Issue Brief: Federal Policy Changes and ADAPs

State and territorial AIDS Drug Assistance Programs (ADAPs) are facing an unprecedented fiscal storm. A wave of federal policies threatens to unravel key pillars of the U.S. health care safety net and roll back the coverage gains that have kept people with HIV insured and in care since the passage of the Affordable Care Act (ACA).

The Congressional Budget Office estimates that the One Big, Beautiful Bill Act (H.R. 1), combined with the expiration of enhanced Premium Tax Credits at the end of 2025, will leave 14.2 million more Americans uninsured by 2034. Another 750,000 to 1.8 million Marketplace enrollees are expected to lose coverage under the 2025 Marketplace Integrity Rule, finalized in June 2025. Together with proposed federal funding cuts for Fiscal Year 2026, this confluence of pressures is poised to push ADAPs past their fiscal limits.

As the payer of last resort for low-income people with HIV, the Ryan White HIV/AIDS Program and ADAPs will bear the burden of ensuring continued medication access when these policies take effect. 

This issue brief outlines the major threats, their potential impact on ADAP operations, and strategies already under consideration in several states to preserve program viability and continuity of care.