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.
The Great Disenrollment: Examining Medicaid's Post-Pandemic Shift
The Medicaid unwinding process that began in April 2023 has significantly impacted healthcare access and coverage retention across the United States. The unwinding, triggered by the end of pandemic-era continuous enrollment provisions, led to substantial shifts in Medicaid enrollment and revealed both strengths and weaknesses in our healthcare system. The process disproportionately affected communities of color and highlighted the need for targeted policy interventions to maintain healthcare access for vulnerable groups, including people living with HIV (PLWH).
The Scope of Medicaid Unwinding
During the COVID-19 pandemic, the Families First Coronavirus Response Act implemented the continuous enrollment provision in March 2020. This policy prohibited states from disenrolling Medicaid beneficiaries in exchange for enhanced federal funding, ensuring that people maintained health coverage during a time of unprecedented health and economic uncertainty. As a result, Medicaid enrollment surged from 71 million people in February 2020 to 94 million by April 2023, according to a Kaiser Family Foundation (KFF) analysis.
The end of the continuous enrollment provision on March 31, 2023, initiated a complex process of eligibility redeterminations for all Medicaid enrollees—a task of immense scale and complexity. By the end of the unwinding period, over 25 million people had been disenrolled from Medicaid, while over 56 million had their coverage renewed, as reported by KFF. The overall disenrollment rate stood at 31%, with significant variation across states. For instance, Montana reported a 57% disenrollment rate, while North Carolina's rate remained below 20%.
Systemic Challenges in the Unwinding Process
One of the most concerning aspects of the unwinding process was the high rate of procedural disenrollments. Of those who lost coverage, 69% were disenrolled for procedural reasons, such as not returning renewal paperwork, rather than being determined ineligible. This suggested that many people who lost coverage may have still been eligible for Medicaid but faced significant challenges navigating the renewal process successfully.
The Government Accountability Office (GAO) highlighted that administrative barriers contributed significantly to these procedural disenrollments. These barriers included:
Outdated Technology Systems: At least 11 states reported that their systems were old or difficult to use, making it challenging to produce real-time analytics essential for processing renewals effectively. This technological lag complicated efforts to implement necessary changes swiftly and efficiently.
Staffing Shortages: High turnover rates among eligibility workers led to vacancy rates reaching up to 20% in some states. Reports of low morale and burnout further affected the workforce's ability to handle the increased workload during the unwinding process.
Communication Barriers: States struggled to effectively engage people in the renewal process, particularly those facing language barriers. Non-English speakers often encountered longer wait times and struggled to reach assistance through call centers. These issues were compounded by a lack of robust state communication and engagement strategies.
Complex Paperwork: The renewal process often involved complicated forms and documentation requirements, which proved challenging for many enrollees to navigate, especially those with limited literacy or language skills.
Dr. Benjamin Sommers, a health policy expert at Harvard T.H. Chan School of Public Health, noted during the process, "The high rate of procedural disenrollments is particularly troubling. It indicates that we're not just seeing people leave Medicaid because they no longer qualify, but because they're struggling with the administrative hurdles of the renewal process."
These challenges led to frustration among enrollees and advocacy groups, highlighting the need for more streamlined and accessible renewal processes. The experience underscored the importance of investing in modernized eligibility systems, adequate staffing, and comprehensive communication strategies to ensure that eligible patients can maintain their coverage during future eligibility redeterminations.
National Enrollment Trends and State-Level Variations
Despite significant disenrollments during the unwinding process, Medicaid enrollment remained higher than pre-pandemic levels. As of May 2024, 81 million people were enrolled in Medicaid, an increase of about 10 million compared to pre-pandemic enrollment. However, this growth was not uniform across all populations. While adult enrollment remained over 20% above February 2020 levels, child enrollment was only about 5% higher.
Several factors influenced these disparities:
The pandemic's economic impact led to more adults becoming eligible for Medicaid due to job losses and income reductions.
