Women living with HIV in the U.S. tend to be disproportionately low-income, for a variety of reasons that are discussed in more detail on our 2013 Economic Justice Factsheet. Public programs that provide access to essentials like housing, food, and health care (often called the “social safety net”) are critical supports for low-income women living with HIV.

The social safety net refers to a vast array of publicly funded programs and services that aim to ensure people can meet their basic human needs. “Net” is an appropriate metaphor: the social safety net is intended to catch people when they fall on hard times. In the U.S., that safety net is full of holes.

A robust social safety net can reduce food insufficiency and unmet medical needs, advance racial and gender equity, and help lift people out of poverty.

Major federally funded safety net programs in the U.S. generally fall into one of the below categories:

Medicaid and the Supplemental Nutrition Assistance Program (SNAP) are two programs that are especially important for people living with HIV. Medicaid is the single largest payer of health care for people with HIV, and it’s estimated that more than 40% of those living with HIV rely on Medicaid. PWN-USA member data consistently show that somewhere between 40-50% of our members–women and people of trans experience living with HIV–depend on SNAP to feed themselves and their families.

Medicaid ensures health care coverage for millions of people with low incomes in the U.S., many of whom otherwise could not afford coverage. It is a state-federal partnership: the federal government sets minimum eligibility and benefits requirements, and each state administers their program flexibly within those guidelines. States can also request Section 1115 waivers, or “demonstration waivers.” If approved by the Department of Health and Human Services (HHS), these waive certain federal requirements so that states can experiment with their Medicaid program if and only if the change would further the core goal of the Medicaid. 1115 waivers can and have been a force for good. However, they are increasingly being used to eliminate services; impose new, burdensome co-pays; and limit eligibility and enrollment by adding restrictions like work requirements, drug testing, time limits, enrollment caps, and lockout periods.

SNAP, otherwise known as food stamps, provides food assistance for 42 million people living near or below the poverty line. It is an essential program that helps fight food insecurity; improves health, wellbeing, and academic success; and lifts people out of poverty. SNAP has cruel requirements that make it less effective, such as limiting people to just three months of food assistance in a 3-year period if they cannot find enough work. However, states with high enough poverty rates have the option of waiving the time limit to protect access to food in areas where jobs are difficult to find.

Severely restrictive income eligibility criteria require people have to stay poor to access essential programs needed to get by. At least 25 states have tried to  impose work or drug testing requirements, time limits, enrollment caps, and restrictions based on immigration status to stop essential programs from reaching those who most need them. Apparently the tactic has been successful: More than one quarter of people living in deep poverty — with incomes below 50% of the federal poverty line — are not connected to major federal social safety net programs.

The current administration encourages policies that revoke essential benefits — like housing, health care, and food assistance — from people who don’t meet or can’t prove meeting work requirements. Work requirements demand that otherwise eligible people show that they have worked an arbitrary number of hours or risk being kicked off of programs. These restrictions do not make sense: There is little evidence that they increase employment or reduce poverty, but ample evidence that they cause people to lose access to critical supports, which itself makes it harder to work. There are many reasons that people cannot work as much as required, including personal or family challenges (like physical or mental health issues), homelessness, lack of child care or transportation, unstable or reduced work hours, or lack of paid time off. Even those who do meet the work requirement can lose benefits because of the increased paperwork involved in reporting work or claiming exemptions properly.

SNAP and state Medicaid programs have been repeat work requirement offenders. HHS has approved Medicaid work requirements in 8 states and 7 have applications pending.  Medicaid work requirements increase coverage gaps, reversing progress made under the ACA, and in some states, like Alabama, would be a cruel catch 22. A parent or caretaker who works enough to satisfy the work requirement would automatically earn too much to qualify for Medicaid. SNAP has a work requirement built in, and 17 states do not have a waiver to lessen the impact of the program’s harsh unemployment disqualification policy. 6 of those states also refuse to extend eligibility (beyond 3 months) to 15% of the people who would otherwise be disqualified because of the work requirement — an option allowed under federal law.

Restrictions designed to limit access to critical programs are based on a combination of judgment of who is deserving of help and a fundamental (often racist, sexist) misunderstanding of the causes of poverty. Instead of vindictive lifetime bans, funding cuts, work requirements, or drug-testing requirements, people with HIV need policies designed to support us in living with health and dignity.

• Are you a person living with HIV who needs help to access some of the services mentioned in this fact sheet? Here is a good place to start!
• PWN
• Economic Justice Policy Agenda
• 2013 Economic Justice Factsheet
• Public Charge Press Release and Webinar
• Social Safety Net, generally
• Center for Budget and Policy Priorities
• Economic Security Programs Cut Poverty Nearly in Half Over Last 50 Years, New Data Shows
• Impact of the Safety Net: State Fact Sheets
• Center for Law and Social Policy (CLASP)
• Income and work support resource center
• Racial Equity Resource Center
• Coalition on Human Needs, Human Needs Reports
• Urban Institute
• Five Things You May Not Know about the U.S. Social Safety Net
• From Safety Net to Solid Ground
• SNAP
• CLASP, “Drug Testing SNAP Applicants is Ineffective and Perpetuates Stereotypes.”
• CLASP, “SNAP and Work.”
• NCLS, “SNAP Work Requirement Fact Sheet.”
• Medicaid
• Kaiser Family Foundation, “Medicaid Waiver Tracker”
• National Health Law Program, “Medicaid: The Coverage Lifeline.”
• All* Above All et al., “Medicaid & Reproductive Justice Fact Sheet”