Congressional Proposals to Change Medicaid Threaten the HIV Response

Ongoing congressional debates over Medicaid will have far-reaching consequences for public health systems across the country. Medicaid is a joint federal-state program that provides health coverage to more than 80 million low-income individuals, including people living with HIV. It is the largest source of insurance coverage for people living with HIV and plays a foundational role in the nation’s HIV care and prevention infrastructure. The current congressional proposal would cut federal Medicaid funding by hundreds of billions of dollars over the next decade, placing significant fiscal pressure on states and threatening coverage for millions. These cuts, coupled with proposed eligibility restrictions, would weaken the delivery systems that support HIV treatment, prevention, and care. Undermining it would shift unsustainable burdens to the Ryan White HIV/AIDS Program, which provides medical care and support services for people living with HIV who are uninsured or underinsured, and AIDS Drug Assistance Program (ADAP), which helps cover the cost of medications. Both programs are already grappling with stagnant federal funding and rising demand. 

Medicaid’s Role in HIV Care 

Medicaid is the largest payer of HIV care in the U.S. Nearly 40% of nonelderly adults with HIV rely on Medicaid to access antiretroviral therapy, lab monitoring, and other core health services. For many, it is the only way to stay consistently engaged in care and maintain viral suppression.

Congressional proposals that would introduce work reporting requirements or authorize new enrollment restrictions threaten to disrupt this access. Similar policies caused widespread disenrollment in the past—not because people were ineligible, but because they struggled with burdensome paperwork and confusing reporting systems. Even brief gaps in coverage can jeopardize health outcomes for people living with HIV and increase transmissions.

Rising Strain on the Ryan White Program and ADAP 

The Ryan White HIV/AIDS Program works alongside Medicaid to fill critical gaps in services and coverage that Medicaid does not provide. When people lose Medicaid coverage, the resulting care needs shift to Ryan White providers and ADAP, who cannot absorb those increases.

If Medicaid access is restricted, jurisdictions must make difficult decisions. These include reintroducing ADAP waitlists or reducing the range of medications covered, which can limit access to effective treatment options. With federal funding stagnant, programs cannot sustainably serve a growing uninsured population without sacrificing access, quality, or continuity of care. States already face steep Medicaid budget pressures, and additional cuts could reduce their ability to support HIV care systems or expand safety-net services.

Medicaid’s Role in HIV Prevention 

Medicaid plays a critical role in supporting HIV prevention. It covers pre-exposure prophylaxis (PrEP) medication and the clinical services supporting adherence and effectiveness, including lab testing, provider visits, and follow-up care. Without this whole continuum of care, people often stop using PrEP, which increases the likelihood of HIV transmission. States that expanded Medicaid have achieved higher PrEP utilization rates. This reflects a broader trend—states that expanded Medicaid have consistently seen improved health access and outcomes, particularly in HIV prevention and care. Limiting access to Medicaid would undermine this progress and widen prevention gaps at the individual and population levels. Reduced access to PrEP also carries serious long-term costs. Every preventable HIV transmission increases lifetime health care expenses, leads to preventable health complications, and strains a care system already operating under pressure.

A Fragile System Under Threat 

The HIV care system in the U.S. depends on coordination across programs. Medicaid, the Ryan White HIV/AIDS Program, and ADAP each serve a unique function. When one of these pillars weakens, the others feel the shock waves.

Congressional proposals allowing states to implement new barriers to coverage—such as premiums, lockout periods, or work reporting requirements—could cause widespread disruption. These policies are not only unnecessary, but they are also harmful. Experience shows they do not increase employment and instead lead to significant coverage losses, especially among people with chronic conditions like HIV who already face systemic obstacles to care.

For people managing a lifelong condition like HIV, stability and consistency are essential. And for public health systems already facing workforce reductions and increased demand, this kind of volatility is simply not sustainable.

ADAP cannot replace broad Medicaid coverage, and it was never intended to do so. Without new federal investment, these programs cannot sustainably fill the coverage gaps created by weakened Medicaid access.

Resources 

• AIDS United – Take Action to Protect Medicaid  
• Commonwealth Fund – Medicaid Work Requirements Would Lead to Job Losses and Harm State Economies 
• KFF – 5 Key Facts About Medicaid Coverage for People with HIV 
• NASTAD – Policy Brief: Medicaid & HIV 
• #SaveHIVfunding – Letter to the Editor Template 
• The AIDS Institute – Call to Action: Stop Unnecessary Medicaid Work Reporting Requirements