Building Stronger Communities, Together: Reflections from Our Patient Affordability Roundtable
Editor's Note: This article was originally published on April 10, 2026, by Lupus Colorado and is republished here with permission. The Patient Affordability Roundtable discussed in this piece was hosted in partnership with Community Access National Network. Lupus Colorado, led by CEO Kristy Kibler, works to improve the lives of people affected by lupus through advocacy, education, and support services across Colorado. Their work on patient affordability, community building, and state-level policy advocacy strengthens the broader chronic disease patient community that CANN serves. To learn more about Lupus Colorado or donate to support their work, visit LupusColorado.org.
Patient advocates and community organization leaders from across the country convene at the Patient Affordability Roundtable, hosted by Lupus Colorado in partnership with Community Access National Network.
At Lupus Colorado, we know that real progress happens when people come together, share openly, and commit to lifting one another up. That spirit was fully alive at our recent Patient Affordability Roundtable, hosted in partnership with Community Access National Network. This gathering brought together a powerful group of advocates and organizations, including End of Endo Project, Mamas Facing Forward, Chronically Informed, ACT NOW, CF United, Chronic Care Collaborative, Michigan Lupus Foundation, National Bleeding Disorders Foundation- CO and Colorado Patients Taking Action.
Centering Community as a Strategy
One of the most meaningful threads throughout the roundtable was a deep and intentional conversation about community building, not just as a value, but as a strategy for change.
We had the opportunity to dig deeper into what it truly takes to build and sustain a strong, effective community. At Lupus Colorado, we see every day that investing in people drives lasting change. Our ongoing collaboration with partners like ACT NOW, CF United, and Chronic Care Collaborative reflects a shared commitment to trust, connection, and leadership that strengthens the entire ecosystem. When we intentionally support one another and follow through on that investment, individuals step forward not just to participate, but to lead, advocate, and create meaningful change for their communities.
That insight carried throughout the conversation. Community is not built overnight. It is cultivated through consistency, care, and a willingness to grow together.
A Deeper Look at Affordability and Who It Impacts
Building on that foundation, the group explored one of the most important questions in our work: how we define affordability.
Too often, systems are designed around averages, what works for a typical patient. But in our communities, especially among those living with complex, chronic conditions like lupus, there is no such thing as typical.
We discussed the distinction between common and complex patient experiences and how policies that appear effective on paper can fall short when applied to real lives. This conversation reinforced a shared understanding that affordability must reflect lived experience, not simplified models.
Learning Across State Lines
These conversations naturally expanded into a broader exchange of ideas across states.
While each state operates within its own policy landscape, many of the challenges we face are deeply aligned. From patient protections to reimbursement policy and affordability frameworks, participants shared both barriers and promising approaches.
There is real momentum in learning from one another. Every insight shared strengthens our collective ability to advocate more effectively and to bring forward solutions that are grounded in both policy and lived experience.
Policy Conversations That Matter
With that shared understanding, the roundtable created space for focused, solutions-oriented policy discussion.
We explored key issues including PDAB reform, concerns related to QALYs, PBM loopholes, and fiduciary responsibility, along with the importance of rebate pass through, stronger patient protections, and oversight of Alternative Funding Programs to ensure patients are not unintentionally burdened. The conversation also emphasized the importance of building informed legislative champions who can advance patient-centered solutions.
Honoring the Patient Voice
Equally important was an honest conversation about the human side of advocacy.
For many individuals, participating in the legislative process means revisiting deeply personal experiences. We acknowledged the reality of re-traumatization and the responsibility we share to create spaces that are not only impactful, but also supportive.
Advocacy should empower, not exhaust. As a community, we are committed to elevating patient voices in ways that also protect and support those who share their stories.
Moving Forward, Together
What emerged from this convening was more than a list of challenges. It was a shared sense of direction and a renewed commitment to working together.
We move forward with stronger relationships, new ideas, and deeper alignment around how to create meaningful change. By continuing to invest in our community, elevate patient voices, and collaborate with partners across the country, we are building a future where access, affordability, and dignity are not aspirations, but expectations.
Together, we are shaping systems that work better, care deeper, and reach further. And that is where real progress begins.
The False Economy of Rationing Life
Across the country, states are making a choice. Faced with budget shortfalls driven by flat federal funding, the expiration of enhanced ACA premium tax credits, and the downstream wreckage of H.R. 1's nearly $800 billion in Medicaid cuts, they are choosing to solve their fiscal problems by restricting access to the medications that keep people living with HIV alive and stop the virus from spreading. Eighteen states have implemented cost-containment measureson their AIDS Drug Assistance Programs, with five more considering changes. Florida slashed ADAP eligibility from 400% to 130% of the federal poverty level on March 1, cutting off more than 12,000 people and removing Biktarvy, which accounts for 52% of the U.S. ARV market, from its formulary. Louisiana is considering HB927, legislation that would repeal the state's long-standing statutory protections against prior authorization and step therapy for antiretrovirals in Medicaid.
The pressures are real. ADAP enrollment surged 30% from 2022 to 2024 as states shed Medicaid enrollees after the pandemic. NASTAD's February 2026 ADAP Watch reports 19 ADAPs forecast deficits for the upcoming fiscal year. When adjusted for inflation, ADAP appropriations have declined 31% since 2005, with the FY2025 appropriation carrying roughly the same purchasing power as FY1999 levels. Nobody disputes the math. What we dispute, forcefully and on the evidence, is the response.
