ADAP in 2026 — the national crisis, state by state.

For a quarter of a million people in the United States, the AIDS Drug Assistance Program is the reason there is medication in the cabinet this month. ADAP is not a small safety-net corner of the HIV response — it is the largest single component of the Ryan White HIV/AIDS Program, and in calendar year 2024 it served 257,644 people across 49 state and territorial programs, roughly 23% of everyone in the country living with diagnosed HIV.5

It works. Eighty-seven percent of ADAP clients were virally suppressed in CY2024, compared with about 67% of people with diagnosed HIV nationally — a gap that has widened in ADAP's favor every year since 2014.5 That is what a program built on continuous medication access produces.

And in 2026 it started coming apart in public — not because the program stopped working, but because the money underneath it stopped moving while everything it pays for got more expensive. This page walks through what changed, where, and what rights and advocacy levers exist in the middle of it.

Why 2026 is different from every other tight year

ADAP has been squeezed before. What makes this cycle distinct is that five separate pressures arrived at once, and none of them are the kind that resolve on their own.

Start with the arithmetic. The federal ADAP earmark has sat at $900,313,000 from FY2015 through FY2026 — the same figure in twelve budgets, with one small dip in FY2018.1 Meanwhile the number of people the program serves grew 56% between 2007 and 2024, and drug prices climbed. KFF's analysts put the combined effect plainly: adjusted for inflation, ADAP appropriations have declined 31% since 2005, and FY2025's appropriation had roughly the purchasing power of the FY1999 appropriation. Per-client, inflation-adjusted federal funding fell from about $3,600 in 2007 to about $1,700 in 2024.11

Second, the client base got more complex and more expensive. ADAP's population is aging — 55% of clients were 45 or older in CY2024 and 14% were 65 or older, up from 9% in CY2019 — meaning more comorbidity, more non-HIV prescriptions, and more Medicare coordination.5 New enrollments rose 30% between 2022 and 2024 across 46 programs, partly because Medicaid unwinding pushed people into Ryan White, and partly because Ending the HIV Epidemic investments succeeded at linking people to care.6 Success generated demand the funding never absorbed.

Third, medication costs. Prescription drug purchasing consumed more than $1.66 billion in CY2024 — about 62% of all ADAP spending — and rose 6.4% in one year.6 Guideline-recommended initial regimens carried average wholesale prices of roughly $25,000–$35,000 in 2012; by 2025 Biktarvy alone was near $61,000.11

Fourth, the insurance side broke. The enhanced ACA premium tax credits created in 2021 expired at the end of 2025. Average annual premiums for people staying in the same marketplace plan jumped from about $888 in 2025 to about $1,904 in 2026 — a 114% increase — and ADAPs that had been buying marketplace coverage as the cheaper option suddenly weren't saving money.11

Fifth, the rebate engine slowed. More than half of ADAP's budget — 52% in FY2024 — now comes from manufacturer rebates tied to the 340B Drug Pricing Program rather than appropriations.7 When that revenue dips, no federal line item fills the hole.

The funding arc — how a flat line becomes a cut

Ryan White money reaches medications through a specific chain, and knowing the links helps when you write to a legislator. Congress appropriates to the Ryan White HIV/AIDS Program by part. Part B goes to all 50 states, DC, Puerto Rico, the U.S. Virgin Islands and six Pacific territories, and it is Part B that funds ADAP.2 Inside Part B there is an ADAP "earmark" — a dedicated non-add amount — plus an ADAP supplemental set-aside for jurisdictions with demonstrated severe need, plus Part B base and supplemental dollars that states may choose to move into ADAP.7

FY2023 through FY2026: the same numbers, four times

HRSA's own budget table is the clearest document in this whole story. For fiscal years 2023, 2024, 2025 and 2026, every Ryan White line is identical: Part A at $680,752,000; Part B at $1,364,878,000 with the ADAP earmark at $900,313,000; Part C at $208,970,000; Part D at $77,935,000; Ending the HIV Epidemic at $165,000,000; program total $2,571,041,000.1 The ADAP earmark has sat at $900,313,000 since FY2015, with a single small dip in FY2018.1

The FY2026 outcome was, in advocacy terms, a defensive win. An earlier House proposal would have cut $525 million from federal HIV programs; the conferenced bill restored it and held Ryan White at $2.571 billion.13 The HIV Medicine Association described the February 2026 result as sustaining funding for all Ryan White parts, while noting the Minority HIV/AIDS Fund still lost $4 million.14 Level funding was the ceiling, not the floor.

