Cutting HIV Treatment and Public Health Clinics Does Not Save Money. It Shifts Costs to Human Lives.

When I began leading infectious disease programs for New York City in 2011, the Great Recession forced us to drastically cut back clinic hours and services. We hoped that patients would continue to receive some of those services elsewhere — at federally qualified health centers, at the public hospital system, at community organizations that had been filling gaps in public coverage for decades. But we also understood, in a way that is easy to forget when you are making budget decisions in a spreadsheet and hard to forget when you are watching it happen to real patients, that there is a reason the concept is called a safety net and not a safety blanket. The net has holes. People fall through.

That experience shapes how I read the current wave of cuts to publicly funded clinical services, and it leads me to a conclusion that I think deserves to be stated plainly: these cuts will not reduce the burden of disease in the United States. They will redistribute it — from the budgets of government programs to the bodies of the people those programs were designed to protect, and eventually back into the health system in the form of emergency care, hospitalizations, and the irreversible consequences of untreated chronic disease.

What Is Happening to HIV Care and Why It Matters

The Ryan White HIV/AIDS Program is the payer of last resort for approximately 25% of the 1.2 million Americans living with HIV — people who fall through the gaps between Medicaid eligibility and private insurance coverage, and for whom the program covers medications, laboratory monitoring, and related services that make the difference between a managed chronic condition and a life-threatening one. About 18 states have already tightened eligibility or cut covered HIV medications under the Ryan White-funded AIDS Drug Assistance Program, with five more currently considering changes.

Florida’s actions represent the most severe example. On March 1, Florida cut off more than 16,000 clients — roughly half its entire caseload — by dropping the income eligibility threshold from 400% of the federal poverty level ($63,840) to 130% ($20,748), and removing Biktarvy, the most prescribed HIV medication in the country, from its formulary. The people affected are among the most medically and economically vulnerable in the state, and the consequences of interrupting their treatment are well understood and deeply serious.

Effective antiretroviral therapy suppresses HIV to undetectable levels, keeping patients healthy and, critically, making them unable to transmit the virus to others. That last point is not a minor clinical detail; it is the mechanism through which HIV treatment functions simultaneously as individual care and population-level prevention. Interrupting treatment does not merely put the individual patient at risk. It also risks the development of drug resistance that can itself be transmitted to others, and it creates the conditions for renewed community spread of a virus that decades of public health effort have worked to bring under control. If HIV treatment disruptions push the United States back toward 2018 infection rates, the projected consequences include an estimated 4,500 additional HIV infections and $3.8 billion in lifetime treatment costs. The arithmetic of cutting HIV care is straightforward, and it does not favor the budget.

The Hidden Cost of Closing Public Health Clinics

The cuts extend well beyond HIV programs. Counties and municipalities across the country, including Los Angeles, are cutting clinical programs spanning immunizations, sexual health, and behavioral health, as reductions in federal funding ripple down through state and local budgets to the front-line services that reach the communities with the least access to private alternatives.

There is a consequence to these closures that goes beyond the immediate loss of clinical capacity, and that I think receives insufficient attention in the policy debate. Public health clinics are among the most tangible and direct ways that communities experience what public health agencies actually do for them. When those clinics exist, residents can see them, use them, and advocate for them. When they close, the work of public health becomes invisible again — and invisible services generate neither the trust that public health depends on during emergencies nor the political constituency that would oppose further cuts in the future. The long-term institutional damage of clinic closures is difficult to quantify, but it is real, and it compounds over time in ways that are genuinely difficult to reverse.

I have seen this cycle play out before, and the lesson it teaches is consistent: cutting public health clinical services saves money in one budget cycle and costs substantially more — in emergency care, in preventable disease burden, and in the erosion of public trust — across every subsequent one.