Federal Policy Changes Threaten to Overwhelm ADAPs

Established in 1987, AIDS Drug Assistance Programs (ADAPs) were the first federally supported initiative to help states purchase AZT (zidovudine), then the only approved antiretroviral drug available for people living with HIV (PLWH). When Congress enacted the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act in 1990, ADAPs were formally incorporated into what would become the Ryan White HIV/AIDS Program. Nearly forty years later, these programs remain the backbone of HIV treatment access in the United States, supporting medication coverage for those without affordable insurance options and sustaining the nation’s viral suppression gains.

That foundation is now under strain. A series of converging federal policy changes threatens to unravel the safety net that ensures continued access to lifesaving HIV treatment.

The One Big Beautiful Bill Act, enacted July 4, 2025, combined with the expiration of enhanced ACA Premium Tax Credits on December 31, 2025, and proposed federal funding reductions for Fiscal Year 2026, have created what NASTAD describes as "an unprecedented fiscal storm." The Congressional Budget Office estimates that H.R. 1, combined with the end of enhanced Premium Tax Credits, will leave 14.2 million more Americans uninsured by 2034. Another 750,000 to 1.8 million Marketplace enrollees are projected to lose coverage under the 2025 Marketplace Integrity Rule.

For ADAPs, the timing could not be worse. NASTAD data show ADAP enrollment increased 8 percent between 2019 and 2023, with new enrollment rising 28 percent and prescription drug expenditures up 10 percent. Program administrators are already managing cost growth, changing insurance landscapes, and expanding client need. The convergence of these federal shifts represents not a single budget gap, but a cumulative structural failure that could overwhelm the system responsible for sustaining treatment access for more than 270,000 people nationwide.

When the Safety Net Last Failed

The last major ADAP funding crisis, in 2010 and 2011, offers a clear warning. During that period, national ADAP waitlists grew from 2,937 to 9,217 people within twelve months, even after an emergency $25 million federal allocation. The consequences were immediate and measurable. Three deaths in South Carolina among people waiting for medication became a national call to action. Congress responded by reprogramming Ryan White funding and authorizing additional emergency allocations between 2010 and 2013, and waitlists were fully eliminated by 2017.

The difference today is scale and complexity. The current threat is not a temporary funding shortfall but a sequence of federal policy changes that simultaneously reduce insurance coverage, restrict Medicaid access, and diminish the resources available to offset those losses. Each component amplifies the pressure on ADAPs, narrowing every available safety valve.

The lessons from 2010 remain relevant. When the safety net fails, the consequences are measured not in spreadsheets but in treatment interruptions, declining viral suppression rates, and preventable deaths. Without urgent federal and state intervention, ADAPs face conditions that could produce a repeat of that crisis, magnified by broader systemic strain and political indifference.

Medicaid Work Requirements: Paperwork as Policy Weapon

H.R. 1 introduces the largest reduction to Medicaid in U.S. history, with nearly $1 trillion in cuts projected from 2025 through 2034. Beginning January 1, 2027, most Medicaid expansion adults will be required to document at least 80 hours of “qualifying activities” each month to maintain coverage. The Congressional Budget Office estimates that these provisions will result in 4.8 million more people losing coverage by 2034.

Research shows that two out of three enrollees who lose Medicaid under work requirement policies are already employed or qualify for exemptions. The result is not an increase in employment but a rise in administrative loss of coverage.

Arkansas’s 2018 work requirement experiment illustrates what lies ahead. More than 18,000 people lost coveragewithin months, primarily due to confusion and difficulties with the state’s online reporting system. Employment rates did not increase.

Nationally, about 10 percent of Medicaid renewals currently result in “procedural disenrollment,” meaning people lose coverage for paperwork reasons despite remaining eligible. H.R. 1 worsens this by requiring Medicaid enrollees to renew eligibility every six months instead of annually, doubling the opportunities for administrative failure.