What "level funding" does to a state budget

Because ADAP's costs rise and its federal earmark does not, states absorb the difference — or stop absorbing it. Three things happened at once in the FY2024 accounting. Part B overall rose about 5% over FY2023 while the ADAP earmark stayed virtually flat, so $899.8 million of a $1.41 billion Part B appropriation (64%) went to ADAPs.7 Thirty-one jurisdictions moved Part B base and supplemental dollars into ADAP in FY2023, covering 7.9% of their ADAP budgets — money that had been paying for case management, transportation, housing and oral health.7 And the state contribution collapsed: states put up 16% of the national ADAP budget in 2011 and just 4% by FY2024.16

The eligibility cliff — who gets cut when a state runs out

When an ADAP cannot close a projected deficit, the fastest lever is the income threshold. Lower the ceiling and people who qualified last month do not qualify this month. Nothing about their health changed.

Federal rules leave this to the states. HRSA's Policy Clarification Notice 21-02 sets three eligibility factors — documented HIV diagnosis, low income, and residency — and expressly leaves the definition of low income and the residency criteria to the recipient, which may measure income as modified adjusted gross income, adjusted gross income, individual gross income, or household gross income.18 That flexibility is why the map looks the way it does.

The 2026 baseline, and who moved

As of January 1, 2024, NASTAD recorded thresholds ranging from 200% FPL in Texas — the lowest in the country — and 250% in Utah, through 300% (Indiana, Missouri, North Carolina, South Dakota, Wisconsin) and 400% (Alabama, Alaska, Arizona, Florida, Georgia, Hawaii, Kansas, Minnesota, Nevada, Puerto Rico, Tennessee), to 500% across most of the Northeast and Midwest and 550% in Oregon, South Carolina and Wyoming.9 Forty-six programs impose no asset limit at all; only Delaware and South Dakota do.9

Then came 2026. By February, five states had already changed ADAP income eligibility and disenrolled people as a result.12 KFF identified them as Florida — by far the most severe — along with Pennsylvania, Kansas, Delaware and Rhode Island.11 By NASTAD's July 2026 survey, Pennsylvania and Rhode Island still had reductions in effect; Kansas and Delaware did not respond that round, so their status was unknown.3

It is worth naming what a threshold cut means in dollars. Florida's January 2026 change took the limit from 400% FPL to 130% — from a maximum income of $63,840 down to $20,748 for one person.11 Reporting cited by the O'Neill Institute put roughly 16,000 people at risk of losing medication coverage entirely, with another 16,000 receiving other state support that could be affected.16

The part nobody expected: three states went the other way

Between April and July 2026, while the national story was contraction, three programs expanded eligibility: Alabama from 400% to 500% FPL, Alaska from 400% to 550%, and South Dakota from 300% to 400%.3 That matters for advocacy framing. These cuts are not inevitable consequences of federal policy — they are state choices, made differently in different capitols, in the same budget year.

Paperwork as a second cliff

Income limits are the visible barrier. Recertification is the quiet one. Sixty percent of ADAP administrators reported that maintaining client eligibility had become somewhat or very challenging, driven substantially by churn out of Medicaid, and 61% reported problems with the IT systems, documentation and data-sharing that eligibility verification depends on.8 Guam was operating a six-month recertification requirement as an active cost-containment measure in July 2026, with Maine and Rhode Island considering it.3 More frequent recertification does not change who is eligible; it changes who stays enrolled.

Formulary changes — when the list gets shorter

A formulary is the list of medications an ADAP will pay for. Nothing else in the program can be trimmed as quickly, and nothing else lands as directly on a specific person's regimen.

