Missouri suspends Ryan White Part B services

In a surprise move, the Missouri Department of Health and Senior Services (MDHSS) suspended Ryan White Part B funding effective May 15, cutting off outpatient mental health, substance use services, oral health and emergency rental and utility assistance. The department also notified Ryan White partners and providers—but not clients—that all non-HIV medications would be removed from the AIDS Drug Assistance Program (ADAP) formulary on June 1. Clinicians and Ryan White navigators, whose job includes explaining the cuts to patients, say they were blindsided by the changes and worry that, even though HIV meds are not impacted, the cuts could undermine adherence for Missourians with HIV. 

Ryan White is a federal safety net for about half the people with HIV in the United States, providing medical care, medications and an array of essential support services to about 600,000 individuals. Each state can administer its funds—or change or suspend them—as it sees fit.

In Missouri, Ryan White offers a variety of services to residents with HIV who earn up to 300% of the federal poverty level, or just under $48,000 for a single person in 2026. Those who have lost program services will have to find support with Medicaid or through the Affordable Care Act (ACA) Marketplace. 

In an email sent to providers in May, MDHSS announced the removal of all non-HIV medications from the ADAP formulary, citing “funding constraints.” The email said the department “remains committed to ensuring access to essential HIV medications and medical care to support viral suppression and reduce new HIV transmissions. This change allows the Part B program to maintain these core medical services, keep current eligibility at 300% of the federal poverty level, and avoid implementing an ADAP waiting list at this time.”

Avoiding a waiting list and maintaining eligibility levels may be cold comfort for people who have relied on the program for more than HIV meds.  

For St. Louis resident Jeff Noble, 65, the changes mean he now has to pay out of pocket for any dental procedures, including cleanings. 

“I’ve got to come up with at least $157 three times a year, and next time I’m due to have X-rays, which will be a couple hundred bucks,” Noble told POSITIVELY AWARE. 

“I can manage it, but my concern is for the people who cannot. Somebody trying their hardest to keep it together, keeps getting knocked down, now suddenly doesn’t have any dental care and maybe they’ve got some depression, too. People are hurting from this.”

Case managers are responsible for helping clients find alternate ways to pay for their health care—and quickly, according to Jordan Braxton, community empowerment manager for Vivent Health in St. Louis, a nonprofit provider that offers medical, dental, mental and behavioral health care, STI testing and housing assistance, in addition to HIV care. (Editor’s note: Vivent Health + TPAN, part of Vivent Health, is publisher of POSITIVELY AWARE.)

About 6,200 Missourians receive some form of Ryan White assistance, according to MDHSS.

“Just think, if you are living with HIV and you have asthma and your inhaler is no longer covered,” Braxton said. “People have to make some tough choices. Do I pay for this or that?”

The latest cuts come six months after the state cancelled EHE funding that was used by Kansas City and St. Louis to help clients above the income threshold for Ryan White pay for their meds. 

Demario Richardson was a peer educator and grant writer for KC Care Health Center in Kansas City but was furloughed last year because of funding shortfalls. He was responsible for helping people get back into care, and says that the interruption of services, such as free transportation, will further increase in the community he served that the medical community won’t be there for them. 

“Especially in the African American community, there’s no trust there,” Richardson said. “People like me can articulate and have a skill set to talk to people who are out of care, and taking that away is going to affect the community. There’s already an issue with trust in the medical system, so to take the funding is going to add more stigma.”

For Richardson, the changes in Missouri have been personal: his co-pay for HIV meds has increased to more than $300 per month. 

In an email to POSITIVELY AWARE, Lisa Cox, a spokesperson for MDHSS, said the suspension of services was temporary, but did not say when they might resume. She said the state anticipates saving $1,961,000 as a result of the cuts. 

“DHSS has been exploring cost containment measures due to increases in program utilization, medication and insurance costs, and decreased rebates,” Cox wrote. “Cost containment measures will continue to be explored and implemented as needed to ensure a balanced budget while also serving clients and maintaining program efficiency.”

The email continued: “Ryan White requires recipients to vigorously pursue other resources and sources of funding before using Ryan White funds. This change was necessary to ensure that essential services remain available and that we meet our financial obligations for the long term.

While Part B services are paused, the department is working closely with federal partners, contractors and community stakeholders to address the identified issues and to pursue corrective steps that allow these services to resume as quickly and safely as possible. We understand the impact this may have on clients and providers, and we are committed to transparent communication throughout this process. As mentioned in advance to providers, additional updates will be shared as soon as they are available.”

In fiscal 2025, Missouri received a total of about $15.9 million in Ryan White Part B funding: $3.84 million in base funding, $9.93 million for ADAP and $2.16 million in supplemental funding.

Missouri is facing an increasingly dire fiscal outlook. A state budget surplus of $3 billion just last year is expected to turn into a $2 billion shortfall by July 2027.