States that expanded Medicaid under the Affordable Care Act saw more substantial increases in adult enrollment.
Children's enrollment remained relatively stable due to higher pre-pandemic enrollment rates and broader eligibility criteria through programs like the Children's Health Insurance Program (CHIP).
The impact of the unwinding process varied significantly across states, reflecting differences in policies, system capacities, and approaches. States that expanded Medicaid under the Affordable Care Act generally showed higher retention rates. Additionally, states that adopted strategies to streamline the renewal process, such as increasing ex parte (automated) renewals, saw better outcomes.
For example, Arizona, North Carolina, and Rhode Island achieved ex parte renewal rates exceeding 90%, while states like Pennsylvania and Texas had rates of 11% or less. These differences underscored the importance of state-level policies and systems in determining unwinding outcomes.
The Centers for Medicare & Medicaid Services (CMS) reported that states with higher ex parte renewal rates tended to have modernized eligibility systems that could effectively leverage data from other programs to confirm eligibility. This reduced the administrative burden on patients and helped maintain continuous coverage.
These variations highlighted the critical role of state-level decision-making and infrastructure in shaping Medicaid enrollment outcomes during and after the unwinding process. They also pointed to potential best practices for maintaining coverage and streamlining enrollment processes in the future.
Racial and Ethnic Disparities in Medicaid Disenrollment
A particularly concerning aspect of the unwinding process is its disproportionate impact on communities of color. According to the Southern Poverty Law Center (SPLC), more than half of the people who lost coverage were people of color. This disparity is exacerbated by existing barriers to healthcare access. The SPLC notes that communities of color face more barriers to healthcare access, such as limited internet, transportation, and inflexible job schedules.
The impact is particularly severe in states that have not expanded Medicaid. The SPLC report highlights that "residents from Alabama, Florida, Georgia, and Mississippi make up over 40% of the adults in the coverage gap nationwide. People of color make up about 60% of the coverage gap nationwide."
The Human Impact of Coverage Loss
The impact of coverage loss extends beyond statistics. Personal stories highlight the real-world consequences of the unwinding process. Justin Gibbs, a 53-year-old from Ohio, had to go without blood pressure medication for a week after losing his Medicaid coverage in December, according to CNN. Such disruptions in care can have serious health implications, particularly for people managing chronic conditions.
A KFF survey reveals the broader health impacts of coverage loss. Among those who became uninsured after losing Medicaid:
75% reported worrying about their physical health
60% worried about their mental health
56% said they skipped or delayed getting needed health care services or prescription medications
Impact on HIV Care and Policy Implications
The Medicaid unwinding process also highlighted significant challenges in maintaining healthcare access for people living with HIV (PLWH). While specific data on Medicaid disenrollment among PLWH during the unwinding were limited, general trends among vulnerable populations indicated potential risks. A KFF report found that many of those who lost Medicaid coverage experienced increased out-of-pocket costs, interruptions in medication adherence, and deteriorating health outcomes. These challenges were particularly critical for PLWH, for whom continuous access to antiretroviral therapy (ART) is essential.
Key considerations for PLWH during the unwinding process included:
Continuity of ART: Ensuring uninterrupted access to antiretroviral medications is mandatory for maintaining viral suppression and overall health.
Role of Ryan White HIV/AIDS Program: This program played a critical role in filling coverage gaps, but it's not a substitute for comprehensive health insurance.
Targeted Outreach: Community-based organizations and AIDS Service Organizations (ASOs) were essential in providing specialized support and enrollment assistance to PLWH.
Data Collection: Improving data collection on Medicaid disenrollment rates among PLWH can inform targeted interventions and policy adjustments.
The unwinding process underscored the need for policies that safeguard continuous healthcare access for PLWH. Implementing strategies that address these specific needs can help prevent coverage disruptions and improve overall health outcomes for people living with HIV.