Four states had reduced formularies in active effect as of July 2026: Missouri, Iowa, Michigan and Pennsylvania.3 Five more — Arizona, Connecticut, Idaho, Illinois and Rhode Island — were considering it.3

Missouri's action is the one to understand, because it shows the shape of the trade-off. Effective June 1, 2026, Missouri removed all non-antiretroviral medications from its ADAP formulary.3 Antiretrovirals survived. Everything else — the statins, the antidepressants, the diabetes and blood-pressure medications, hepatitis treatment, opportunistic-infection prophylaxis — came off. For a program whose median client is in their late forties or older and carries other diagnoses, that is a large practical change even though HIV treatment itself continues.

Georgia took a different route in the same quarter, adding a cost cap on high-cost dual and combination antiretroviral regimens administered through prior authorization, together with changes to its hepatitis C program.3

Why single-tablet regimens are the pressure point

The most consequential formulary decision of 2026 was Florida's removal of Biktarvy from direct dispensing. KFF's analysis explains the significance: Biktarvy accounted for 52% of the U.S. antiretroviral market and was the only single-tablet regimen among the guideline-recommended initial regimens, leading KFF to conclude that "no other state has made a formulary reduction as consequential."11 The O'Neill Institute made the clinical point: single-tablet regimens account for more than half of prescribed antiretroviral therapy in the U.S. and matter for staying on treatment day after day.16

If you want to check what your own state covers rather than infer it, NASTAD maintains a free National ADAP Formulary Database with coverage as of January 1, 2026, searchable by state across antiretrovirals, opportunistic-infection medications, hepatitis B and C treatment, substance use disorder medications and vaccines — including whether a state runs an open formulary, which categories are excluded, whether separate formularies apply to direct-dispense versus insurance clients, and which specific drugs require prior authorization.10

State-by-state variance — the same diagnosis, fifty different programs

ADAP is often described as a national program. It is more accurate to call it 50-plus programs sharing a name and a funding stream. NASTAD's quarterly ADAP Watch is the closest thing to a live scoreboard, and the July 2026 edition — built from a request for information circulated July 6–24, 2026, with 43 jurisdictions responding — gives the clearest snapshot available.3

What is driving the deficits

Administrators in the 15 deficit programs were asked to name causes, and could pick more than one. Increased drug costs led at 13 of 15 (87%), followed by rising premium costs (10, or 67%), increased enrollment (9, 60%), expiration of the enhanced premium tax credits (9, 60%), decreased 340B rebate revenue (8, 53%), changes in federal allocations or supplemental awards (8, 53%), and state revenue reductions (2, 13%).3 Two of the top four causes are federal policy decisions, not state mismanagement.

Enrollment caps: the quieter waiting list

Two programs were operating hard enrollment ceilings in July 2026. Indiana set a maximum of 5,500 clients, raised from 4,500 in April. Utah set a maximum of 225.3 A cap is functionally a waiting list that has not been labeled one — when the program is full, the next eligible person does not get served.

Beyond caps, the July cost-containment tally showed 10 jurisdictions reducing Part B funding to ADAP (Hawaii, Illinois, Iowa, Massachusetts, Michigan, Missouri, Nevada, Pennsylvania, plus new additions Puerto Rico and South Carolina), five making premium assistance changes (Michigan, Montana, New Jersey, Oklahoma, Wisconsin), four reducing formularies, two imposing expenditure caps (Colorado, Nevada), and Massachusetts implementing a staff reduction-in-force.3

Waiting lists — a decade-long absence, ended in March 2026

An ADAP waiting list is what happens when a person meets every eligibility requirement and is told the program will serve them when a slot opens. It is the sharpest edge of a funding crisis, and it has a long American history.

In the early 2000s lists were routine: KFF's monitoring documented 1,108 people waiting across seven states in July 2002, a peak of 1,629 people in May 2004, and 20 programs having used a list at some point.17 September 2007 was the first month with zero waiting lists nationally.17

Then came the recession. Peer-reviewed analysis records the high-water mark: 9,298 people on ADAP waiting lists in 2011, spread across a dozen states.17 HRSA distributed $40 million in emergency ADAP assistance to 30 states and territories in September 2011, and the significant lists were finally cleared with emergency federal funding in 2013.11

For more than a decade after that, no state used one. As late as March 2, 2026, KFF was able to report that although Arkansas, Louisiana and New Jersey were considering waiting lists, none were in place.11

Iowa, March 9. Utah, March 19.

