In this resource center, you can find the following sections:

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

Announcement:
Medicaid agencies have begun sending out notices of Medicaid policy changes. Pay close attention to any messages you receive from your state Medicaid agency or health plan. Watch your physical mail, email, text messages, and online Medicaid account for notices. If you are asked to provide documents, respond with the requested information as soon as possible. If your state Medicaid program says you are no longer eligible and you believe that decision is wrong, you can appeal it. Please reach out to your state Medicaid healthcare navigator and your ASO for more information about keeping coverage.

🚨Urgent Update! (October 2026):

Starting October 1, 2026, new federal rules will change who qualifies for Medicaid and CHIP based on immigration status. Some immigrants who were previously eligible (i.e. refugees, people granted asylum, survivors of domestic violence or trafficking, etc.) may lose their coverage. But do not assume that coverage loss is guaranteed based on immigration status. Different rules apply to different scenarios, and some people may still qualify for Medicaid depending on if they have a green card, whether they are pregnant, what state they live in, whether their state has its own program that provides coverage. Other folks that may still qualify include some Cuban and Haitian entrants, and citizens of certain Pacific Island Nations. States can also continue to cover children. 

People who are impacted by this policy change may receive notices from their state Medicaid agency or managed care organization informing them of changes to their coverage or requesting documentation in order to maintain coverage. If an agency incorrectly determines someone is ineligible, they can provide documentation or attest to their eligible status, appeal the decision, and may be able to maintain coverage for 90 days while providing additional documentation. 

Stay informed, review all notices carefully, and seek trusted help to further understand your options!


▶️ July 2026 Update: Medicaid Work Reporting Requirements and CMS Interim Final Rule

On June 3, the Centers for Medicare and Medicaid Services issued an Interim Final Rule on Medicaid Work Reporting Requirement. The rule will add barriers to care and threaten coverage for people living with HIV and other serious health conditions. The good news is states are fighting back! Attorneys General from 24 states and two Governors filed a lawsuit challenging the CMS rule.  We will keep you updated as this develops!

Learn more about the CMS rule and how to save Medicaid coverage for people living with HIV and other serious health conditions in the Policy Recommendation Section.

Read more here: 

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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: 

  • defend and invest more in Medicaid and 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/

On June 1, 2026, the Centers for Medicare & Medicaid Services (CMS) issued an Interim Final Rule (IFR) explaining how States must implement the new Medicaid work reporting requirements created by H.R. 1. An IFR is a federal regulation that takes effect before the public comment process is complete (although CMS must still consider public comments and feedback before finalizing the rule). While H.R.1 requires many folks to document at least 80 hours of work or other qualifying activities (volunteering, caregiving, or being enrolled as a student) each month beginning January 1, 2027. The CMS rule goes beyond what was intended in H.R. 1 by limiting State’s flexibility, restricting when State’s can accept self-attestation, and creating narrower definitions of who qualifies as “medically frail.” 

Medicaid is the largest source of health insurance for people living with HIV, and many folks who receive coverage through the expansion States will be  subject to these work reporting requirements. The rule creates a new two-part test for medical frailty exemption, meaning it is not longer enough to have a serious or complex medical condition; people must also now prove that their condition significantly limits their ability to meet the work requirement. Although HIV is listed as a complex medical condition, the CMS IFR makes it clear that living with HIV alone does not qualify someone for an exemption. 

The rule also limits the use of self-attestation, making it harder for people to report their own health conditions when medical documentation is unavailable. For people living with HIV, this will mean additional paperwork, leading to delays, privacy concerns and more burden on providers to certify diagnoses and whether it affects their ability to work. Many people living with HIV can thrive because they have consistent access to Medicaid and treatment, but under this rule, being healthy could make it harder to qualify for care, as it would be an issue to meet the medical frailty exemption. At the same time, losing coverage because of reporting requirements and the red tape that they create can interrupt treatment, worsen health outcomes and place additional strain on already underfunded Ryan White Program services. These requirements will take coverage away from eligible people because the red tape is too hard to navigate, not because they are ineligible for Medicaid services

Twenty-five states and the District of Columbia have filed a lawsuit asking a federal court to block CMS from enforcing key parts of the Interim Final Rule. The states are arguing that CMS went beyond what Congress allowed in HR1, by making it harder for people who are “medically frail” to qualify for an exemption from the Medicaid work reporting requirements. The states are saying that the IFR adds a new rule that is not in HR1, requiring people with certain medical conditions to prove that their condition also makes it hard for them to meet the work reporting rules. If the court agrees and blocks these parts of the IFR, this could protect many people from losing Medicaid coverage and delay or limit how the IFR is put into effect.

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. 

Access to live-saving care cannot be contingent on employment, especially considering the persistent  stigma and discrimination that people living with HIV face. 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. State and federal policymakers have a range of tools at their disposal to mitigate Medicaid coverage losses and strengthen HIV care now. 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: 

  • maximize work requirement exemptions and screen for exemption eligibility proactively4.
  • 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.
  • make the exemption process as simple and streamlined as possible for people living with HIV and other serious health conditions 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/