Economic Implications of the Unwinding Process
The Medicaid unwinding process had significant economic implications for patients, healthcare providers, and states. For people who lost Medicaid coverage, the consequences often included financial instability and increased medical debt. A study by the Urban Institute found that adults who experienced a gap in Medicaid coverage were more likely to report problems paying medical bills and to have medical debt.
Healthcare providers, particularly safety-net hospitals and community health centers, faced increased rates of uncompensated care as a result of the unwinding process. This strained their financial resources and potentially affected their ability to provide care to their communities. The Commonwealth Fund noted that increased uninsured rates could lead to higher healthcare costs in the long term due to delayed care and increased emergency room visits.
For states, the unwinding process presented complex economic challenges. As the enhanced federal matching rate provided during the pandemic phased out, many states grappled with increased administrative costs associated with the unwinding process. A report from the Brookings Institution highlighted that states faced a complex set of trade-offs as they navigated the unwinding process, balancing the need to control Medicaid spending with the imperative to maintain access to care for vulnerable populations.
The full economic impact of the unwinding process continues to unfold, with ongoing implications for state budgets, healthcare provider finances, and patient economic well-being. These insights will be important in shaping future Medicaid policies and developing strategies to mitigate economic challenges associated with coverage transitions.
Policy Recommendations and Best Practices
To address these challenges, several key strategies have been identified:
Streamlining Renewal Processes: Increasing ex parte (automated) renewal rates can reduce the burden on people and minimize procedural disenrollments. For instance, Louisiana achieved a 49% ex parte renewal rate by leveraging data from other public benefit programs and improving data matching processes.
Targeted Outreach: Conducting outreach to vulnerable populations, including communities of color and people with chronic conditions, can help reduce disenrollments. The Ohio Department of Medicaid partnered with community-based organizations for door-to-door outreach in areas with high procedural disenrollments.
Implementing Continuous Eligibility: Policies that provide 12-month continuous eligibility can stabilize coverage and reduce churn. Oregon implemented a two-year continuous eligibility policy for children under six.
Enhanced Federal Oversight: Strengthening monitoring and enforcement of federal requirements ensures state compliance. CMS should leverage new authorities to require corrective action plans from states with high procedural disenrollments.
Improving Data Collection: Robust data collection and timely reporting enable quick identification of problems. States should report disaggregated data on disenrollments by race, ethnicity, and other demographics to address disparities.
Leveraging Technology: Modernizing eligibility systems improves accuracy and efficiency. Implementing text messaging, email communication, and mobile-friendly online portals helps people update information and complete renewals more easily.
Expanding Presumptive Eligibility: Allowing qualified entities to make preliminary eligibility determinations provides temporary coverage while full applications are processed, ensuring continuous access to care.
Addressing Systemic Inequities and Long-Term Solutions
The unwinding process exposed systemic inequities within the healthcare system, particularly affecting communities of color and rural areas. Long-term solutions include:
Investing in Underserved Communities: Enhancing access to healthcare services in marginalized areas.
Improving Health Literacy: Providing education to help people understand their health coverage options and navigate the system.
Strengthening Social Safety Nets: Expanding programs that address social determinants of health, such as housing, nutrition, and transportation.
Without significant policy interventions, coverage losses could lead to worse health outcomes and increased disparities, as emphasized by the Urban Institute.
Conclusion
The Medicaid unwinding process revealed both challenges and opportunities in our healthcare system. It highlighted the need for more efficient, equitable, and resilient approaches to health coverage. Key lessons include the importance of streamlined processes, targeted outreach, and robust oversight.
Moving forward, policymakers, healthcare providers, and advocates must work together to implement solutions that ensure continuous, accessible care for all, especially vulnerable populations. This effort is not just about health policy—it's a matter of equity and human rights.
As we continue to navigate the evolving healthcare landscape, our goal should be to build a system that provides stable, continuous coverage and leaves no one behind. This commitment is essential for improving health outcomes, reducing disparities, and strengthening our nation's overall health infrastructure.