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What Is The Big Ugly Murder Bill?

The Big Ugly Murder Bill is our more appropriate name for H.R. 1 (One Big Beautiful Bill Act), a federal bill that slashes funding for Medicaid, attacks several safety net programs, criminalizes people based on their immigration status, and lays the groundwork for devastating consequences for marginalized communities, including people living with HIV. The Big Ugly Murder Bill was signed into law by Donald Trump on July 4, 2025, representing the largest rollback of federal health care support in the history of this nation. It is estimated that 15 million people will lose health insurance as a result of this law. 

We will be seeing the impacts of the bill roll out over time, but here is what we know so far:

  • Medicaid cuts will push thousands of people living with HIV off life-saving care.
  • More red tape: eligibility reporting requirements, including work requirements and renewals, will cause many to lose coverage
  • Public health infrastructure will be gutted, especially in the South.
  • Trans and gender-affirming care will be restricted or eliminated in many states
  • Immigrant communities will face even greater barriers to care and increased criminalization

How Does This Impact People Living with HIV?

  • The devastating cuts to Medicaid will cut care for people living with, and vulnerable to, HIV. Medicaid covers HIV screening, prevention and treatment services and has been a major catalyst for efforts toward ending the epidemic. Medicaid is also the primary insurance plan for people living with HIV. Forty percent of people living with HIV rely on Medicaid for comprehensive and cost-friendly healthcare. 
  • Most Medicaid enrollees living with HIV qualify through the Affordable Care Act (ACA)’s Medicaid expansion program and disability related-pathways. This is important because the Medicaid work requirements in the Big Ugly Murder Bill specifically apply to people in the Medicaid expansion population. These work requirements will lead to devastating coverage loss among people living with HIV, which would place overwhelming demand on the Ryan White HIV/AIDS Program
  • Medicaid renewal – or proving your eligibility – will be required more frequently. This is a tactic of using red tape to make staying on Medicaid more difficult, effectively moving people off of the program through creating unnecessary hurdles. 
  • When people living with HIV  lose healthcare coverage, the need and costs for their care don’t disappear. They fall on already overwhelming safety-net programs like Ryan White, or they go unmet entirely, causing unnecessary interruptions in treatment.

 

Key Resources

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Policy Recommendations

What You Can Do About the Big Ugly Murder Bill

The federal government must protect and sustain critical funding for HIV prevention, care and treatment. The CDC and HRSA fund the backbone of our national public health infrastructure, supporting the HIV programs that support millions of people in the US. HR1 introduces several new Medicaid rules that could disrupt access to HIV care by imposing work requirements and twice yearly verification of such. Some groups would be exempt (e.g. pregnant people, caregivers, and those facing short-term hardship) but this is largely left at the interpretation of the federal and state governments.

The Congressional Budget Office estimates that these new provisions will result in almost 15 million people losing their health care coverage by 20341. This would result from coverage loss due to Medicaid work requirements, eligibility changes, limited funding for state Medicaid programs, and increased administrative burden to implement and maintain work requirements. With Medicaid being the primary source of insurance coverage for people living with HIV2, this is a devastating blow to access to HIV care. Moreover, access to live-saving care should never be contingent on employment, especially considering the persistent stigma and discrimination that people living with HIV face. 

States have an opportunity to protect people living with HIV from losing their healthcare coverage. States must:

  • Explicitly recognize HIV as a complex health condition and include people living with HIV as categorically exempt from work requirements.
  • Adopt broad definitions of activities that satisfy work requirement rules such as volunteering and caregiving and allow a wide range of documentation to suffice as verification
  • In order to prevent unnecessary disenrollment, minimize reporting obligations as low as the federal government will allow, offer simple submission options (e.g. via phone, mail, or online) and phase in implementation only after administrative systems are ready
  • Closely monitor unemployment by county to make sure states can identify which counties will qualify for federal waivers during periods of high joblessness.

