What Are Trigger Laws?
When states expanded Medicaid under the ACA, some included "trigger" provisions in their expansion legislation. These laws automatically roll back expansion if federal funding drops below a specified threshold (typically 90% FMAP). The One Big Beautiful Bill Act, signed July 2025, creates conditions that could activate these triggers.
The 12 States at Risk
Automatic termination if FMAP drops below 90%
In these 9 states, Medicaid expansion ends automatically without further legislative action:
| State | Trigger Condition | Medicaid Expansion Population |
|---|---|---|
| Arkansas | FMAP below 90% | ~300,000 adults |
| Illinois | FMAP below 90% | ~700,000 adults |
| Indiana | FMAP below 90% | ~500,000 adults |
| Montana | FMAP below 90% | ~100,000 adults |
| New Hampshire | FMAP below 90% | ~50,000 adults |
| North Carolina | FMAP below 90% | ~600,000 adults |
| Utah | FMAP below 90% | ~100,000 adults |
| Virginia | FMAP below 90% | ~500,000 adults |
| Arizona | FMAP below 90% | ~400,000 adults |
Review process (likely termination)
These 3 states would undergo a legislative review process that could lead to expansion ending:
| State | Trigger Condition |
|---|---|
| New Mexico | FMAP decrease triggers review |
| Iowa | FMAP decrease triggers review |
| Idaho | FMAP decrease triggers review |
What this means: If Medicaid expansion ends in your state, adults earning below 138% of the federal poverty level who gained coverage through expansion would lose Medicaid. Many would fall into the "coverage gap" — too much income for traditional Medicaid, too little for marketplace subsidies.
Compare PrEP access options
Telehealth providers, local clinics, state programs, Medicaid, and manufacturer assistance can all be valid routes. Compare cost, lab method, medication options, location, privacy, and follow-up instead of defaulting to one provider.
Compare providers and programs →Timeline: When Could This Happen?
The enhanced FMAP for new expansion states was eliminated in January 2026 under the OBBBA. However, the 90% matching rate for existing expansion states has not been cut — yet. The risk is:
- Future budget reconciliation or appropriations bills could reduce FMAP
- The FY2026 budget proposal included provisions that could affect matching rates
- States facing fiscal pressure from other Medicaid cuts may choose not to fight for expansion
This is not happening tomorrow, but the legal mechanism is in place and the political will to cut Medicaid is active. Preparation is prudent.
What to Do If You're in a Trigger Law State
- Sign up with MISTR now: Having an active telehealth PrEP relationship means zero interruption if Medicaid changes.
- Apply for Gilead MAP: Pre-qualify for the Medication Assistance Program so you can activate it quickly if needed.
- Know your state's PrEP DAP: Check your state's programs for backup options.
- Locate your nearest FQHC: Community health centers serve everyone regardless of insurance status. Find one here.
- Monitor your state legislature: Trigger laws can sometimes be repealed or modified. Stay informed through local HIV advocacy organizations.