The Coming HIV Care Crisis
The One Big Beautiful Bill Act (OBBBA)'s reduction of Medicaid expansion eligibility from 138% to 100% of the federal poverty level (FPL) creates an unprecedented crisis for HIV care in the United States, threatening to force approximately 200,000 people living with HIV off coverage while simultaneously undermining the Ryan White HIV/AIDS Program's capacity to serve as an adequate safety net, ultimately jeopardizing decades of progress toward ending the HIV epidemic and disproportionately harming communities of color and rural populations who already face significant barriers to care.
A Crisis at the Intersection of Policy and Survival
The One Big Beautiful Bill Act, signed into law on July 4, 2025, represents, according to the National Alliance of State and Territorial AIDS Directors (NASTAD), a moment when "AIDS Drug Assistance Programs (ADAPs) stand at a critical precipice." Let us not mince words: this legislation systematically dismantles the interconnected safety net that has enabled the United States to achieve the highest rates of viral suppression in the history of the epidemic.
The math, like those who passed this legislation, is cruel and unforgiving. With 40% of non-elderly adults living with HIV relying on Medicaid for coverage—nearly three times the rate of the general population—this eligibility reduction targets precisely the demographic most dependent on public health insurance. The Congressional Budget Office (CBO) projects that 7.8 million people will lose Medicaid coverage overall, with advocacy organizations estimating that approximately 200,000 people living with HIV will be among those stripped of coverage.
The timing creates a perfect storm. As NASTAD warns, "enhanced premium tax credits associated with Marketplace plans are set to expire later this year." At the same time, state health departments face "drastic budget cuts and reductions in force because of federal agency cuts." This convergence of federal policy changes threatens to create what NASTAD calls "sharp increases in the number of uninsured people with low incomes," precisely when the safety net programs designed to catch them are facing their own funding constraints.
The Medicaid Foundation: Why This Coverage Matters
The reduction from 138% to 100% of the federal poverty level specifically targets the income bracket where HIV prevalence is highest. Research demonstrates that 42% of Medicaid enrollees with HIV gained coverage through the Affordable Care Act's expansion, with this figure rising to 51% in expansion states. More than a mere statistical abstraction, it represents hundreds of thousands of people living with HIV (PLWH) who gained access to consistent, comprehensive healthcare for the first time.
The financial implications reveal the complexity of HIV care. Average Medicaid spending reaches $24,000 per HIV enrollee compared to $9,000 for non-HIV enrollees, reflecting the intensive medical management required for effective HIV treatment. When coverage disappears, these costs don't vanish—they shift to an already overwhelmed safety net or go unmet entirely, leading to treatment interruptions that increase viral loads and HIV transmission risk.
State-level analyses paint an even grimmer picture. Louisiana and Virginia face 21% spending cuts over the 10-year period, while Southern states that bear 52% of new HIV diagnoses despite comprising only 38% of the population will see disproportionate impacts. The legislation includes five major provisions that collectively cut $896 billion from Medicaid: work requirements, repealing Biden-era eligibility rules, provider tax restrictions, state-directed payment limits, and increased eligibility redeterminations.
The Ryan White Program: Last Resort, Impossible Math
The Ryan White HIV/AIDS Program operates on a fundamentally different model than Medicaid—one that makes absorbing massive coverage losses mathematically impossible. With $2.6 billion in discretionary funding requiring annual Congressional appropriations, the program lacks Medicaid's entitlement structure that automatically expands to meet growing needs.
The program's current client base reveals the scale of the challenge. Ryan White already serves over 576,000 clients annually, representing more than half of all diagnosed HIV cases. Critically, 39% of Ryan White clients have Medicaid as their primary payer, meaning they use Ryan White for wraparound services Medicaid doesn't cover. When these people lose Medicaid, Ryan White must suddenly cover their entire care costs—an impossibility given current funding constraints.
NASTAD's analysis warns this would "shift unsustainable burdens to the Ryan White HIV/AIDS Program," potentially forcing jurisdictions to reintroduce AIDS Drug Assistance Program (ADAP) waitlists not seen since the early 2010s. The program's "payer of last resort" status means it legally must serve anyone without other coverage options, creating an unfunded mandate when Medicaid disappears.
Historical evidence demonstrates the program's existing capacity limitations. From 2017-2019, 58.7% of uninsured persons had unmet needs for HIV ancillary care services, yet the program achieved 90.6% viral suppression rates among clients in 2023—a testament to its effectiveness when adequately resourced.
