ADAPs Work. Federal Policy Is Defunding Them on Accident.

NASTAD released its 2026 National Ryan White HIV/AIDS Program (RWHAP) Part B AIDS Drug Assistance Program (ADAP) Monitoring Project Annual Report this month, and the numbers tell two stories at once. In 2024, state and territorial ADAPs served 257,644 people living with HIV across 49 reporting jurisdictions, achieving an 87% viral suppression rate among clients served. That figure significantly outpaces the estimated 67% suppression rate among all people living with diagnosed HIV in the United States, and it was achieved within a population where 65% of clients live at or below 200% of the Federal Poverty Level (FPL). By any clinical measure, ADAPs are delivering.

The second story is fiscal. Drug rebates generated through the 340B Drug Pricing Program now constitute 52% of total ADAP budgets, dwarfing the federal ADAP earmark at just 29%. A $2.7 billion safety net serving nearly one-quarter of all people living with diagnosed HIV in the country is now majority-funded by a revenue source that multiple federal policy changes are actively eroding. And demand is about to surge.

The Unwinding as Stress Test

The post-COVID Medicaid unwinding that began in April 2023 showed us what happens when coverage shifts push low-income people living with HIV off their insurance. ADAPs absorbed a 30% increase in new client enrollments and an 11% increase in total enrollment compared to 2022. Across 40 jurisdictions with comparable data, prescription drug spending grew 17% in two years, from $1.31 billion to $1.54 billion. Some states faced localized shocks: Pennsylvania's drug costs rose 82%, Arizona's nearly tripled. A JAMA Health Forum study confirmed that more than 25 million people nationally had Medicaid terminated during unwinding, with coverage losses concentrated among younger, healthier adults most likely to fall out of care when coverage disappears.

The system held. But the unwinding was a stress test, not the main event.

The Rebate Dependency Trap

Congressional appropriations for RWHAP Part B totaled $1.41 billion in FY2024, with ADAP-specific funding essentially flat. States have bridged the gap through 340B rebate revenue. In FY2019, 73% of rebates were applied to ADAP budgets; by FY2024, that figure reached 86%. Programs are retaining nearly every rebate dollar generated, and it still barely meets demand.

The Inflation Reduction Act (IRA) creates an unintended problem here. Its Medicare Part D reforms cap annual out-of-pocket drug costs at $2,000 in 2025 and $2,100 in 2026, which genuinely benefits Medicare beneficiaries. But ADAPs generate "partial-pay rebates" on cost-sharing payments made on behalf of clients enrolled in Medicare Part D. Lower cost-sharing means lower rebate revenue. The IRA's Medicare Drug Price Negotiation Program is likely to further compress the pricing benchmarks driving rebate calculations. The third negotiation round, announced in January 2026, selected Biktarvy for negotiated pricing effective in 2028. Biktarvy is the most widely prescribed single-tablet HIV regimen in the country and cost Medicare approximately $3.9 billion for 101,000 beneficiaries in the most recent measurement period. A negotiated reduction in Biktarvy's Medicare price could directly lower the "best price" benchmark that determines ADAP rebate revenue on the very drug that anchors most clients' treatment.

Layer on the PBM reform provisions signed into law in February 2026 requiring 100% rebate pass-through in Medicare Part D starting in 2028, plus manufacturer restrictions on 340B contract pharmacies that 54% of ADAPs report are creating payment challenges, and the picture is clear: the revenue stream funding more than half the HIV safety net is being squeezed from multiple directions, all at once, and the pressure is increasing.

Each of these policies may have merit on its own terms. But none were designed with a safety net impact assessment in mind, and the cumulative downstream effect on ADAP financing is significant and remains unaddressed.

