10.1016/j.ypmed.2003.11.020.

^[9] Morgan Maner et al., “Infectious Disease Surveillance in U.S. Jails: Findings from a National Survey,” PLOS One 17, no. 8 (2022): e0272374, https://doi.org/10.1371/journal.pone.0272374.

^[10] TB/HIV/STD Unit, “Hepatitis C in Texas,” Texas Department of State Health Services (DSHS), November 2014, https://www.dshs.texas.gov/sites/default/files/hivstd/info/edmat/HCVinTexas.pdf; Anne C. Spaulding, “Estimates of Hepatitis C Seroprevalence and Viremia in State Prison Populations in the United States,” The Journal of Infectious Diseases 228, Supplement 3, no. 15, (2023): S160–7, https://doi.org/10.1093/infdis/jiad227.

^[11] HIV/STD Program, “Hepatitis C Data,” DSHS, accessed September 2025, https://www.dshs.texas.gov/hivstd/info/hepatitis-c/data; Hyun-seok Kim et al., “Low Yield of Hepatitis C Infection in an Outreach Screening Program in Harris County, Texas,” Open Forum Infectious Diseases 7, no. 7 (2020): ofaa191, https://doi.org/10.1093/ofid/ofaa191.

^[12] Emily Hoff et al., “Hepatitis C Epidemiology in a Large Urban Jail: A Changing Demographic,” Public Health Reports 138, no. 2 (2022): 248–58, https://doi.org/10.1177/00333549221076546. 

^[13] Davis Rich, “Prison Health Care Costs Are Higher than Ever in Texas. Many Point to an Aging Prison Population,” Texas Tribune, November 25, 2019, https://www.texastribune.org/2019/11/25/texas-prison-health-care-budget-parole/.

^[14] Josiah D. Rich et al., “How Health Care Reform Can Transform the Health of Criminal Justice — Involved Individuals,” in “The ACA & Vulnerable Americans: HIV/AIDS; Jails,” special issue, Health Affairs 33, no. 3 (2014): 462–7, https://doi.org/10.1377/hlthaff.2013.1133.

^[15] Dale Parent et al., “Key Legislative Issues in Criminal Justice: Mandatory Sentencing,” National Institute of Justice, January 1997, https://www.ojp.gov/library/publications/key-legislative-issues-criminal-justice-mandatory-sentencing. 

^[16] Davis Rich; Josiah D. Rich et al.; and Leah Wang, “Punishment Beyond Prisons 2023: Incarceration and Supervision by State,” Prison Policy Institute, May 2023, https://www.prisonpolicy.org/reports/correctionalcontrol2023.html. 

^[17] Shanoor Seervai and Emily Wang, “Health Behind Bars — How the U.S. Could Improve Care for Incarcerated People,” in The Dose, produced by Jody Becker, Mickey Capper, Naomi Leibowitz, and Joshua Tallman, April 8, 2022, https://doi.org/10.26099/xqf6-dn34.

^[18] TDCJ, “Texas Correctional Managed Health Care Committee,” https://www.tdcj.texas.gov/divisions/cmhc/.   

^[19] Seervai and Wang.

^[20] E. Bernadette McKinney, “Hard Time and Health Care: The Squeeze on Medicine Behind Bars,” Virtual Mentor 10, no. 2 (February 2008): 116–20, https://doi.org/10.1001/virtualmentor.2008.10.2.msoc2-0802.

^[21] “Tackling Fear and Misinformation May Help Increase Hepatitis C Testing in Prison,” National Institute for Health and Health Care Research, September 29, 2020, https://doi.org/10.3310/alert_41630; Kathryn Jack et al., “How Do People in Prison Feel about Opt-Out Hepatitis C Virus Testing?,” Journal of Viral Hepatitis 27, no. 10 (2020): 961–1092, https://doi.org/10.1111/jvh.13338.

^[22] Matthew J. Akiyama et al., “Hepatitis C Elimination Among People Incarcerated in Prisons: Challenges and Recommendations for Action Within a Health Systems Framework,” The Lancet Gastroenterology & Hepatology 6, no. 5 (2021): 391–400, https://doi.org/10.1016/S2468-1253(20)30365-4.

^[23] “B-510, Termination of Medical Coverage for People Confined in a Public Institution,” in Texas Works Handbook, DHHS, accessed October 2025, https://www.hhs.texas.gov/handbooks/texas-works-handbook/b-510-termination-medical-coverage-people-confined-a-public-institution.

^[24] “Texas Department of Criminal Justice: Agency Operating Budget 2024,” TDCJ, August 25, 2023, 5, https://www.tdcj.texas.gov/documents/bfd/FY24_Agency_Operating_Budget.pdf.

^[25] “Texas Department of Criminal Justice: Agency Operating Budget 2024,” 6.

^[26] “Financial Report on Correctional Managed Health Care: Quarterly Report FY2024 Fourth Quarter,” TDCJ, 2024, 1, https://www.tdcj.texas.gov/divisions/cmhc/docs/cmhcc_financial_reports/FY24_4th_Qtr_Report.pdf.

^[27] Estelle v. Gamble, 429 U.S. 97 (1976), https://www.supremecourt.gov/pdfs/transcripts/1976/75-929_10-05-1976.pdf.

^[28] Cecille Joan Avila, “Prison Health Care Is Only Available If You Can Afford It,” Prism, October 31, 2022, http://prismreports.org/2022/10/31/prison-health-care-hidden-costs/.

^[29] “TDCJ Annual Health Care Services Fee Pamphlet,” TDCJ, last modified September 2022, https://www.tdcj.texas.gov/divisions/cmhc/docs/TDCJ_Annual_Health_Care_Services_Fee_Pamphlet.pdf.