The proposed FY 2026 budget compounds this crisis by cutting Ryan White funding to $2.5 billion while eliminating Part F entirely. Part F includes AIDS Education and Training Centers that reached 56,383 health professionals last year, representing a critical workforce development component that would disappear precisely when demand for HIV care is expected to surge.
Healthcare Infrastructure Under Siege
Federally Qualified Health Centers (FQHC), serving as the backbone of HIV care in underserved communities, face an existential crisis. With Medicaid comprising 43% of FQHC revenue, the reconciliation bill threatens the fundamental business model of these safety-net providers. FQHCs currently operate on razor-thin margins approaching negative 2.2%, with 42% reporting 90 days or less cash on hand.
The rural healthcare crisis intensifies these challenges. Over 700 rural hospitals face closure risk—representing one-third of all rural hospitals—with 171 having shut down since 2005. The bill's $25 billion rural transformation fund provides only 43% of what experts calculate is needed to offset Medicaid cuts.
For HIV care, this means losing critical access points in areas already designated as priority jurisdictions for the Ending the HIV Epidemic (EHE) initiative. Research demonstrates that FQHCs in the rural South could reduce median drive time to HIV care from 50 to 10 minutes—but only if they remain financially viable. When Medicaid patients lose coverage, FQHCs must still serve them as uninsured patients by law, creating additional uncompensated care costs the facilities cannot absorb.
The 340B Program: Hidden Financial Hemorrhaging
The removal of Pharmacy Benefit Manager (PBM) spread pricing prohibitions represents a significant blow to 340B savings that HIV programs depend on for sustainability. The 340B program generated $38 billion in discounts in 2020 alone, with Ryan White clinics using these savings to serve an additional 43,000 people living with HIV.
Without spread pricing protections, PBMs can continue diverting these savings through discriminatory practices. States have documented massive overcharges: Ohio lost $224.8 million in one year, Pennsylvania $605 million over four years, and Maryland $72 million annually to spread pricing schemes. For HIV programs already operating on minimal margins, these losses represent the difference between serving patients, implementing waitlists, or shutting down altogether.
The policy intersection becomes particularly cruel when considering substance use services. While the OBBBA protects substance use disorder services from cost-sharing requirements—a "modest but important win" according to county officials—the broader context undermines these protections. Research shows 23.94% of people with HIV need treatment for alcohol or substance use, with people who inject drugs facing 30 times higher HIV risk than non-users.
Geographic and Demographic Devastation
The reconciliation bill's impacts fall hardest on communities already bearing disproportionate HIV burdens. Black and Hispanic/Latino people account for 64% of all people with HIV while representing only 31% of the population. These communities have higher Medicaid coverage rates due to lower incomes and higher disability rates, making them particularly vulnerable to coverage losses.
Southern states face a catastrophic combination of high HIV prevalence, limited state resources, and political resistance to mitigation strategies. The region accounts for 52% of new diagnoses, and includes many non-expansion states where 66% of HIV-positive adults rely on disability-related Medicaid pathways.
Nine states have trigger laws automatically ending Medicaid expansion if federal matching rates drop, creating immediate coverage cliffs. The intersection of geography, race, and poverty creates concentrated zones where HIV care infrastructure may collapse entirely, reversing decades of progress in communities that have historically faced the greatest barriers to care.
Clearly, This Isn’t About Fiscal Responsibility
The legislation represents fiscal malpractice when considering the long-term costs of new HIV transmissions. Each new HIV infection creates $501,000 in lifetime healthcare costs, while achieving 72% viral suppression would cost $120 billion over 20 years. The math is unambiguous: preventing new infections through sustained treatment is far more cost-effective than treating them after they occur.
The HIV community's response demonstrates the severity of the threat. Over 113 organizations relaunched the #SaveHIVFunding campaign, while the Partnership to End HIV, STI, and Hepatitis Epidemics united major organizations in opposition, emphasizing that "healthcare is not a reward for paperwork—it is a human right."
As NASTAD's analysis concludes, "When one of these pillars weakens, the others feel the shock waves"—and this bill doesn't just weaken pillars, it demolishes them. Without immediate action to reverse these cuts, the United States will witness a preventable reversal of decades of progress in HIV care, measured not in budget savings but in lives lost to a disease we know how to treat.
