Insurance removes one barrier, but it's not the only one.
Between 2012 and 2023, the expansion of Medicaid under the Affordable Care Act opened a meaningful path to HIV prevention for millions of Americans, as researchers at Rutgers Health confirmed that broader insurance coverage increased access to PrEP — a medication that stops the virus before it takes hold. Yet the data reveals a society still divided along racial lines: white Americans received PrEP at rates nearly seven times higher than Black Americans, even as Black and Hispanic communities bore a disproportionate share of new infections. A tool that works, it turns out, is not the same as a tool that reaches everyone. And now, with federal funding cuts projected to strip coverage from 7.5 million people over the next decade, even the partial progress achieved stands in jeopardy.
- A decade of Medicaid expansion measurably reduced HIV diagnoses and increased PrEP prescriptions nationwide — but the gains landed unevenly, with white Americans absorbing the largest benefits.
- The racial gap is not subtle: 94% of eligible white Americans received PrEP in 2022, compared to just 13% of Black Americans and 24% of Hispanic Americans — communities already facing the heaviest burden of new infections.
- Researchers warn that insurance coverage alone cannot close the divide, as deeper barriers — geographic access, institutional trust, and systemic inequity — remain untouched by policy expansion.
- Congress has now passed legislation eliminating the enhanced federal funding that made Medicaid expansion viable, with work requirements and eligibility checks expected to push 7.5 million people off coverage.
- With only 36% of those who could benefit from PrEP currently receiving it, and rollbacks looming, the communities that gained the least from expansion now face losing even that fragile foothold.
Between 2012 and 2023, Medicaid expansion under the Affordable Care Act quietly shifted the landscape of HIV prevention in America. Researchers at Rutgers Health analyzed prescription data across all fifty states and found that when states extended coverage to lower-income adults, more people received PrEP — the medication that prevents HIV infection. HIV diagnoses fell. Prescriptions rose. The policy, at least in aggregate, worked.
But the aggregate concealed a troubling interior. When Elizabeth Stone and her colleagues broke the data down by race, the picture sharpened into something harder to look away from. In 2022, ninety-four percent of white Americans who could benefit from PrEP received a prescription. For Black Americans, that figure was thirteen percent. For Hispanic and Latino Americans, twenty-four percent — even as those communities experienced the highest rates of new HIV diagnoses. The medication existed. The coverage existed. And still, three out of four Black Americans who could have been protected were not.
Stone, an instructor in psychiatry at Robert Wood Johnson Medical School, was direct about what the findings mean: Medicaid expansion is a tool that works, but it is not sufficient. The barriers that remain — geography, trust, medical literacy, systemic inequity — are not dissolved by an insurance card. Removing one obstacle does not remove them all.
Now even the gains made are at risk. The One Big Beautiful Bill Act, passed in July, eliminates the enhanced federal funding that made Medicaid expansion financially viable for states, while adding work requirements and more frequent eligibility checks. The Congressional Budget Office projects that 7.5 million people will lose coverage over the next decade — many of them in the communities that already saw the smallest improvements in PrEP access. The CDC estimates 35,000 to 40,000 new HIV infections occur in the United States each year. Without policy interventions that address the social and systemic roots of inequity, researchers warn, the disparities will not merely persist — they will grow.
Between 2012 and 2023, something measurable shifted in how many Americans at risk of HIV infection could access preexposure prophylaxis—a pill or injection that prevents the virus from taking hold. Medicaid expansion under the Affordable Care Act opened a door. Researchers at Rutgers Health tracked prescription data across all fifty states and Washington, D.C., and found that when states extended coverage to adults earning up to 138 percent of the federal poverty line, more people got the medication they needed. The numbers moved in the right direction overall. HIV diagnoses fell. PrEP prescriptions rose.