Federal HIV funding is necessary. Without it, states will be forced to dismantle entire systems of care that have saved lives, increased the quality of life for people living with HIV, advanced health equity, and worked hard to end the epidemic overall. Though it feels daunting, now is the time to double down. Congress must: 

  • fully defend Medicaid and fully fund HIV prevention and treatment programs or risk reversing decades of progress.


1: https://www.cbpp.org/research/health/by-the-numbers-harmful-republican-megabill-will-take-health-coverage-away-from
2: https://www.kff.org/medicaid/5-key-facts-about-medicaid-coverage-for-people-with-hiv/

Medicaid and the Affordable Care Act (ACA) are essential lifelines for people living with HIV1 as they provide access to affordable, comprehensive healthcare coverage. Medicaid offers many people living with HIV coverage for critical services such as antiretroviral therapy (ART) and case management, often with minimal out-of-pocket costs. Similarly, ACA Premium Tax Credits reduce monthly insurance premiums for low- to moderate-income folks, ensuring affordability for private health insurance plans in the ACA marketplace. For people living with HIV, continuous access to care is a matter of survival. 

Medicaid cuts impose serious threats to people living with HIV. Disruptions in Medicaid eligibility or enrollment processes could mean missed treatment for HIV as well as any other comorbidities. The red tape created by the Big, Ugly Murder Bill, such as work reporting requirements, will complicate enrollment and re-enrollment and increase burdensome paperwork, which could result in loss of coverage2. For people living with HIV, even short gaps in coverage can be detrimental to health. 

As of January 1, 2026, the Affordable Care Act (ACA) enhanced premium tax credits have expired. This change represents a significant shift in the affordability of Marketplace coverage. Many enrolled are now required to contribute a higher share of income towards insurance premiums, and some no longer qualify for financial assistance (particularly those with moderate incomes). These changes will lead to coverage instability, including switching plays, delayed payments, or a loss of coverage altogether, with disproportionate impacts on older adults and folks closer to the Federal poverty line. Limiting access to ACA subsidies may force people living with HIV to forgo coverage altogether due to unaffordable premiums

We must demand federal and state policymakers to save Medicaid from cuts and protect the ACA Premium Tax Credits. These programs are not safety nets, they are lifelines for people living with HIV and there is no ending the HIV epidemic without them. We must prioritize the health, dignity and quality of life for people living with HIV.

Congress must: 

  • support a permanent extension on the ACA Enhanced Premium Tax Credit to sustain folks currently enrolled as well as increase the number of folks insured3, without any restrictions on abortion or gender affirming care.

State officials must: 

  • have a range of tools at their disposal to mitigate Medicaid coverage losses and strengthen HIV care now. States must maximum work exemptions and more specific must exempt people living with HIV from the Medicaid work reporting requirements in HR1. States should also screen for exemption eligibility proactively4. Access to live-saving care cannot be contingent on employment, especially considering the persistent  stigma and discrimination that people living with HIV face. States must work with community-based organizations and people with lived experience to decide what forms of reporting feel safe. States should also choose not to require people to submit any “proof” that they meet an exemption and require the least amount of self-disclosed personal health information needed5. And, states must exempt people living with HIV from the Medicaid work reporting requirements in the Big Ugly Murder Bill. 


1: https://www.hiv.gov/federal-response/other-topics/the-affordable-care-act-and-hiv-aids
2: https://www.kff.org/medicaid/the-impact-of-h-r-1-on-two-medicaid-eligibility-rules/
3: https://bipartisanpolicy.org/issue-brief/enhanced-premium-tax-credits-who-benefits-how-much-and-what-happens-next/
4: https://www.lac.org/assets/files/MitigatingHarmsforPeoplewithHIV_FINAL.pdf
5: https://www.lac.org/assets/files/Mitigating-the-Harm-of-H.R.-1_Minimizing-the-Burdens-for-Demonstrating-Exemptions-from-the-Medicaid-Work-Requirements.pdf

