Over the next 12-24 months, a wave of federal policy changes is poised to fundamentally reshape how low-income individuals access, and keep, essential health care coverage. For AIDS Drug Assistance Programs (ADAPs), Ryan White providers, and public health organizations across the country, the implications are profound.
A new analysis from NASTAD* outlines the scale of what’s ahead: deep cuts to Medicaid, the expiration of enhanced Premium Tax Credits (ePTCs), and new Marketplace enrollment barriers could collectively push millions of people out of coverage. At the same time, these losses will drive unprecedented demand onto safety-net programs that are already operating near their fiscal limits.
Three Shifts Creating an Unprecedented Coverage Cliff
According to NASTAD’s analysis, three major forces are converging to destabilize coverage for people with HIV and the safety-net programs that support them.
1. Major Medicaid Losses Under New Federal Policy
The One Big Beautiful Bill Act (or H.R. 1) introduces sweeping Medicaid changes that are projected to push millions of individuals out of coverage, including many who remain eligible.
These changes include:
- Strict work-reporting requirements
- Shortened coverage windows, reducing retroactive eligibility
- More frequent renewals, now required at least every six months
- New cost-sharing obligations for low-income adults in the Medicaid expansion group
Beginning January 1, 2027, most adults enrolled through the ACA Medicaid expansion will need to document 80 hours per month of “qualifying activities” to remain covered. Failure to report, even due to confusion, technology issues, or paperwork errors, will result in termination. New applicants who aren’t already working will be denied enrollment entirely. Historically, these rules have no demonstrated gain: in Arkansas’ 2018 pilot, more than 18,000 people lost Medicaid because they couldn’t navigate the reporting system, and employment rates did not improve.
The Congressional Budget Office projects that 10 million people will lose Medicaid coverage by 2034 under these policies. For people with HIV, interruptions in Medicaid coverage jeopardize access to therapy, labs, mental health services, and the consistent care required to maintain viral suppression.
2. Instability in the ACA Marketplace
The ACA Marketplace faces a two-part crisis:
- The expiration of enhanced Premium Tax Credits at the end of 2025
- The “Marketplace Integrity Rule,” which adds enrollment barriers and raises out-of-pocket costs
Without ePTCs, premiums are expected to increase an average of 114%, pricing many households out of coverage. ADAPs, which rely on subsidized Marketplace plans to stretch limited funding, would be forced back into a far more expensive pre-ACA “full-pay” model just as enrollment demand rises.
3. HIV Program Funding Cuts on the Horizon
Several federal proposals would further weaken the HIV care infrastructure by:
- Eliminating Parts C, D, F, and SPNS
- Cutting Ending the HIV Epidemic (EHE) funding
- Reducing or consolidating key CDC and SAMHSA prevention programs
This comes at a time when ADAPs are already seeing higher demand. According to NASTAD’s ADAP Monitoring Report:
- Total ADAP enrollment is up 8%
- New client enrollment is up 28%
- Prescription drug expenditures have risen 10% in five years
Safety-net systems are absorbing more people, with fewer resources, and federal policy changes threaten to widen that gap dramatically.
The Patient Impact: Rising Risk of Coverage Interruptions
When Medicaid, Marketplace plans, and subsidies fall away, the burden does not disappear – it shifts.
Patients will increasingly rely on:
- ADAP for direct medication assistance
- Ryan White clinics for coverage navigation
- Case managers for re-certifications and appeals
- Providers to bridge gaps in treatment and medication access
Coverage churn means more late renewals, more gaps between plans, more returned prescriptions, more emergency medication needs, and more patients falling out of care. For people with HIV specifically, even a single disruption in coverage can trigger viral rebound or significant health decline.
State ADAPs are Already Planning for the Fallout
NASTAD’s report highlights several strategies states are evaluating to protect clients and maintain fiscal stability, including:
- More advanced forecasting and cost-per-client modeling
- Aggressive pursuit of supplemental federal, state, and local funding
- Emergency medication access pathways
- Strengthened case management and navigation
- Improving communication across clients, providers, and safety-net programs to create a more coordinated referral system
But even with the best fiscal strategy, the underlying challenge remains: more people will need help navigating coverage, and far fewer will be able to do it alone. Which is why enrollment assistance programs are about to become an essential link in the safety net.
Why PIAPs Provide the Stability Patients Need
As federal policy changes reshape access, a Premium Insurance Assistance Program (PIAP) becomes not just helpful, but essential.
PIAPs fill the exact gap that these policy shifts will widen:
✔ Guide patients through increasingly complex Medicaid and Marketplace criteria, especially as work requirements and administrative burdens increase.
✔ Ensure eligible individuals secure ACA or Medicaid coverage, reducing churn and keeping patients retained in care.
✔ Offloads administrative burden on already overstretched Ryan White and ADAP teams.
✔ Mitigate financial strain, by maximizing subsidized coverage wherever possible.
In short: PIAPs keep patients insured, and keep ADAPs and Ryan White programs stable, during the most significant coverage transition in over a decade.
The Path Forward: Investing in Support Now
The policy changes coming into effect over the next 18 months will test the resilience of our country’s safety-net systems. Medicaid will tighten, Marketplace costs will rise, and federal dollars will remain uncertain. Coverage disruptions are preventable, but only if we invest in the systems that keep people insured.
PIAP is designed for this moment. American Exchange stands ready to partner with programs nationwide to meet this challenge head-on, ensuring patients stay covered, supported, and connected to care.
Learn how we can help. Schedule a consultation today at American Exchange.
Source citation:
NASTAD, “Federal Policy Changes and Their Impact on AIDS Drug Assistance Programs” Link