That sentence aged in seventeen days. NASTAD's July 2026 ADAP Watch documents two active waiting lists: Iowa, with 1,035 people, opened March 9, 2026, and Utah, with 48 people, opened March 19, 2026.3 These are the first ADAP waiting lists in the United States in over a decade.

The trajectories differ. Iowa's list shrank from 1,106 people in April to 1,035 in July, and Iowa reported anticipating that it would resume pharmacy services by the next reporting period.3 Utah's grew from 10 people in April to 48 in July, alongside a 225-client enrollment cap and a 250% FPL threshold that is already the second-lowest in the country.39

Appeals and grievances — the rights you actually have

Most people who are denied, disenrolled, or told a medication is not covered assume the decision is final. It usually is not — and knowing which body to address matters more than how strongly you object.

Working the process, in order

1. Get the denial in writing, with a reason. "Not covered" is not a reason. You need to know whether the issue is income calculation, missing documentation, a formulary exclusion, a prior authorization requirement, a step-therapy rule, an expenditure cap, or a waiting list. Each has a different remedy.
2. Check the income math yourself. States differ on whether they use gross income, modified adjusted gross income, net income, individual income, household income, or family income — and NASTAD found all six methods in active use across the programs.9 Miscounting a household member or including income the state excludes is one of the most common and most fixable errors.
3. Ask your ADAP for its written grievance procedure. Ryan White recipients and their pharmacy benefit vendors are expected to maintain client grievance processes; NASTAD's benefits-management guidance for ADAPs covers this territory directly and is worth citing by name when you ask.19
4. Get your prescriber into it. For formulary exclusions, prior authorization and step therapy, a clinical letter explaining why a specific regimen is medically necessary — prior intolerance, resistance, drug interactions, adherence considerations with a single-tablet regimen — is the document that moves a decision. Many states allow additional drugs with clinical provider approval.10
5. Escalate outside the program. Your state's Ryan White Part B planning body, your HIV planning council, your state health department's HIV/AIDS section, and your state legislators all have standing here. Florida's 2026 sequence — emergency appropriation in March, restored funding in June — happened because people escalated.3
6. Do not stop taking medication while you appeal. Ask your case manager or clinic pharmacy about bridge supplies, manufacturer patient assistance, or Part C support to cover the gap.

Coverage transitions — the premium tax credit shock

Roughly a third of ADAP's work is now insurance, not pills. In CY2024, 49 programs used funds for insurance purchasing or continuation, supporting more than 138,000 clients at a cost of about $880 million — 33% of all ADAP expenditures, averaging $6,377 per insured client.6 Thirty-seven percent of clients had private insurance, and 45% of those were in ACA marketplace plans.6

That model rests on a simple calculation: if buying someone a marketplace plan costs less than buying their medications outright, buy the plan. Enhanced premium tax credits made that math work for four years. Their expiration for 2026 broke it.

The numbers are stark. Average annual premiums for people staying in the same plan rose from about $888 in 2025 to about $1,904 in 2026 — up 114%. Benchmark premiums rose 26% nationally, with Florida up 33% and Texas up 35%. And about 7% of clients served through insurance purchasing have incomes above 400% FPL, meaning they lost subsidy eligibility entirely.11

The cost curve underneath

Even before the credits lapsed, insurance costs were compounding. National ADAP premium spending rose from $345 million in 2020 to $397 million in 2024 (+15%), while cost-sharing spending rose 36% to $286 million — with extraordinary state-level swings: Illinois cost-sharing up 684%, from $2.5 million to $20.0 million, Ohio up 165%, Tennessee up 97%, and Georgia's premium investment up 114%.6

This is why premium assistance was the second-most-common thing states cut. Nine programs made premium assistance changes in April 2026, five still had them in effect in July, and four more — Alabama, Arizona, Connecticut, Illinois — were considering them.3

Medicare, Medicaid, and the wraparound role

ADAP also functions as the wraparound for people on Medicare, covering Part D premiums and cost-sharing.5 The Inflation Reduction Act's out-of-pocket cap changed that arithmetic in a way that is good for people and hard for programs: the cap fell from roughly $3,300 in 2024 to $2,000 in 2025 and $2,100 in 2026, so ADAPs make fewer cost-sharing payments and therefore generate fewer partial-payment rebates.7 A benefit for individuals became a revenue loss for the program.