Utilization Management on ARVs Is Clinically Indefensible
Step therapy requires a patient to "fail" a medication before accessing the one their provider has already determined is best for them. In HIV treatment, failure means the virus has replicated in the presence of inadequate drug levels and potentially developed resistance, rendering the entire associated drug class less effective or ineffective. For someone on PrEP, "failing" a regimen means they have seroconverted and acquired HIV, possibly with resistance that limits their treatment options from day one. Prior authorization creates gaps in access while paperwork is processed. Drug resistance can develop within several weeks of stopping ART, as some components of a combination regimen remain in the body longer than others, leaving HIV exposed to one or two drugs instead of a full suppressive regimen. CD4+ cell counts can decline by up to 100 cells/mm³ within weeks of interruption. The SMART trial demonstrated that episodic ART interruption was associated with increased risk of opportunistic disease and death, findings so conclusive the strategy was abandoned entirely.
The CMS Medicare Part D Manual specifically notes that utilization management tools like PA and step therapy are generally not employed in best-practice formulary models for HIV/AIDS drugs. The American Academy of HIV Medicine issued a white paper with a single recommendation: HIV medications should be exempt from prior authorization requirements. As of 2019, 14 states had enacted laws prohibiting at least some UM techniques for ARVs. The broader health policy world is arriving at the same conclusion about PA generally: a January 2026 KFF Health Tracking Poll found that four in ten people with chronic conditions say prior authorization is their single biggest healthcare burden beyond costs, and KFF President Drew Altman has openly questioned whether its short-term cost control benefits are worth the costs to patients in an already overburdened system. If the mainstream is questioning PA broadly, the case for applying it to ARVs, where the clinical stakes include drug resistance, viral transmission, and death, does not exist.
The Math Doesn't Work, and the Motive Is Worse
Here is where we need to stop treating this conversation as though it is happening in good faith.
The stated rationale for stripping UM protections from ARVs is cost containment. But anyone who has watched private insurance markets operate over the past two decades recognizes what utilization management on high-cost drug classes actually produces: leverage. Private payers have used UM as a negotiating tool for years, threatening to restrict formulary access unless manufacturers offer deeper discounts. The people whose treatment gets disrupted in the process are the collateral damage that makes the threat credible.
CANN has been warning for years that as state Medicaid programs face mounting budget pressure, the temptation to adopt this same playbook would grow. That is exactly what is unfolding. When states impose PA and step therapy on antiretrovirals, the practical effect extends well beyond cost management. It creates a bargaining position where patient access to life-saving medication becomes a concession to be traded for supplemental rebates from manufacturers. This is the private payer model of healthcare as revenue generation imported into public health programs responsible for managing a communicable disease. It transforms the health of people living with HIV into a bargaining chip, and it represents a fundamental betrayal of what public health programs exist to do.
The people whose medications get delayed, whose viral loads rebound, whose resistance profiles narrow while prior authorizations are processed are not an unfortunate side effect of this model. They are the leverage. That is not healthcare. It is government treating public health as a profit center.
The economics don't support it either. Every new infection from someone with a detectable viral load carries an estimated lifetime medical cost of $326,500, with the cost avoided by preventing that infection estimated at $229,800. More recent analyses from HIVMA put average lifetime expenditures between $500,000 and more than $1.2 million. A Precision Health Economics analysis estimated that allowing UM on Part D antiretrovirals alone could result in over 6,750 new HIV infections. Whatever supplemental rebate a state might extract by threatening formulary restrictions will be dwarfed by the downstream costs. And in a U.S. cohort studied between 2021 and 2023, 28% of people with HIV experienced a treatment interruption of 90 days or more, with those affected disproportionately women, Black, dealing with substance use, and less likely to have commercial insurance. These barriers concentrate harm on the people who are already most structurally vulnerable.
We Have Already Watched This Fail
We don't need to theorize. We watched it happen with Hepatitis C. For years, state Medicaid programs and MCOs imposed PA, step therapy, sobriety requirements, and prescriber restrictions on curative direct-acting agents for HCV. People were denied treatment while their disease progressed. By the end of 2025, 34 jurisdictions had removed PA requirements for most Medicaid HCV patients, reflecting the national consensus that those restrictions never served patients or budgets. Louisiana itself now receives an "A" grade for HCV Medicaid access. As CANN's letter to Vice Chair McMahen on HB927 notes, the bill proposes substantially similar risks to HIV medication access as those once imposed on HCV, in a state that passed model PrEP and PEP legislation in 2024 that these same UM tools would undermine.
What Must Happen
Florida's own legislature proved these cuts are not inevitable when it passed HB 697 in mid-March with $31 million to restore ADAP eligibility for over 11,000 people. Bipartisan, responsive, and proof that different choices are available when the political will exists.
States must fight for adequate federal ADAP funding, which has been flat-funded since FY2014 while program costs have grown relentlessly. They must leverage 340B rebates and supplemental funding rather than cutting the people the programs exist to serve. They must design Medicaid formularies to ensure access following federal HIV treatment guidelines, not undermine them. And their federal legislators should realize that if we can fund the Department of Defense at a trillion dollars a year, we can surely pay to keep people from dying from AIDS.
There is no clinical necessity for removing ARV protections. Doing so will not balance budgets. It will create drug resistance, increase transmission, push people into more expensive care settings, and compound the harms of H.R. 1's Medicaid budget cuts and work requirements, which threaten coverage for 42% of Medicaid enrollees with HIV. At every level of analysis, this approach fails. What it succeeds at is transferring the cost of federal policy failures onto the bodies of people living with HIV, and that is not fiscal responsibility. It is abandonment dressed in budget drag.