But the gains were not evenly distributed. When Elizabeth Stone and her team at Rutgers looked at the data by race, a stark picture emerged. In 2022, ninety-four percent of white Americans who could benefit from PrEP received a prescription. For Black Americans, the figure was thirteen percent. For Hispanic and Latino Americans, twenty-four percent. The medication exists. Insurance now covers it for more people. Yet three out of four Black Americans who could prevent infection through PrEP were not receiving it. The disparities were largest precisely where the burden of new infections was heaviest.
Medicaid itself is a joint federal-state program designed to insure people with low incomes and disabilities. The ACA gave states the option to expand it, with the federal government picking up most of the cost. As of November, forty states plus D.C. had taken that option. The research shows it worked—at least partially. Men saw stronger gains than women. People in their late twenties and early thirties benefited more than other age groups. White communities experienced the largest relative increases in access. Black and Hispanic communities, who carry a disproportionate share of new HIV diagnoses, saw smaller improvements despite the expansion.
Stone, an instructor in psychiatry at Robert Wood Johnson Medical School, framed the finding plainly: Medicaid expansion is a tool that works, but it is not enough. "The disparities we observed underscore the need to intentionally address barriers that may be limiting access to PrEP for Black and Hispanic communities specifically," she said. The barriers are not just about insurance. They involve trust, geography, medical literacy, and systemic factors that a policy alone cannot fix. Expanding coverage removes one obstacle. It does not remove them all.
The gains themselves now face a threat. In July, Congress passed the One Big Beautiful Bill Act, which eliminates the increased federal funding that made Medicaid expansion affordable for states. The law also introduces work requirements and more frequent eligibility checks. The Congressional Budget Office projects that over the next decade, 7.5 million people will lose Medicaid coverage as a result. Many of those people will be among the communities already experiencing the smallest gains in PrEP access. The progress made between 2012 and 2023—modest as it was for Black and Hispanic Americans—risks being reversed.
The CDC estimates that between 35,000 and 40,000 new HIV infections occur annually in the United States. Only about thirty-six percent of people who could benefit from PrEP currently receive it. Common medications include Truvada and Descovy. The research published in Health Affairs, conducted with colleagues from the University of Pennsylvania and Rhode Island Hospital, makes clear that insurance expansion alone cannot close the gap. "We need policy interventions that address the social and systemic factors driving inequities in PrEP access," Stone said. Without them, the disparities will persist—and soon, they may widen.
Citações Notáveis
Medicaid expansion is a powerful tool for improving HIV prevention, but the disparities we observed underscore the need to intentionally address barriers that may be limiting access to PrEP for Black and Hispanic communities specifically.— Elizabeth Stone, lead author, Rutgers Health
We need policy interventions that address the social and systemic factors driving inequities in PrEP access.— Elizabeth Stone, Rutgers Health
A Conversa do Hearth Outra perspectiva sobre a história
Why did Medicaid expansion help some communities more than others if the same insurance became available to everyone?
Insurance removes one barrier, but it's not the only one. A Black American in a rural area might have Medicaid coverage now, but if there's no clinic nearby that prescribes PrEP, or if they've had bad experiences with the medical system, or if they don't know the medication exists, coverage alone doesn't get them the drug.
So the disparities aren't about money at that point.
Not entirely. They're about trust, geography, medical education, and how health systems have historically treated Black and Hispanic patients. Medicaid expansion was a real win, but it exposed how much work remains beyond just paying for things.
The new law cuts federal funding. Does that mean the gains disappear immediately?
Not immediately, but yes—over time. States will have to choose whether to keep funding expansion on their own dime, and most won't. Seven and a half million people lose coverage. Many of them are in the communities that already had the hardest time accessing PrEP.
So the disparities get worse.
Almost certainly. You're removing insurance from the people who benefited least from having it in the first place.
What would actually close the gap?
The researchers are saying you need to go deeper than policy. You need clinics in underserved areas, you need community trust-building, you need providers trained to serve these populations intentionally. Insurance is necessary but not sufficient.