Nearly 70,000 new hepatitis C cases in 2023 were twice the US target
England cut hepatitis C deaths 36% with free testing; the US treats half its chronic cases.
By The Weekend · · 5 min read
Nearly 70,000 new hepatitis C infections were reported in the United States in 2023 — double the annual target the Centers for Disease Control and Prevention had set for the country. The medication that cures more than 95% of chronic cases in eight to 12 weeks has existed for over a decade. England used it to cut hepatitis C deaths by 36% in ten years. The US used it to treat about half the people who have the infection.
England didn't get a better drug. It got a different delivery system.
The cure arrived in the 2000s, and it works everywhere it's tried: a once-daily pill, taken for two to three months, clears chronic hepatitis C in more than 95% of patients. That number is the same whether the patient is in Bristol or Baltimore. What differs is who gets offered the pill in the first place, and that gap is entirely a matter of policy, not pharmacology.
England built an "opt-out" testing regime — anyone showing up at an emergency department gets tested for HIV, hepatitis B and hepatitis C unless they actively decline. It added mobile testing vans and outreach teams aimed at people who inject drugs, the population with by far the highest infection rates. It mailed free at-home test kits to anyone who asked. And when a test came back positive, the National Health Service prescribed the cure at no cost to the patient, with no prior authorization fight, no formulary tier, no copay.
The results are measurable and specific. England has already hit its interim target of treating 80% of people with hepatitis C. Among people who inject drugs — the group driving most new transmissions — infection prevalence fell from 28.6% in 2015 to 5.2% in 2024. That is not a rounding change; it is a population going from roughly one in three infected to roughly one in twenty in under a decade.
The US has the same pill and a different payer
Only about 50% of Americans with chronic hepatitis C are currently on medication, despite coverage through Medicaid and most commercial insurance. The shortfall isn't access to a drug that doesn't exist — it's the machinery between diagnosis and prescription. Many state Medicaid programs have historically required proof of liver damage, documented sobriety, or prescription by a liver specialist before approving treatment — restrictions that have eased in several states but persist in others, adding months of delay to a disease that keeps replicating during the wait.
New infections in the US rose steadily from 2013 to 2021, then plateaued — not dropped — from 2021 to 2023. A plateau above target is still a failure to meet the goal; it just stopped getting worse. Compare that trajectory to England's: a national system where testing is the default and treatment is free produces a declining curve. A system where testing is incidental and treatment requires insurance navigation produces a flat one, at a level twice the CDC's own benchmark.
The constraint nobody prices into "cure": diagnosis is silent, and silence is expensive
Hepatitis C is frequently asymptomatic for years or decades. People can carry the virus, transmitting it and accumulating liver damage, with no symptom urgent enough to prompt a doctor's visit. That single biological fact is why opt-out testing beats symptom-triggered testing in every country that has tried both: if you wait for people to feel sick enough to ask, you catch them after cirrhosis has already started, not before.
This is also the part of the US system that a focus on drug price obscures. Direct-acting antivirals have gotten cheaper since their 2013-14 debut, and most insured Americans face little or no out-of-pocket cost. The bottleneck has moved upstream, to testing infrastructure and the administrative friction of actually initiating treatment once a diagnosis exists. A country can have affordable medication and still fail at elimination if the testing net is full of holes and the prescribing pathway has too many checkpoints.
Egypt and Norway, cited alongside England as elimination leaders, took different routes to the same two levers — testing volume and prescribing speed — which is the tell that this is a systems problem with a known fix, not a mystery requiring new science. Egypt ran a national campaign to test tens of millions of adults and subsidized treatment heavily; Norway leaned on harm-reduction services already embedded with people who inject drugs. Different populations, same two dials turned up.
Who actually pays for a hepatitis C infection that goes untreated
Untreated chronic hepatitis C is a leading cause of cirrhosis and hepatocellular carcinoma, and it is the second most common reason for medically necessary liver transplants in the US, after alcohol-associated liver disease. A liver transplant costs the health system vastly more than a course of antivirals — the mismatch isn't subtle, it's an order of magnitude — which means the US isn't avoiding spending by under-treating hepatitis C; it's deferring it to a more expensive and less survivable point in the disease. Medicaid and commercial insurers who resist covering the pill now are, on average, underwriting the transplant later.
The people who pay the intermediate price are the roughly half of Americans with chronic infection who remain undiagnosed or unmedicated — many in populations, like people who inject drugs or the uninsured, least equipped to navigate a multi-step authorization process. The World Health Organization's 2030 elimination target assumes countries close that gap through public health infrastructure, not through patients independently finding their way to treatment.
What would actually move the US plateau, and how you'd know
The lever with the clearest track record is opt-out testing at points of contact people already have with the health system — emergency rooms, syringe service programs, primary care visits — paired with same-visit or fast-tracked prescribing. Several states have already dropped Medicaid's sobriety and specialist-referral requirements for hepatitis C treatment; the honest test of this approach is whether new infection numbers in those states diverge from the national plateau over the next two to three years. If they don't, the testing-and-friction theory is wrong and something else is driving US cases. If they do, it confirms that the remaining 70,000 annual infections are a policy artifact, not a biological ceiling.
The CDC's own target — half of the 70,000 cases reported in 2023 — gives a concrete number to watch. England took about a decade to go from policy change to an 80% treatment rate and a 36% drop in deaths. The US has the same cure, already paid for by most insurance plans. What it hasn't built is the testing default that gets people into a doctor's office before the disease makes the decision for them.