This summer, Arkansas will begin implementing new federal work requirements for Medicaid recipients. Penalties for not fulfilling work requirements won't begin until January 2027, but the state's Department of Human Services will begin enforcing requirements for adults enrolled in the expanded Medicaid program as early as July 1. Registered Arkansans between ages 19 and 64 must work, volunteer or go to school for at least 20 hours per week unless exempt.
One exemption left out is those living with HIV. Carl Schmid is executive director of the HIV+Hepatitis Policy Institute and says nationwide, 40 percent of people with HIV rely on Medicaid. He tells Ozarks at Large's Daniel Caruth this oversight could be detrimental for the nearly 6,000 Arkansans who have HIV.
Carl Schmid: These days, people, if they have access to the remarkable drugs that are paid for by Medicaid, they can live healthy lives. It used to be you would die, unfortunately, pretty quickly. But now with the drugs, people live long. And also when you are on the drugs, it's really prevention as well, because then your virus is so low, you cannot transmit it to other people as well.
Work requirements — it's not like we're against work. I think people should be able to, if they can, work, volunteer or whatever. But it's just the way the legislation was written, it's black and white. If you do not work and you are on Medicaid — and this is expanded Medicaid, the people that got on through the Affordable Care Act — then you're gone. You will not be covered by Medicaid. And we cannot risk that for people living with HIV. They cannot risk losing the access to their healthcare.
There are exemptions in the law, and Arkansas is implementing the law pretty quickly. There are exemptions for people with disabilities, and that means people with full-blown AIDS — that's a disabling condition, they're exempt. But there's also an exemption for caregivers and for people who have a serious or chronic condition. And we feel that HIV should automatically qualify for that. So what we're asking the state to do, instead of asking every individual person to ask for the exemption, we would like a blanket exemption.
Daniel Caruth: I know that in 2018 work requirements were added and about 18,000 people lost coverage. Can you talk a bit about the impact of that, and how difficult it is for someone who has these health conditions to also go and try to get an exemption and work around these complicated bureaucratic systems?
Schmid: One thing I want to underscore is that for people with HIV, it's not going to change — once you have HIV, you have it forever. So why do you have to keep on getting recertified every six months or something? If you're on HIV drugs, the state knows that and they should be able to just exempt people. But having all these barriers has resulted in people losing coverage. And that's not good. When people fall out of care, they become sick, and it actually costs the healthcare system more money in the long run because people end up going into the hospital.
We are very fortunate that there is a fallback program for people living with HIV called the Ryan White HIV/AIDS Program that does provide drugs and treatment and healthcare for low-income people. But that program is really struggling right now. We haven't seen an increase in the program for the drug component of it since 2013 — that's 13 years ago. And states are reducing eligibility. So it's a bad situation out there. It's not good for people and it's not good for our public health as well.
Caruth: Arkansas had 400 new HIV infections in 2022 and one of the highest rates in the country. Can you talk a little bit about who is impacted most by HIV? I feel like we don't speak as much about HIV and about prevention now that there have been advancements in medicine. Can you talk a little bit about why it still is a risk and who is most at risk?
Schmid: There are around 6,000 people living with HIV in Arkansas. The people primarily impacted are lower-income people, African Americans, Latinos, gay men. Still, around a quarter of all people living with HIV are women, and particularly Black women. Arkansas is in the South, and we're seeing most of the new infections in this country in the South because people don't talk about these issues anymore. People are not dying like they used to in the '80s and '90s. But we cannot forget about them. We have to be vigilant in both making sure people have treatment and, because people are living longer too because of the treatments, also preventing HIV. We have new drugs called PrEP that we're trying to get to more and more people. It seems like a lot of white males are getting access to those drugs, but not Black and Latino men and women. So we have to focus both on treatment and prevention. We need leadership from our government — both state and local — because we cannot forget about HIV. If we do, we're just going to see new infections rise.
Caruth: When these sorts of requirements and barriers pop up, does that hurt the prevention element as well? Does it limit access to those types of drugs too?
Schmid: The Medicaid work requirements would impact access to preventive drugs as well. We've done an analysis — as I said, 40 percent, Medicaid is the biggest payer for HIV treatment. But also, if you look at the eligible population of people who should be on PrEP, Medicaid is the biggest payer. So yes, this would also impact access to preventive drugs as well.
Caruth: What kinds of conditions are usually exempt from things like this?
Schmid: Women who have children at home are exempt. The law also recognizes mental health issues and substance use issues. In the past, HIV has been indicated as a population that could be exempt. But we don't want to fight this state by state — that's putting too many lives in jeopardy. We would like something from the national government to say this. But since Arkansas is moving forward so quickly, we submitted comments to the state to make sure that HIV is exempt. Arkansas has recognized HIV as a concern in the past when they implemented work requirements, so we hope it will continue in the future. But there's a lot at risk right now.
Caruth: Have you heard anything from the state since you submitted those requests?
Schmid: No, I haven't. We know they're moving forward, though, and they said they would exempt people with special health needs, but they didn't illustrate which ones they are.
Caruth: For people listening to this, what do they need to know? What are the next steps?
Schmid: Continue to encourage the state to exempt people living with HIV from the work requirements. They're moving forward, so individuals who can get an exemption should push for them and be mindful of all the communication that Medicaid recipients receive from the state, because there may be a lot of paperwork ahead and a lot of data submissions. It's really important for people to pay attention to this implementation because you do not want to lose your healthcare access.
Caruth: Do you think this is an oversight on Arkansas's part, or why was this specific issue left out?
Schmid: I hope we don't give up, and I hope that right now they're doing broad strokes and as the rules get more clarified and get closer to the implementation date, they will be more specific and exempt people with HIV. If not, then there's some danger on the horizon.
Carl Schmid is the executive director of the HIV+Hepatitis Policy Institute, based in Washington, D.C. He spoke with Ozarks at Large's Daniel Caruth earlier this week.
Ozarks at Large transcripts are created on a rush deadline and edited for length and clarity. Copy editors utilize AI tools to review work. KUAF does not publish content created by AI. Please reach out to kuafinfo@uark.edu to report an issue. The audio version is the authoritative record of KUAF programming.
