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.

The Coming HIV Care Crisis

The One Big Beautiful Bill Act (OBBBA)'s reduction of Medicaid expansion eligibility from 138% to 100% of the federal poverty level (FPL) creates an unprecedented crisis for HIV care in the United States, threatening to force approximately 200,000 people living with HIV off coverage while simultaneously undermining the Ryan White HIV/AIDS Program's capacity to serve as an adequate safety net, ultimately jeopardizing decades of progress toward ending the HIV epidemic and disproportionately harming communities of color and rural populations who already face significant barriers to care.

A Crisis at the Intersection of Policy and Survival

The One Big Beautiful Bill Act, signed into law on July 4, 2025, represents, according to the National Alliance of State and Territorial AIDS Directors (NASTAD), a moment when "AIDS Drug Assistance Programs (ADAPs) stand at a critical precipice." Let us not mince words: this legislation systematically dismantles the interconnected safety net that has enabled the United States to achieve the highest rates of viral suppression in the history of the epidemic.

The math, like those who passed this legislation, is cruel and unforgiving. With 40% of non-elderly adults living with HIV relying on Medicaid for coverage—nearly three times the rate of the general population—this eligibility reduction targets precisely the demographic most dependent on public health insurance. The Congressional Budget Office (CBO) projects that 7.8 million people will lose Medicaid coverage overall, with advocacy organizations estimating that approximately 200,000 people living with HIV will be among those stripped of coverage.

The timing creates a perfect storm. As NASTAD warns, "enhanced premium tax credits associated with Marketplace plans are set to expire later this year." At the same time, state health departments face "drastic budget cuts and reductions in force because of federal agency cuts." This convergence of federal policy changes threatens to create what NASTAD calls "sharp increases in the number of uninsured people with low incomes," precisely when the safety net programs designed to catch them are facing their own funding constraints.

The Medicaid Foundation: Why This Coverage Matters

The reduction from 138% to 100% of the federal poverty level specifically targets the income bracket where HIV prevalence is highest. Research demonstrates that 42% of Medicaid enrollees with HIV gained coverage through the Affordable Care Act's expansion, with this figure rising to 51% in expansion states. More than a mere statistical abstraction, it represents hundreds of thousands of people living with HIV (PLWH) who gained access to consistent, comprehensive healthcare for the first time.

The financial implications reveal the complexity of HIV care. Average Medicaid spending reaches $24,000 per HIV enrollee compared to $9,000 for non-HIV enrollees, reflecting the intensive medical management required for effective HIV treatment. When coverage disappears, these costs don't vanish—they shift to an already overwhelmed safety net or go unmet entirely, leading to treatment interruptions that increase viral loads and HIV transmission risk.

State-level analyses paint an even grimmer picture. Louisiana and Virginia face 21% spending cuts over the 10-year period, while Southern states that bear 52% of new HIV diagnoses despite comprising only 38% of the population will see disproportionate impacts. The legislation includes five major provisions that collectively cut $896 billion from Medicaid: work requirements, repealing Biden-era eligibility rules, provider tax restrictions, state-directed payment limits, and increased eligibility redeterminations.

The Ryan White Program: Last Resort, Impossible Math

The Ryan White HIV/AIDS Program operates on a fundamentally different model than Medicaid—one that makes absorbing massive coverage losses mathematically impossible. With $2.6 billion in discretionary funding requiring annual Congressional appropriations, the program lacks Medicaid's entitlement structure that automatically expands to meet growing needs.

The program's current client base reveals the scale of the challenge. Ryan White already serves over 576,000 clients annually, representing more than half of all diagnosed HIV cases. Critically, 39% of Ryan White clients have Medicaid as their primary payer, meaning they use Ryan White for wraparound services Medicaid doesn't cover. When these people lose Medicaid, Ryan White must suddenly cover their entire care costs—an impossibility given current funding constraints.

NASTAD's analysis warns this would "shift unsustainable burdens to the Ryan White HIV/AIDS Program," potentially forcing jurisdictions to reintroduce AIDS Drug Assistance Program (ADAP) waitlists not seen since the early 2010s. The program's "payer of last resort" status means it legally must serve anyone without other coverage options, creating an unfunded mandate when Medicaid disappears.

Historical evidence demonstrates the program's existing capacity limitations. From 2017-2019, 58.7% of uninsured persons had unmet needs for HIV ancillary care services, yet the program achieved 90.6% viral suppression rates among clients in 2023—a testament to its effectiveness when adequately resourced.

