“Imagine if you went to get your mammogram, and they said, ‘you've got this [lump] here, but we're not going to do anything about it until it gets bigger,’” Bush told me recently. “How would you take that, as a patient?”

With enough paperwork and tenacity, for a while Bush was able to secure free doses of Sovaldi directly from its manufacturer, Gilead Sciences. But that strategy, too, has become tougher in recent months after Gilead limited the types of patients who could receive free drugs.

New Mexico health-care workers aren’t the only ones struggling to secure these new treatments for their patients. Other states also require patients to be in late-stage liver disease, get urine drug screens, or prove abstinence from drugs and alcohol before they’ll consider covering them. Hep C patients commonly find themselves being forced to get sicker before they can get better.

Hep C is a liver disease transmitted by blood. It’s most common among baby boomers, most of whom contracted it through blood transfusions or by using contaminated needles to inject drugs. Left untreated, Hep C attacks the liver and can lead to cancer or liver failure.

Sovaldi costs $84,000 for a 12-week course of treatment, or about $1,000 per pill. It’s a great drug, working nearly 90 percent of the time and with few side effects. Sovaldi and the similarly pricey Harvoni, also made by Gilead, are a big improvement over older cures like interferon, which was only effective about half the time and whose side effects—rashes, fever, and nausea—were sometimes described as worse than the disease itself.

If state governments were to pay for Sovaldi or Harvoni for all of the Hep C patients on their Medicaid and prison rolls, the total bill would have been $55 billion. Most state Medicaid programs, therefore, are sharply limiting access to them. An August study in the Annals of Internal Medicine found that most states were only making these new drugs available to Medicaid patients who had advanced fibrosis, or liver scarring. Two-thirds required urine drug tests for drugs and alcohol before they would cover the medication. These measures, the study notes, are inconsistent with the recommendations of prominent health organizations and FDA guidelines.

Liver Disease Required for Medicaid Coverage of Sovaldi

State Medicaid programs, meanwhile, feel their hands are tied. “The states can't afford it,” said Matt Salo, executive director of the National Association of State Medicaid Directors. “If we were to pony up for [Sovaldi], we would spend as much on this one drug as we would for all other drugs in the entire program. We don't have the luxury of having a state legislature saying, ‘You want 5 to 10 percent more [money] this year? Cool, here's your money.’ Many state legislatures are saying, ‘You've got to save, because revenues are down.’”