Abrupt, and without warning or explanations

Despite MDHSS stating that it is committed to transparent communication, advocates and case managers in Missouri say the state has been anything but transparent. Braxton said that after Florida made its ADAP cuts in January, HIV advocates throughout Missouri were on high alert. “We asked the Missouri DHSS if [the Florida changes] might happen here, and they said no, everything was fine. That’s incredible to me that they would obfuscate, unless there was something dramatic that happened in early April. We understand that there are financial challenges, but we don’t understand why DHSS didn’t acknowledge these challenges sooner.”

Unlike in Florida, where state lawmakers implemented stopgap measures through June 30, at the end of the state’s fiscal year, in response to its ADAP changes, Missouri is unlikely to see a legislative workaround to its Ryan White cuts, at least this year. The legislative session ended May 15, and lawmakers won’t return for the rest of the year. 

Bill Keeton, chief advocacy officer for Vivent Health, said advocates are trying to understand whether the state has looked for alternatives to address its budget crisis. 

“MDHSS says they're going back to the essentials, what they believe to be the absolutely necessary to keep the program financially sustainable,” Keeton said. “But what we haven’t been able to find out yet is what are the actual numbers we’re dealing with. What is the size of the loss in rebate revenue?”

Keeton said that Missouri health department officials are encouraging the Ryan White Part A groups in St. Louis and Kansas City to reallocate funding levels to make up for some of these cuts. “But that’s a robbing Peter to pay Paul strategy that doesn’t really address longer-term sustainability issues.”

He added that the state hasn’t given any guidance on what clients in need should do about dental care or substance abuse counseling, or any other services that were cut from Ryan White.

Vivent’s dental clinic in St. Louis serves about 800 patients, 75% of whom use services covered by Ryan White Part B, according to Keeton. “People will still have access to antiretrovirals but access to a host of other medications is impacted.” 

It’s not just Missouri

HR-1, the so-called “One Big, Beautiful Bill,” passed by Congress in 2025, set the stage an increasingly dire situation for state ADAPs by limiting access to insurance through the Affordable Care Act (ACA) and sunsetting the temporary enhanced ACA premium tax credits, which were implemented as part of the COVID-19 emergency response. 

Elimination of those tax credits has restricted the ability of states to support Ryan White Part B services, according to Tim Horn, director of medication access and pricing at NASTAD.

“Drug prices continue to increase, even with 340B, and we see changes coming as a result of HR-1, so there's been a confluence of variables that are creating significant fiscal pain points for ADAPs.”

The federal 340B Drug Pricing Program requires drug manufacturers to provide discounted medications to eligible hospitals, clinics and other safety-net healthcare providers, including many HIV clinics.

Horn pointed out that ADAPs have been relatively flat-funded for more than 15 years while enrollment has increased significantly over the past 25 years. The situation has become so critical that NASTAD resumed issuing its ADAP Watch reports in February for the first time in a dozen years.  

ADAP Watch found that Iowa and Utah have implemented something that the U.S. hasn’t seen in more than a decade: waiting lists for ADAP. Pennsylvania, Kansas, Florida, Delaware and Rhode Island have lowered their federal poverty level eligibility criteria for the program. Arkansas, Connecticut, Delaware, Kansas, Louisiana, Michigan, Pennsylvania, Rhode Island, Virginia and Wisconsin have reduced funding for core services, while Florida, Michigan, Montana, Oklahoma and Wisconsin have decreased premium assistance. 

Horn added that even the success of the EHE initiative, which has been effective in driving down transmission and linking people with HIV into care, has put a strain on the system.

“We’ve seen almost double the number of clients being linked to care and reengaged to care as a result of those EHE efforts, but a lot of those clients are coming into the program needing medication coverage, so many enroll in an ADAP,” he said.

Even funds available for competitive awards, such as ADAP emergency relief funds, have remained relatively flat as an increasing number of states compete for the money. “The most recent ADAP emergency relief fund was $75 million,” he said. “Ten years ago, $75 million went 10 ways. Fast forward to 2024, where $75 million was split 34 ways. These programs can’t bank on getting those awards, and that's challenging.”

Horn added that NASTAD and coalition partners are pushing for an increase in appropriations for fiscal year 2027, asking for an additional $175 million, part of which would be available to all ADAPs as part of the formula-based award, with the rest to be used for an ADAP emergency relief fund.

Until and unless those funds come through, providers in states like Missouri will continue scrambling to keep vulnerable patients in care while pressing state governments to stop slashing programs. 

Keeton said he and other advocates have been imploring Missouri’s decision-makers to help them find acceptable solutions that save money while causing the least amount of pain for the most vulnerable. “Look, we can’t print money, we get it, but bring us to the table so we can talk about how to do this.”

“We are a very resilient community, and we know how to work and how to shift things around. If they just had talked to us about what was going on, we could [have helped] come up with plausible solutions,” Braxton said.