The Demand Surge

While revenue contracts, demand is set to spike. H.R. 1, signed July 4, 2025, enacts the largest Medicaid cuts in the program's history. The Congressional Budget Office (CBO) estimates $911 billion in federal Medicaid spending reductions over a decade. KFF notes that more than 10.3 million people are likely to lose Medicaid. A Center for American Progress analysis found the bill's approximately $1 trillion in Medicaid cuts is roughly matched by approximately $1 trillion in tax reductions directed to the top 1% of earners. The priorities embedded in that budget math deserve scrutiny, to put it mildly.

And then the enhanced ACA premium tax credits expired at the end of 2025 without extension. Approximately 22 million people received those credits last year, and the average recipient has seen premiums more than double. The Urban Institute estimates roughly 5 million people may drop coverage and go uninsured, with the impact falling disproportionately on Black and low-income communities in metro areas like Houston and Atlanta, per the Economic Policy Institute. When the CBPP tallies all coverage losses, the total reaches roughly 15 million people newly uninsured by 2034.

For people living with HIV, these numbers carry specific weight. Medicaid is the single largest source of coverage for adults living with HIV at an estimated 40%, with 42% of those enrollees qualifying through the ACA expansion pathway H.R. 1's work requirements directly target. People living with HIV also rely on ACA Marketplace plans at higher rates than the general population; at least 40,000 ADAP clients were enrolled in Marketplace plans as of 2023. KFF estimates the premium tax credit expiration alone will cost state ADAPs an estimated $83.7 million in additional premium costs, with ADAPs in non-expansion states facing the steepest increases. If ADAPs cannot absorb those costs, KFF outlines the consequences: reduced income eligibility, restricted formularies, increased utilization management, and the possible return of waiting lists for the first time since 2012.

We don't have to speculate about what this looks like. On January 8, 2026, the Florida Department of Health announced sweeping changes to its ADAP, effective March 1: slashing income eligibility from 400% FPL to 130% FPL, eliminating insurance premium assistance, and removing Biktarvy from the formulary. NASTAD estimates more than 16,000 people will lose ADAP coverage. Florida cited rising premiums and the premium tax credit expiration, yet has not released an ADAP budget in over a year and bypassed the stakeholder engagement required under federal Ryan White guidelines. Every structural vulnerability the NASTAD report identifies played out in a single state in a matter of weeks.

What We Should Be Doing

The NASTAD report warns that H.R. 1 and the premium tax credit expiration threaten to "unravel the coverage gains" it documents. ADAPs serve 23% of all people living with diagnosed HIV. The Ending the HIV Epidemic (EHE) initiative depends on sustained viral suppression, which depends on treatment access, which depends on these programs remaining solvent. The data demands specific action. Short of reversing the policies of H.R. 1 and actually insuring poor people as a just and moral society might choose to do, several targeted measures could prevent the worst outcomes.

Congress should increase the federal ADAP earmark to reflect documented enrollment growth and the surge H.R. 1 will drive, and pursue RWHAP reauthorization to replace the year-to-year appropriations the program has relied on since its authorization lapsed in 2013. Flat funding in the face of 30% enrollment growth is a policy choice with consequences measured in lives.

Congress should reinstate and make permanent the enhanced ACA premium tax credits. For people already navigating the social determinants of health that create barriers to care, losing insurance coverage removes one of the few reliable pathways to sustained treatment access and viral suppression. Future drug pricing legislation should include safety net impact assessments to identify and offset downstream revenue effects on programs like ADAPs before those effects become crises.

States need targeted investment in ADAP administrative infrastructure to manage the coming enrollment wave. 60% of ADAPs already report maintaining client eligibility as challenging and 38% report difficulties implementing long-acting injectables and provider-administered drugs. The 30% enrollment surge during unwinding stretched existing capacity. What H.R. 1 delivers will be larger and longer-lasting.

The 2026 NASTAD report documents a system that works. An 87% viral suppression rate among a low-income population, achieved through sophisticated fiscal management and a decades-long commitment to keeping people in care, is a public health accomplishment we should be protecting. The question is whether we will defend the infrastructure that makes it possible, or let it collapse under the weight of policy decisions that were never designed to account for it.