Budget issues are forcing state AIDS Drug Assistance Programs (ADAPs) to make tough decisions. These state-run programs provide HIV medications to low-income Americans living with HIV.
Federal appropriations have declined by 31% in inflation-adjusted dollars since 2005. Congress has appropriated $900 million annually for the program since 2014. As a percentage of all ADAP funding sources, the federal appropriation share peaked in fiscal year 2000 at 68%. By FY 2023, federal outlays only made up 30% of total ADAP funding. Flat funding limits the buying power of state ADAPs, which are managing the financial squeeze from increased patient enrollments, rising insurance costs, and soaring drug prices. In effect, state assistance programs have fewer resources to purchase more expensive drugs for more patients.
Budget constraints are a bipartisan issue. Many states, irrespective of their political alignment, are taking steps to contain costs. Nineteen states are projecting budget deficits for the fiscal year that began April 1.
Florida opted for draconian containment measures: The state eliminated health insurance premium assistance, reduced its federal poverty level eligibility for patients from 400% to 130%, and removed Biktarvy, the preferred HIV medication of most patients and their prescribers, from its formulary.
Four other states—Pennsylvania, Kansas, Rhode Island, and Delaware—have introduced financial eligibility limits. Three states—Arkansas, New Jersey, and Louisiana—are considering waiting lists. Several others are implementing cost-saving measures such as formulary restrictions and limiting or eliminating insurance premium assistance.
The National Alliance of State and Territorial AIDS Directors has called for a $175 million increase in federal funding to address the financial hardships facing state programs. States cannot cut their ADAP budgets and deliver the same level of care for people living with HIV.
Increasing the federal ADAP appropriation would help states mitigate projected budget shortfalls and ensure that the patients most in need can access their lifesaving medications.
John Arcano is Senior Manager of Policy and Government Affairs at AIDS Healthcare Foundation.
