What’s Affordable, Anyway?

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

New polling data from the Kaiser Family Foundation (KFF) found that the cost of living—particularly healthcare and gasoline costs—is at the top of Americans’ minds as the U.S. heads into the 2026 mid-term elections. KFF found that, when asked if they were worried about being able to afford different basic needs, 60% of respondents indicated that healthcare costs, including the costs of health insurance and out-of-pocket expenses, such as office visits and prescription drugs, were of most concern, followed by 59% of respondents indicating that gasoline and transportation costs were top of mind (Schumacher et al., 2026).

Source: Gallup

This raises a key question with which few are willing to grapple:

How are we defining “affordable”?

In the strictest sense, “affordable” means something is priced low enough to be easily paid for or purchased.

But this raises another important question:

Affordable for whom?

According to Donald J. Trump, “The word ‘affordability’ is a Democrat scam” (Revell, 2025). He’s also called the concept of affordability a “fake narrative,” a “hoax,” and a “con job” (Green, 2025).

None of this is surprising, as the president has never had to “afford” anything in his entire life; nor, apparently, have any key members of his administration, including Trump Secretary of the Treasury, Scott Bessent, who claimed that Americans should be worried about affordability because, “…the Biden Administration destroyed affordability” (Wang & Farrow, 2026).

This has been the refrain of Republicans at both the state and federal levels since time immemorial: when costs increase during a Republican administration, it is always the fault of Democratic policies and politicians, regardless of how long Republicans have been in power and irrespective of objective reality.

But let us not lay the blame of unaffordability directly at the feet of just Republicans. Democrats have regularly abused the word “affordable,” with the naming of the Affordable Care Act (ACA) serving as one of the primary examples of how simply slapping the word “affordable” on something does not make it affordable. Despite its promises to control healthcare cost growth, national healthcare expenditures (in 2024 U.S. dollars) have soared from $3.83 trillion in 2014, when much of the ACA took effect, to $5.28 trillion in 2024 (Rakshit et al., 2026).

The issue with affordability is that it is largely subjective: when you’re poor, virtually nothing is “affordable” unless it’s free; when you’re wealthy and don’t have to worry about choosing food or healthcare, your concept of affordability skews toward your own experiences.

And maybe this is the crux of the issue: the people who set the policies that affect prices—from filing fees to taxes to tariffs to rates for goods and services—live in a bubble where “affordability” is largely an afterthought.

Source: Institute for New Economic Thinking

Despite consistent promises made by every presidential administration since the 1970s’ stagflation crisis to make life more affordable for Americans, nothing seems to change, in no small part because the private entities that set prices for food, healthcare services, and medications are often the largest donors to American politicians. When it comes time to craft meaningful legislative and administrative solutions to actually make life affordable, those donors expect obeisance from the officials they’ve purchased.

When it comes to healthcare costs, the same truths come into sharper focus. Few other industries are so regularly and publicly asked to substantiate the costs of their services to the American public—or Congress—than actors in the healthcare space. Health insurers, pharmaceutical manufacturers, and hospital industry representatives are often required to show up and justify why costs are so high, but little decisive action to reduce costs for consumers is ever taken; instead, we get political theater, even when both political teams come out swinging against the healthcare industry, and no real changes.

Why is that?

The simplest explanation is that nobody wants to truly upset the two proverbial apple carts:

The first apple cart holds the industries that provide healthcare services to Americans. In 2024, healthcare expenditures in the U.S. accounted for 18% of economic spending as a percentage of Gross Domestic Product (GDP), and that number is expected to grow to 21% by 2034 (Peter G. Peterson Foundation, 2026). Moreover, the U.S. healthcare system depends heavily on various funding mechanisms, such as the 340B Drug Pricing Program, for survival, meaning that trying to solve the healthcare affordability crisis by addressing just one aspect of healthcare services could cause another to collapse.

For example, 340B-eligible hospitals argue that if they are forced to demonstrate they are using 340B revenues appropriately, they will have to close locations. Why? Because that level of transparency would cost them their eligibility.

But this isn’t just the argument made by hospitals. Virtually any policy that is designed to lower costs for consumers is met with thinly veiled threats by healthcare industry players:

The most common refrain we hear from pharmaceutical partners is that any price controls introduced in the U.S. will force them to slow innovation, slow or halt drug development, or simply take products off the market. Health insurers echo this refrain, arguing that any attempt to force them to lower premiums and deductibles will force them to close operations and leave people without health insurance coverage.