When Algorithms Deny Care: The Insurance Industry's AI War Against Patients
The assassination of UnitedHealthcare CEO Brian Thompson in December 2024 laid bare a healthcare crisis where insurance companies use artificial intelligence to systematically deny care while posting record profits. Federal data shows UnitedHealthcare, which covers 49 million Americans, denied nearly one-third of all in-network claims in 2022 - the highest rate among major insurers.
This reflects an industry-wide strategy that insurance scholar Jay Feinman calls "delay, deny, defend" - now supercharged by AI. These systems automatically deny claims, delay payment, and force sick people to defend their right to care through complex appeals. A Commonwealth Fund survey found 45% of working-age adults with insurance faced denied coverage for services they believed should be covered.
The consequences are devastating. As documented cases show, these automated denial systems routinely override physician recommendations for essential care, creating a system where algorithms, not doctors, decide who receives treatment. For those who do appeal, insurers approve at least some form of care about half the time. This creates a perverse incentive structure where insurers can deny claims broadly, knowing most people will not fight back. For the people trapped in this system, the stakes could not be higher - this is quite literally a matter of life and death.
The Rise of AI in Claims Processing
Health insurers have increasingly turned to AI systems to automate claims processing and denials, fundamentally changing how coverage decisions are made. A ProPublica investigation revealed that Cigna's PXDX system allows its doctors to deny claims without reviewing patient files, processing roughly 300,000 denials in just two months. "We literally click and submit. It takes all of 1.2 seconds to do 50 at a time," a former Cigna doctor reported.
The scope of automated denials extends beyond Cigna. UnitedHealth Group's NaviHealth uses an AI tool called "nH Predict" to determine length-of-stay recommendations for people in rehabilitation facilities. According to STAT News, this system generates precise predictions about recovery timelines and discharge dates without accounting for people's individual circumstances or their doctors' medical judgment. While NaviHealth claims its algorithm is merely a "guide" for discharge planning, its marketing materials boast about "significantly reducing costs specific to unnecessary care."
Only about 1% of denied claims are appealed, despite high rates of denials being overturned when challenged. This creates a system where insurers can use AI to broadly deny claims, knowing most people will not contest the decisions. The practice raises serious ethical concerns about algorithmic decision-making in healthcare, especially when such systems prioritize cost savings over medical necessity and doctor recommendations.
Impact on Patient Care
The human cost of AI-driven claim denials reveals a systemic strategy of "delay, deny, defend" that puts profits over patients. STAT News reports the case of Frances Walter, an 85-year-old with a shattered shoulder and pain medication allergies, whose story exemplifies the cruel efficiency of algorithmic denial systems. NaviHealth's algorithm predicted she would recover in 16.6 days, prompting her insurer to cut off payment despite medical notes showing she could not dress herself, use the bathroom independently, or operate a walker. She was forced to spend her life savings and enroll in Medicaid to continue necessary rehabilitation.
Walter's case is not unique. Despite her medical team's objections, UnitedHealthcare terminated her coverage based solely on an algorithm's prediction. Her appeal was denied twice, and when she finally received an administrative hearing, UnitedHealthcare didn't even send a representative - yet the judge still sided with the company. Walter's case reveals how the system is stacked against patients: insurers can deny care with a keystroke, forcing people to navigate a complex appeals process while their health deteriorates.
The fundamental doctor-patient relationship is being undermined as healthcare facilities face increasing pressure to align their treatment recommendations with algorithmic predictions. The Commonwealth Fund found that 60% of people who face denials experience delayed care, with half reporting their health problems worsened while waiting for insurance approval. Behind each statistic are countless stories like Walter's - people suffering while fighting faceless algorithms for their right to medical care.
The AI Arms Race in Healthcare Claims
Healthcare providers are fighting back against automated denials by deploying their own AI tools. New startups like Claimable and FightHealthInsurance.com help patients and providers challenge insurer denials, with Claimable achieving an 85% success rate in overturning denials. Care New England reduced authorization-related denials by 55% using AI assistance.
While these counter-measures show promise, they highlight a perverse reality: healthcare providers must now divert critical resources away from patient care to wage algorithmic warfare against insurance companies. The Mayo Clinic has cut 30 full-time positions and spent $700,000 on AI tools simply to fight denials. As Dr. Robert Wachter of UCSF notes, "You have automatic conflict. Their AI will deny our AI, and we'll go back and forth."