The proposed FY 2026 budget compounds this crisis by cutting Ryan White funding to $2.5 billion while eliminating Part F entirely. Part F includes AIDS Education and Training Centers that reached 56,383 health professionals last year, representing a critical workforce development component that would disappear precisely when demand for HIV care is expected to surge.

Healthcare Infrastructure Under Siege

Federally Qualified Health Centers (FQHC), serving as the backbone of HIV care in underserved communities, face an existential crisis. With Medicaid comprising 43% of FQHC revenue, the reconciliation bill threatens the fundamental business model of these safety-net providers. FQHCs currently operate on razor-thin margins approaching negative 2.2%, with 42% reporting 90 days or less cash on hand.

The rural healthcare crisis intensifies these challenges. Over 700 rural hospitals face closure risk—representing one-third of all rural hospitals—with 171 having shut down since 2005. The bill's $25 billion rural transformation fund provides only 43% of what experts calculate is needed to offset Medicaid cuts.

For HIV care, this means losing critical access points in areas already designated as priority jurisdictions for the Ending the HIV Epidemic (EHE) initiative. Research demonstrates that FQHCs in the rural South could reduce median drive time to HIV care from 50 to 10 minutes—but only if they remain financially viable. When Medicaid patients lose coverage, FQHCs must still serve them as uninsured patients by law, creating additional uncompensated care costs the facilities cannot absorb.

The 340B Program: Hidden Financial Hemorrhaging

The removal of Pharmacy Benefit Manager (PBM) spread pricing prohibitions represents a significant blow to 340B savings that HIV programs depend on for sustainability. The 340B program generated $38 billion in discounts in 2020 alone, with Ryan White clinics using these savings to serve an additional 43,000 people living with HIV.

Without spread pricing protections, PBMs can continue diverting these savings through discriminatory practices. States have documented massive overcharges: Ohio lost $224.8 million in one year, Pennsylvania $605 million over four years, and Maryland $72 million annually to spread pricing schemes. For HIV programs already operating on minimal margins, these losses represent the difference between serving patients, implementing waitlists, or shutting down altogether.

The policy intersection becomes particularly cruel when considering substance use services. While the OBBBA protects substance use disorder services from cost-sharing requirements—a "modest but important win" according to county officials—the broader context undermines these protections. Research shows 23.94% of people with HIV need treatment for alcohol or substance use, with people who inject drugs facing 30 times higher HIV risk than non-users.

Geographic and Demographic Devastation

The reconciliation bill's impacts fall hardest on communities already bearing disproportionate HIV burdens. Black and Hispanic/Latino people account for 64% of all people with HIV while representing only 31% of the population. These communities have higher Medicaid coverage rates due to lower incomes and higher disability rates, making them particularly vulnerable to coverage losses.

Southern states face a catastrophic combination of high HIV prevalence, limited state resources, and political resistance to mitigation strategies. The region accounts for 52% of new diagnoses, and includes many non-expansion states where 66% of HIV-positive adults rely on disability-related Medicaid pathways.

Nine states have trigger laws automatically ending Medicaid expansion if federal matching rates drop, creating immediate coverage cliffs. The intersection of geography, race, and poverty creates concentrated zones where HIV care infrastructure may collapse entirely, reversing decades of progress in communities that have historically faced the greatest barriers to care.

Clearly, This Isn’t About Fiscal Responsibility

The legislation represents fiscal malpractice when considering the long-term costs of new HIV transmissions. Each new HIV infection creates $501,000 in lifetime healthcare costs, while achieving 72% viral suppression would cost $120 billion over 20 years. The math is unambiguous: preventing new infections through sustained treatment is far more cost-effective than treating them after they occur.

The HIV community's response demonstrates the severity of the threat. Over 113 organizations relaunched the #SaveHIVFunding campaign, while the Partnership to End HIV, STI, and Hepatitis Epidemics united major organizations in opposition, emphasizing that "healthcare is not a reward for paperwork—it is a human right."

As NASTAD's analysis concludes, "When one of these pillars weakens, the others feel the shock waves"—and this bill doesn't just weaken pillars, it demolishes them. Without immediate action to reverse these cuts, the United States will witness a preventable reversal of decades of progress in HIV care, measured not in budget savings but in lives lost to a disease we know how to treat.