The Trump regime has been consistently targeting the rights, health and safety of the trans community since they took office. Early House versions of the Big Ugly Murder Bill included a proposed ban on Medicaid coverage for gender-affirming care. That cruel provision was ultimately stripped out of  the final bill. However, any threat to Medicaid is still a threat to transgender people’s lives. By imposing harsh restrictions on Medicaid and Marketplace eligibility, H.R. 1 is one of the most sweeping rollbacks of transgender healthcare in history. This would shift financial burden to the states through Medicaid at a time where the massive funding cuts to Medicaid are already deepening state budget crises. These changes would jeopardize access to essential, life-saving care for transgender people. The transgender community relies on Medicaid at about twice the rate of the overall population, making these cuts especially catastrophic. 

At least 10 million people stand to lose coverage altogether, including over 100,000 transgender people and as many as 700,000 transgender Medicaid enrollees who depend on these programs for medically necessary, life-saving healthcare1. Changes to programs like Medicaid and SNAP under HR1 also disproportionately affect transgender folks, 12% of whom rely on Medicaid as their primary source of health insurance, compared to 7% of non-LGBT adults. Further, 21% of trans people in the U.S. live in poverty, this is nearly double the rate of non-LGBT people2. Congress must protect and expand access to affordable and necessary healthcare for transgender people. Their lives depend on it.

To mitigate HR1’s most damaging provisions, Congress must:  

  • take immediate actionable steps to restore and protect healthcare access. 
  • support all opportunities to maintain federal Medicaid funding for gender-affirming care and prohibit the use of federal funds for any policy that discriminates based on gender identity. Federal and state lawmakers must act to defend access to care and uphold the fundamental right to medically necessary healthcare.


1: https://healthlaw.org/california-pride-as-pride-month-draws-to-a-close-california-must-commit-to-maintaining-gender-affirming-care/
2: https://www.thetaskforce.org/news/the-impacts-of-the-big-bill-of-betrayal/

H.R. 1 creates profound and dangerous restructuring of the reproductive healthcare landscape in the US. One that does not prioritize the bodily autonomy, health, and economic stability of millions of people. By targeting Medicaid reimbursement for Planned Parenthood, which is the primary source of preventive care such as cancer screenings, contraception, and STI testing in many communities, the Trump regime is trying to create a de facto national abortion ban while simultaneously destabilizing the basic healthcare infrastructure that many people rely on. 

Nearly 200 clinics nationwide are already at risk of closure, leaving more than two million people without access to essential health care1. This harm is not theoretical: denying people the ability to control their reproductive lives systematically undermines their dignity, health and future. Evidence from states with abortion bans already shows increased medical complications, delays in emergency care, and avoidable maternal mortality2. It is unconscionable that federal policy would exacerbate these inequities, given the proven effects of such bans. 

Congress must: 

  • restore Medicaid funding to Planned Parenthood and enact comprehensive protections for reproductive health care, including abortion, consistent with medical evidence, constitutional rights and public health imperatives. 
  • Pass national legislation that removes barriers to abortion and maternal health care, protects clinicians from criminalization, reaffirms that the Comstock Act cannot be weaponized to restrict lawful healthcare and ensures that the FDA’s evidence-based regulation of mifepristone and misoprostol remains free from political interference. 
  • investigate and monitor the discriminatory impacts of abortion bans and related reproductive health restrictions, particularly those disproportionately harming low-income folks, Black and brown people, young people, people with disabilities and people who live in rural communities. 

States must:

  • Repeal preexisting abortion bans and fetal-personhood provisions that erase the rights of birthing people3. 
  • Adopt robust shield laws protecting patients and providers from civil or criminal attacks. 
  • Continue to expand funding, strengthen legal protections for patients and clinicians, and ensure that no person is denied care they need because of where they live. 

