An infectious diseases physician in Kentucky has raised concerns that new Medicaid work requirements could threaten access to essential healthcare for people living with HIV and other serious medical conditions.
The doctor, who provides HIV care, recalled treating a young uninsured man who arrived at the hospital after months of worsening health. The patient had experienced neurological problems, substantial weight loss, persistent fever, breathing difficulties and confusion before eventually being diagnosed with advanced HIV.
The physician said the case demonstrated the potentially severe consequences of interrupted healthcare and fragmented medical treatment.
More than 1.2 million people are living with HIV in the United States, while approximately 38,000 new cases are diagnosed each year. About 22 per cent of newly diagnosed patients are diagnosed at a late stage, when their immune systems have already suffered significant damage.
Consistent HIV treatment can suppress the virus to undetectable levels, allowing patients to remain healthy while preventing sexual transmission of the virus. However, only about 69 per cent of people diagnosed with HIV in the US are currently virally suppressed and benefiting from treatment.
The doctor stressed that maintaining HIV treatment requires regular medical appointments, laboratory monitoring and access to antiretroviral medication. Some patients also require support for substance use, mental health conditions and other illnesses such as diabetes, cardiovascular disease and cancer.
The physician said the Affordable Care Act and Medicaid expansion had significantly improved insurance coverage among patients in Kentucky.
Before Medicaid expansion, about 40 per cent of the doctor’s patients lacked health insurance. Twelve years later, that figure had fallen to around 10 per cent, close to the national uninsured rate of 8 per cent. Nearly half of Americans living with HIV now receive Medicaid coverage.
Before the Affordable Care Act, many people with HIV struggled to obtain private insurance because of pre-existing condition restrictions and other practices. For low-income patients, Medicaid eligibility often depended on being sufficiently disabled to qualify through the Social Security Insurance programme.
When Medicaid expansion began in 2014 in states that adopted it, the physician said uninsured patients experienced enormous relief because they could finally obtain dependable coverage for the healthcare they needed.
However, that progress is now facing potential disruption.
The 2025 H.R. 1 legislation requires most Medicaid expansion beneficiaries aged between 19 and 64 to document at least 80 hours of employment or approved “community engagement” activities each month from January 1, 2027.
Although the legislation included an exemption for people with serious or complex medical conditions, the physician said an interim rule from the Centers for Medicare and Medicaid Services appears to narrow that protection.
Under the rule, people living with HIV and others with serious or complex illnesses would reportedly have to demonstrate significant impairment caused by their condition to qualify for the exemption.
The physician argued that the requirements fail to account for the circumstances facing many low-income patients, including difficulties with transportation and limited access to computers, smartphones and reliable internet.
Missing a deadline, medical appointment or prescription refill can have serious consequences for people living with HIV, the doctor warned.
The administrative burden is also affecting healthcare providers. The physician said nearly 40 per cent of the clinic’s patients are covered by Medicaid, with about 90 per cent of those patients needing assistance every six months to complete paperwork required to maintain coverage.
The introduction of additional reporting requirements could therefore increase the workload for already stretched medical teams.
The physician also pointed to previous experiments with Medicaid work requirements, noting that Arkansas experienced higher uninsured rates without seeing an increase in employment.
According to the doctor, the experience of treating patients with HIV demonstrates both the weaknesses of the US healthcare system and the benefits of expanded Medicaid coverage.
The physician argued that maintaining uninterrupted access to treatment is particularly important for people living with HIV, as gaps in medication can allow the virus to rebound and cause potentially irreversible damage to the immune system.
The doctor urged policymakers to reconsider policies that could make healthcare access more difficult for vulnerable patients, warning that administrative requirements could ultimately undermine the progress achieved through Medicaid expansion.
Reliable access to medical care, the physician argued, is essential not only for people living with HIV but also for patients managing other serious or complex conditions.