This technological arms race exemplifies how far the American healthcare system has strayed from its purpose. Instead of focusing on patient care, providers must invest millions in AI tools to combat insurers' automated denial systems - resources that could be spent on direct patient care, medical research, or improving healthcare delivery. The emergence of these counter-measures, while potentially helpful for providers and patients seeking care, highlights fundamental flaws in our healthcare system that require policy solutions, not just technological fixes.
AI Bias: Amplifying Healthcare Inequities
The potential for AI systems to perpetuate and intensify existing healthcare disparities is deeply concerning. A comprehensive JAMA Network Open study examining insurance claim denials revealed that at-risk populations experience significantly higher denial rates.
The research found:
Low-income patients had 43% higher odds of claim denials compared to high-income patients
Patients with high school education or less experienced denial rates of 1.79%, versus 1.14% for college-educated patients
Racial and ethnic minorities faced disproportionate denial rates:
Asian patients: 2.72% denial rate
Hispanic patients: 2.44% denial rate
Non-Hispanic Black patients: 2.04% denial rate
Non-Hispanic White patients: 1.13% denial rate
The National Association of Insurance Commissioners (NAIC) Consumer Representatives report warns that AI tools, often trained on historically biased datasets, can "exacerbate existing bias and discrimination, particularly for marginalized and disenfranchised communities."
These systemic biases stem from persistent underrepresentation in clinical research datasets, which means AI algorithms learn and perpetuate historical inequities. The result is a feedback loop where technological "efficiency" becomes a mechanism for deepening healthcare disparities.
Legislative Response and Regulatory Oversight
While California's Physicians Make Decisions Act and new Centers for Medicare & Medicaid Services (CMS) rules represent progress in regulating AI in healthcare claims, the NAIC warns that current oversight remains inadequate. California's law prohibits insurers from using AI algorithms as the sole basis for denying medically necessary claims and establishes strict processing deadlines: five business days for standard cases, 72 hours for urgent cases, and 30 days for retrospective reviews.
At the federal level, CMS now requires Medicare Advantage plans to base coverage decisions on individual circumstances rather than algorithmic predictions. As of January 2024, coverage denials must be reviewed by physicians with relevant expertise, and plans must follow original Medicare coverage criteria. CMS Deputy Administrator Meena Seshamani promises audits and enforcement actions, including civil penalties and enrollment suspensions for non-compliance.
The insurance industry opposes these safeguards. UnitedHealthcare's Medicare CEO Tim Noel argues that restricting "utilization management tools would markedly deviate from Congress' intent." But as the NAIC emphasizes, meaningful transparency requires more than superficial disclosures - insurers must document and justify their AI systems' decision-making criteria, training data, and potential biases. Most critically, human clinicians with relevant expertise must maintain true decision-making authority, not just rubber-stamp algorithmic recommendations.
Recommendations for Action
The NAIC framework provides a roadmap for protecting patients while ensuring appropriate oversight of AI in healthcare claims. Key priorities for federal and state regulators:
Require comprehensive disclosure of AI systems' training data, decision criteria, and known limitations
Mandate documentation of physician recommendation overrides with clinical justification
Implement regular independent audits focused on denial patterns affecting marginalized communities
Establish clear accountability and substantial penalties when AI denials cause patient harm
Create expedited appeal processes for urgent care needs
Healthcare providers should:
Document all cases where AI denials conflict with clinical judgment
Track patient impacts from inappropriate denials, including worsened health outcomes
Report systematic discrimination in algorithmic denials
Support patient appeals with detailed clinical documentation
Share denial pattern data with regulators and policymakers
The solutions cannot rely solely on technological counter-measures. As the NAIC emphasizes, "The time to act is now."
Conclusion
The AI-driven denial of care represents more than a technological problem - it's a fundamental breach of the healthcare system's ethical foundations. By prioritizing algorithmic efficiency over human medical judgment, insurers have transformed life-saving care into a battlefield where profit algorithms determine patient survival.
Meaningful change requires a multi-pronged approach: robust regulatory oversight, technological accountability, and a recommitment to patient-centered care. We cannot allow artificial intelligence to become an instrument of systemic denial, transforming healthcare from a human right into an algorithmic privilege.
Patients, providers, and policymakers must unite to demand transparency, challenge discriminatory systems, and restore the primacy of human medical expertise. The stakes are too high to accept a future where lines of code determine who receives care and who is left behind. Our healthcare system must be rebuilt around a simple, non-negotiable principle: medical decisions should serve patients, not corporate balance sheets.