States like California and Colorado4 have already demonstrated what responsible governance looks like: stepping in with emergency funding to keep clinics open, preserving access to vital services and reaffirming reproductive freedom in the face of federal hostility. These actions are necessary, but they are not sufficient. Reproductive health care is a human right. The federal government’s attempt to dismantle it demands an equally firm commitment from Congress and the states to safeguard the health, safety and autonomy of everyone. A functioning health care system cannot exist when millions of people are stripped from their right to choose their provider or to access necessary health care. 


1: https://www.smith.senate.gov/u-s-senators-tina-smith-patty-murray-representatives-friedman-williams-and-pappas-introduce-new-legislation-to-restore-federal-funding-to-planned-parenthood/
2: https://phr.org/wp-content/uploads/2025/09/Cascading-Harms-Research-Brief_PHR_September-2025.pdf
3: https://nwlc.org/wp-content/uploads/2025/09/All-Part-of-the-Plan-Factsheet-3.pdf
4: https://coloradonewsline.com/briefs/colorado-legislature-passes-bill-to-fund-medicaid-reimbursements-for-planned-parenthood

The Big Ugly Murder Bill constitutes one of the most sweeping rollbacks of immigrant rights in modern U.S. policy and is purposefully designed to inflict harm and masked as “solving a problem” by drastically expanding detention, authorizing the indefinite imprisonment of children, and pouring billions into militarized enforcement with almost no oversight. The law effectively codifies hate, prejudice and bigotry as U.S. policy. The invasive examinations of unaccompanied children, and expedited deportation processes strip migrants of their right to due process and violates core human rights. 

H.R. 1 dramatically expands the federal immigration enforcement apparatus while stripping basic support from immigrant families. The law allocates $45 billion to detention, which more than quadruples ICE’s budget, and explicitly authorizes detention of immigrants and children, violating long-standing protections1. It adds another $32 billion for interior enforcement, including expedited removal with minimal oversight2. At the border, H.R. 1 funnels over $75 billion into militarization, including $47 billion for border wall construction and $6.2 billion for surveillance technology3. The bill also imposes steep fees on humanitarian protections such as $100 annual asylum fee, $1,000 or more in parole fees, and $5000 penalties for people who cross the border4. This essentially makes it much harder, and in some cases impossible, for asylum seekers. 

H.R. 1 also cuts immigrants off from accessing Medicaid and SNAP, even for lawfully present immigrants like refugees, asylees, trafficking survivors and Violence Against Women Act (VAWA) applicants. Early estimates suggest that these restrictions will push tens of thousands of families off of the nutrition and health programs they need to survive, increasing food insecurity for about 90,000 people per month and leaving many immigrants living with HIV without access to the treatment that they need to survive5. These actions sever families from essential resources, deepen poverty, and entrench racialized inequities across generations. The result of HR1 will be predictable and devastating: destabilized families and communities, worsening public health, and eroded core legal protections. 

Congress must:

  • Urgently undo the damage by repealing HR1’s sweeping detention and enforcement expansions, restoring access to federal benefits for all lawfully present immigrants, and erecting guardrails to ensure immigration policy cannot be weaponized as a tool for racialized punishment. This means eliminating punitive fees that block asylum, safeguarding due process and rebuilding pathways to safety by strengthening, rather than dismantling, asylum processing and prohibiting child and family detention. 
  • Reinstate access to nutrition and health programs such as SNAP, Medicaid, and CHIP – these are lifesaving programs that people depend on for their livelihood. 

States must:

  • Mitigate harm by rejecting local-federal immigration deputization, expanding sanctuary and privacy protections and  funding food and health programs for excluded immigrants. 

Together, state and federal leaders must reject policies rooted in fear and exclusion and commit to an immigration system grounded in humanity and equal opportunity that strengthens the communities that are the heart of this country.



1: https://www.nilc.org/resources/the-anti-immigrant-policies-in-trumps-final-big-beautiful-bill-explained/
2: Ibid.
3: Ibid.
4: Ibid.
5: https://www.nilc.org/articles/what-new-federal-snap-restrictions-and-guidance-mean-for-immigrant-communities/