On the Medicaid side, the concern running through 2026 was policy-driven coverage loss. The O'Neill Institute names work requirements and more stringent eligibility verification among the contributors to the ADAP crisis, and recommends that states exempt people with HIV from Medicaid work requirements and simplify recertification to reduce the load landing on Ryan White.16

The 340B connection — why half the budget sits outside appropriations

To understand why a flat federal earmark produces a crisis rather than a plateau, look at where ADAP's money actually comes from. In FY2024, ADAP's total national budget was about $2.7 billion — 35% larger than in 2019 — but manufacturer rebates supplied 52% of it, and the federal ADAP earmark only 29%.7

Compare that to 2011, when the earmark was 43% of the ADAP budget, the state share was 16%, and rebates were 33%. By FY2024 the earmark had fallen to 29%, the state share to 4%, and rebates had risen to 52%.16 The program did not stop growing; it changed what it grew on.

How ADAP rebates work — and why ADAP is the exception

The 340B Drug Pricing Program requires manufacturers to sell outpatient drugs to covered entities at a discounted ceiling price. Most covered entities get that discount up front, at purchase. ADAPs are unique in being permitted to take it as a rebate instead: they pay a higher price, then claim the difference back. Legal analysis of the 340B program notes that ADAPs have been the sole exception permitted to use a rebate mechanism since 1998.19

Rebate retention has become the load-bearing wall. Programs retained 73% of rebate revenue in FY2019 and 86% by FY2024.7 NASTAD's accounting is hybrid as a result: direct-purchase programs report drug costs net of the 340B ceiling price, while rebate programs report pre-rebate figures.6

The three ways this revenue is eroding

Eight of the 15 deficit ADAPs named decreased 340B rebate revenue as a cause.3 Three mechanisms are at work.

• Cash-flow timing. Fifty-four percent of ADAPs reported challenges receiving timely rebate payments from manufacturers — which becomes an operational crisis when more than half the budget depends on money arriving on schedule.8
• Competition among covered entities. When an ADAP and another 340B covered entity — a Ryan White Part C clinic, for instance — could both claim the discount on the same prescription, "right-of-way" determinations are needed to avoid duplicate discounts. Those determinations divide a fixed pool, and manufacturer restrictions on contract pharmacies further limit where direct-purchase ADAP clients can fill prescriptions at all.8
• Structural change to the whole model. HRSA announced a revised 340B Rebate Model Pilot Program on July 31, 2026, with manufacturer rebate plans due August 24, 2026 and an effective date of January 1, 2027.20 Under the pilot, participating covered entities buy at wholesale acquisition cost and claim a rebate equal to the difference from the 340B ceiling price, with rebates paid or denied within 10 calendar days.19 An earlier version of the pilot was paused at the end of 2025 and vacated after an Administrative Procedure Act challenge.19

At least one manufacturer's guidance to 340B stakeholders states the rebate pilot does not apply to programs listed as Ryan White Part B ADAP Rebate Option grantees.19 ADAP's carve-out appears to be holding — but the pilot reshapes the surrounding 340B environment that ADAP revenue depends on.8

Advocacy paths — what actually moves this

Two things about 2026 should encourage anyone deciding whether to bother. The FY2026 appropriation was going to cut $525 million from federal HIV programs, and organized advocacy restored it.13 And Florida's ADAP went from a 130% FPL threshold in January to a restored 400% threshold with full medication coverage by July, through an emergency appropriation and then a budget line.3 Neither outcome was predicted in January.