For people living with HIV, Medicaid is a primary source of healthcare coverage. Nationally, approximately 40 percent of people receiving HIV care are enrolled in Medicaid. These provisions directly threaten treatment continuity by increasing administrative barriers and coverage interruptions. The legislation also reduces retroactive eligibility from three months to one or two months, raising costs for ADAPs that depend on retroactive reimbursement for medications dispensed while coverage applications are pending.

The Marketplace Affordability Cliff

The expiration of enhanced ACA Premium Tax Credits will create an affordability crisis for people living with HIV who earn too much to qualify for Ryan White services but depend on subsidized marketplace plans. KFF estimates that marketplace enrollees will see average premium payments more than double in 2026, increasing by 114 percent from $888 annually to $1,904. Approximately 1.5 million people earning above 400 percent of the federal poverty level will lose all subsidies entirely.

A larger share of people living with HIV receive marketplace coverage than the general population. For a 45-year-old in Miami-Dade County earning $38,000, annual premiums would rise by $1,699, from $117 to $259 per month. Given that antiretroviral therapy typically costs $36,000 to $48,000 annually and total healthcare expenses average $30,000, marketplace affordability is critical to maintaining viral suppression.

Insurers are building in additional premium increases of roughly four percent in anticipation of the subsidy expiration, assuming healthier enrollees will drop coverage and leave behind a sicker risk pool. Average Healthcare.gov plan premiums are projected to rise 26 percent for 2026. The Congressional Budget Office projects that the uninsured population will grow by 2.2 million people in 2026 alone without an extension of the tax credits, eventually reaching 4.2 million.

Federal Funding Cuts Compound the Crisis

While coverage losses increase, federal budget proposals for FY2026 would eliminate the very programs that support ADAPs and coordinated HIV care. The White House budget proposes a $74 million reduction to the Ryan White HIV/AIDS Program, lowering total funding to $2.5 billion by eliminating Part F programs that include the AIDS Education and Training Centers, dental programs, and Special Projects of National Significance.

The House Appropriations Committee proposes deeper reductions, eliminating $525 million in Ryan White funding, or roughly 20 percent of the program’s total. These cuts would affect more than 400 HIV clinics that provide medication, case management, and medical care nationwide.

The House proposal also eliminates the entire $1 billion budget for CDC HIV prevention, including $220 million for the Ending the HIV Epidemic initiative. The HIV+Hepatitis Policy Institute describes this as “not a bill for making America healthy again, but a disastrous bill that will reignite HIV in the United States.” The Foundation for AIDS Research projects that ending prevention funding alone could lead to 144,000 new HIV diagnoses, 15,000 deaths, and $60.3 billion in healthcare costs by 2030.

The Senate Appropriations Committee rejected these reductions by a bipartisan vote of 26–3, maintaining existing levels for domestic HIV prevention programs. This outcome offers temporary stability, but reconciliation between House and Senate versions remains uncertain.

Immediate Actions Required

The NASTAD analysis warns that the convergence of federal coverage losses and funding reductions could force ADAPs into crisis conditions reminiscent of 2010. While states can employ fiscal management strategies to delay the impact, the core solutions lie in federal policy.

Congress must extend enhanced Premium Tax Credits through at least 2027 to stabilize the individual marketplace and prevent subsidy loss for people living with HIV who rely on private coverage. Lawmakers should reject proposed eliminations of Ryan White Part F and CDC HIV prevention funding, which have produced measurable long-term savings by reducing new infections and sustaining treatment continuity. Maintaining these investments is far less costly than responding to the resurgence of uncontrolled HIV transmission.

States also play a central role. Strengthening coordination between Ryan White programs, ADAPs, and marketplace enrollment systems, as demonstrated in California and New York, can mitigate insurance disruptions and preserve treatment adherence during policy transitions.

NASTAD emphasizes that continuity of care must remain the guiding principle throughout any period of programmatic change. Ensuring uninterrupted access to medication, case management, and communication between providers and clients is critical to maintaining public trust and preventing viral rebound.

The intersection of these federal policies represents a defining test for HIV care in the United States. The ADAP crisis of 2010 showed that delay has a human cost measured in treatment lapses and preventable deaths. Policymakers again face a choice between sustaining a proven safety net or repeating the mistakes that history has already documented.