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Curative treatments for hepatitis C virus (HCV) can alter the course of a devastating epidemic, but high drug prices have contributed to restrictions on HCV treatment access.We aimed to learn how state health agencies have responded to the challenges of treatment access for HCV.Qualitative study using semistructured key informant interviews focused on aspects of HCV treatment access between June 2016 and March 2017. Content analysis was used to identify dominant themes.United States.Eighteen health officials and treatment advocates across 6 states selected using purposive sampling.Drug pricing is the most important barrier to access, encouraging restrictive authorization criteria from payers that in turn discourage providers from offering treatment. However, payers have not experienced the budget impact that was initially feared. Although authorization criteria are being lifted for fee-for-service Medicaid programs, ensuring that managed care organizations follow suit remains a challenge. The effect of stigma, a shortage of treating providers, and lack of political motivation are additional challenges to expanding treatment. The response to the human immunodeficiency virus epidemic can augment or inform strategies for HCV treatment delivery, but this is limited by the absence of dedicated funding.While treatment eligibility criteria for HCV treatment are improving, many other barriers remain to achieving the scale-up needed to end the epidemic. Political disinterest, stigma, and a lack of specialty providers are continued barriers in some jurisdictions. States may need to invest in strategies to overcome these barriers, such as engaging in public and provider education and ensuring that treatment by primary care providers is reimbursed. Despite uncertainty about how federal policy changes to Medicaid may affect states' ability to respond, states can identify opportunities to improve access.