Background: New curative treatments for hepatitis C have the potential to alter the course of a devastating epidemic. High drug prices, however, are widely believed to contribute to restrictions on treatment access. We aimed to learn how state health agencies have responded to the challenges of treatment access for HCV. Methods: Using a key informant interview design, we interviewed 14 health officials and 4 treatment advocates in six states. States were chosen using purposive sampling based on diverse geography, population size, known HCV treatment eligibility criteria and Medicaid expansion status. Interviews were semi-structured with questions that focused on aspects of HCV treatment access. We used content analysis to analyze transcripts for dominant themes. Results: Treatment cost was the most significant barrier to expanding access and acted by directly influencing payers to restrict access, as well as creating the impression among guideline committees and providers that HCV treatment needed to be prioritized. Treatment eligibility criteria from state Medicaid programs did not necessarily reflect the actions of managed care organizations, who could be more variable. Additional barriers to access included stigma around HCV and substance use, as well as provider availability, especially in rural areas. The political and fiscal environment within states could aid or hinder treatment access, and evolving federal health policy surrounding Medicaid evoked concern that funding for HCV treatment access could be diminished. Individuals co-infected with HIV and HCV had additional mechanisms to access treatment. Conclusions: While treatment eligibility criteria for HCV treatment are improving, a number of other barriers remain to achieving the scale-up needed to end the epidemic. Further work to mitigate the effects of stigma and build treatment capacity will be needed. The effects of federal health policy changes on Medicaid funding may impact states’ ability to respond to this epidemic.