^[30] “Frequently Asked Questions,” TDCJ, accessed October 2025, https://www.tdcj.texas.gov/faq/cid.html; “TDCJ Annual Health Care Services Fee Pamphlet.”

^[31] Tex. Gov. Code, Sec. 501.054(i) (1989), https://statutes.capitol.texas.gov/Docs/GV/htm/GV.501.htm.

^[32] “Policy B-14.11: Human Immunodeficiency Virus (HIV) Infection,” in “CMHC Infection Control Policy Manual,” Center Managed Health Care Committee (CMHC), April 2, 2025, https://www.tdcj.texas.gov/divisions/cmhc/docs/cmhc_infection_control_policy_manual/B-14.11.pdf.

^[33] “Policy B-14.11: Human Immunodeficiency Virus (HIV) Infection.”

^[34] Tex. Health and Safety Code, Sec. 89 (1993), https://statutes.capitol.texas.gov/Docs/HS/htm/HS.89.htm.

^[35] Tex. Health and Safety Code, Sec. 89.

^[36] “Correctional Tuberculosis Screening Plan Instructions,” DHHS, last modified May 2017, https://www.tcjs.state.tx.us/wp-content/uploads/2019/08/TB805_TB_Instructions.pdf.

^[37] “CMHC Infection Control Policy Manual B-14.13.03,” CMHC, last modified 2023, https://www.tdcj.texas.gov/divisions/cmhc/docs/cmhc_infection_control_policy_manual/B-14.13.03.pdf.

^[38] “Disease Management Guidelines,” TDCJ, 2024, HCV 1–6, https://www.tdcj.texas.gov/Divisions/cmhc/docs/Disease_Management_Guidelines_2024.pdf.

^[39] Gabrielle Banks and Keri Blakinger, “Texas Inmates Sue for Hepatitis C Drug, Alleging Lack of Treatment Is ‘Cruel and Unusual,’” Houston Chronicle, last modified September 18, 2019, https://www.houstonchronicle.com/news/houston-texas/houston/article/Texas-inmates-sue-for-hepatitis-C-drug-alleging-14453099.php.

^[40] “Financial Report on Correctional Managed Health Care Quarterly Report FY2024 Fourth Quarter,” 6.

^[41] Diehl and McGhee, eds., “CMC Formulary, 31st Edition, Version 1.0,” 65.

^[42] “CMC Formulary 26th Edition,” 2020.

^[43] Matt Clarke, “Texas Agrees to Settlement Providing Prisoners Hep C Treatment, Will Pay $950,000 in Attorney Fees,” Prison Legal News, January 1, 2022, https://www.prisonlegalnews.org/news/2022/jan/1/texas-agrees-settlement-providing-prisoners-hep-c-treatment-will-pay-950000-attorney-fees/.

^[44] Neeraj Sood et al., “A Novel Strategy for Increasing Access to Treatment for Hepatitis C Virus Infection for Medicaid Beneficiaries,” Annals of Internal Medicine 169, no. 2 (2018): 118–9, https://doi.org/10.7326/m18-0186; Mark R. Trusheim et al., “Alternative State-Level Financing for Hepatitis C Treatment — The ‘Netflix Model,’” JAMA 320, no. 19 (2018): 1977–8, https://doi.org/10.1001/jama.2018.15782; Samantha G. Auty et al., “Medicaid Subscription-Based Payment Models and Implications for Access to Hepatitis C Medications,” JAMA Health Forum 2, no. 8 (2021): e212291, https://doi.org/10.1001/jamahealthforum.2021.2291; Auty et al., “Improving Access to High-Value, High-Cost Medicines: The Use of Subscription Models to Treat Hepatitis C Using Direct-Acting Antivirals in the United States,” Journal of Health Politics, Policy and Law 47, no. 6 (2022): 691–708, https://doi.org/10.1215/03616878-10041121; and David W. Matthews et al., “The Payer License Agreement, or ‘Netflix Model,’ for Hepatitis C Virus Therapies Enables Universal Treatment Access, Lowers Costs and Incentivizes Innovation and Competition,” Liver International 42, no. 7 (2022): 1503–16, https://doi.org/10.1111/liv.15245.

^[45] STD/HIV Program, “Solicitation for Offers for Pharmaceutical Manufacturer(s) to Enter into Contract Negotiations to Implement Hepatitis C Subscription Model,” Office of Public Health, Louisiana Department of Health, January 10, 2019, 8–10, https://ldh.la.gov/assets/oph/SFO/LDH_Hep_C_SFO.pdf.

^[46] Melinda Deslatte, “Louisiana Reaches ‘Netflix-Model’ Deal to Tackle Hepatitis C,” Associated Press, June 26, 2019, https://apnews.com/general-news-domestic-news-domestic-news-bc074b5c06024926a5c58163de8bab9d.

^[47] STD/HIV Program, “Solicitation for Offers for Pharmaceutical Manufacturer(s) to Enter into Contract Negotiations to Implement Hepatitis C Subscription Model”; Louisiana Department of Health, “Taking Control of Hep C,” 2025, http://ldh.la.gov/assets/hepc/prod/.

^[48] Louisiana Department of Health, “Taking Control of Hep C.”

^[49] Louisiana Department of Health, “Taking Control of Hep C”; STD/HIV/Hepatitis Program, 2020 Hepatitis B & Hepatitis C: Surveillance Report, Office of Public Health, Louisiana Department of Health, 2020, 36, https://ldh.la.gov/assets/oph/HIVSTD/Hepatitis_Factsheets/AnnualHepatitisReport2020.pdf.

^[50] Auty et al., “Medicaid Subscription-Based Payment Models and Implications for Access to Hepatitis C Medications.”

^[51] “Financial Report on Correctional Managed Health Care Quarterly Report FY2024 Fourth Quarter,” 6.

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