A handful of organizations do the primary work you can attach yourself to. NASTAD publishes the quarterly ADAP Watch and the annual monitoring report every other analysis cites.4 The HIV+Hepatitis Policy Institute carries the appropriations testimony,12 AIDS United mobilizes on appropriations outcomes,13 and the HIV Medicine Association mobilizes clinicians.14 KFF and the O'Neill Institute reframe state decisions as national policy failures.1116 Community publications including POZ, Positively Aware and TheBody carry the lived-experience reporting that makes the numbers legible — and if you have been disenrolled, waitlisted, or switched off a working regimen, those are places your story can reach the people writing policy.

Florida — the sharpest case, and where it landed

Florida became the national example of the ADAP crisis in 2026, first for the depth of its cuts and then for the speed of its reversal. Because that sequence has its own statutes, emergency rules, litigation and dollar figures, we cover it in full detail on a dedicated page: Florida ADAP changes. What follows is the national-context summary.

Florida entered 2026 by dropping its ADAP income threshold from 400% FPL to 130% FPL — a maximum income falling from $63,840 to $20,748 for a single person — while removing Biktarvy from direct dispensing and rolling back insurance premium assistance.11 Reporting cited by the O'Neill Institute estimated roughly 16,000 people at risk of losing medication coverage outright and another 16,000 receiving other state support that could be affected.16

Then it moved back. In March 2026 the governor signed legislation containing $30.9 million in stopgap funding through June 30, 2026, restoring the 400% FPL threshold — though without premium assistance or single-tablet regimen coverage.16 On June 29, 2026, the governor signed the FY2026–27 state budget including $75 million for state ADAP funding, restoring the full-pay medication program to its pre-cut form. Effective July 1, 2026, Florida ADAP eligibility remains at 400% FPL and all previously covered medications, including Biktarvy, are restored — with a new full-pay enrollment cap of 21,000 clients. Insurance premium assistance was not restored.3

The Florida Department of Health confirms the current posture on its own program page: direct medication coverage for people at or below 400% FPL, with Biktarvy and Descovy restored to the formulary for direct-dispense enrollees, and copay assistance available to insured clients from 0–400% FPL.21

What to do this month

The gap between "this is a national crisis" and "here is what I do Tuesday" is where most policy writing fails. So, concretely.

If you are enrolled in ADAP right now

• Confirm your recertification date and calendar it with a reminder two months out. Eligibility maintenance was named a challenge by 60% of programs, and a lapse you could have prevented is the most common way people lose coverage in a tight year.8
• Check whether your specific medications are on your state's current formulary using NASTAD's formulary database, and ask your case manager whether your state runs separate formularies for direct-dispense and insurance clients.10
• Ask directly whether your state has an enrollment cap, an expenditure cap, or a pending cost-containment proposal. Programs are required to notify clients of changes, but notification and understanding are different things.
• Keep 30 days of medication ahead if your program allows it. Transitions and appeals take weeks.

If you were just denied, disenrolled, or waitlisted

• Request the denial in writing with the specific reason and the appeal timeline.
• Recheck the income calculation. Six different calculation bases are in use nationally; errors are common and correctable.9
• Ask for the written grievance procedure and follow it in order, in writing, keeping copies.19
• Get a medical necessity letter from your prescriber if the issue is a formulary exclusion, prior authorization, or step therapy.10
• Do not go without medication while this proceeds. Manufacturer patient assistance programs, Part C and Part D clinics, and local Part A programs exist specifically for gaps like this.

If you want to change the underlying problem

• Contact your two senators and your representative with the specific FY2027 ask: a $175 million increase for ADAP, and Part B at $1.075 billion.1215 Mention that the earmark has not moved since 2013.
• Contact your state legislators about the state share. Four percent is the number to quote.16
• Read each quarterly ADAP Watch when it publishes and check whether your state is on a "considering" list.4 Stopping a proposal is easier than reversing a policy.
• Show up to your Ryan White planning body's public comment period. Very few people do.
• Tell your story where it will be read. Advocacy organizations and community publications need named, specific accounts of what a threshold cut or formulary change did to a real regimen.

One last thing worth holding onto. ADAP's 87% viral suppression rate — against about 67% nationally — is not an accident of who enrolls.5 It is what happens when a program removes the cost barrier and keeps medication continuous, year after year, for a quarter of a million people. The 2026 crisis is not a story about a program that failed. It is a story about a program that works, funded as though it did not.