This makes the first apple cart particularly pernicious: healthcare industries are more than willing to threaten service reductions or closures when their profits are threatened.

The second apple cart holds the donors that can make or break political campaigns.

Source: Politico

It’s hard to demand substantive changes from those who have paid their way into office, or who have used their position to enhance their personal wealth. When industries are allowed to bankroll politicians—actions that have been deemed “protected speech” by the U.S. Supreme Court—it’s not surprising that they then expect those politicians to fall in line when it comes to advancing their interests over the interests of everyday Americans. As a result, we get regulatory frameworks without teeth; healthcare laws that don’t actually control healthcare costs; endless Congressional investigations and hearings that provide excellent soundbites, but don’t go anywhere in terms of legislation and policymaking.

The hard truth for many to swallow is that making healthcare affordable means making it affordable for everyone, whether healthcare industry players like it or not. This means regulations and eligibility requirements that have teeth; it means making it more expensive for companies to fall out of compliance than to comply; it means revoking eligibility for federal programs, subsidies, and pricing agreements if providers are regularly non-compliant.

But this is not a conversation that many are willing to have, because in America, the Almighty Dollar is King. And so long as profits are high and shareholders are happy, we plebeians can go kick rocks!

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] Green, E. L. (2025, December 02). Trump Calls Affordability a ‘Con Job’ as His Edge on the Economy Slips. New York, NY: The New York Times: US: Politics. https://www.nytimes.com/2025/12/02/us/politics/trump-affordability-economy-messaging.html

[2] Peter G. Peterson Foundation. (2026, August 11). Chart Pack: Healthcare. New York, NY: Peter G. Peterson Foundation. https://www.pgpf.org/article/chart-pack-healthcare/

[3] Rakshit, S., Winger, A., Cotter, L., McGough, M., Wager, E., & Cox, C. (2026, January 22). How has U.S. spending on healthcare changed over time? San Francisco, CA: Peterson-KFF Health System Tracker: Health Spending. https://www.healthsystemtracker.org/chart-collection/u-s-spending-healthcare-changed-time/

[4] Revell, E. (2025, December 02). Trump calls affordability 'a Democrat scam' as inflation concerns persist nationwide. New York, NY: Fox Business: Politics. https://www.foxbusiness.com/politics/trump-calls-affordability-a-democrat-scam-inflation-concerns-persist-nationwide

[5] Schumacher, S., Valdes, I., Mulugeta, M., Kearney, A., Kirzinger, A., & Hamel, L. (2026, October 06). KFF Health Tracking Poll: Health Care Issues in the Lead-Up to the 2026 Midterm Election. San Francisco, CA: KFF: Public Opinion. https://www.kff.org/public-opinion/kff-health-tracking-poll-health-care-issues-in-the-lead-up-to-the-2026-midterm-election/

[6] Wang, S. & Farrow, F. (2026, January 28). Bessent says Americans 'should be worried about affordability,' but blames Biden for cost issues. New York, NY: ABC News: Politics. https://abcnews.com/Politics/bessent-americans-worried-affordability-blames-biden-cost-issues/story?id=129636939

340B: The Glue That Should Hold Our Healthcare System Together

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

In June 2026, ADAP Advocacy released its latest policy paper—340B Program: The Glue That Should Hold Our Healthcare System Together—focusing on the explosive growth of the 340B Program from just 1,000 covered entities (CEs) and 503 contract pharmacies (CPs) in 1992 to over 53,000 CEs and 34,840 CPs in 2024. In addition to examining this growth and its causes, ADAP Advocacy also provided concrete recommendations to ensure the 340B Program can function in perpetuity (Macsata, et al., 2026). The policy paper is the latest in a series supporting the organization's argument that the 340B Program is too big to fail.

Source: ADAP Advocacy

ADAP Advocacy argues that, because the 340B Program spans more than 42,000 healthcare organizations and 32,000 pharmacies, it should be the glue that holds our healthcare system together. Instead, the 340B program has essentially become a slush fund for unscrupulous CEs—primarily hospitals—that lines executives’ pockets while cutting corners, costs, and services for both staff and patients. That’s not to suggest the program isn’t vitally important, or that there aren’t plenty of good actors…CEs…in the 340B space, because it is, and there are. The fact of the matter is a healthcare program of this size and magnitude cannot be entrusted to good faith alone; rather, improved transparency guardrails are needed to ensure its success and ultimately its intended beneficiaries: patients.

Primary Drivers of Growth:

ADAP Advocacy identified several key drivers of growth in the 340B program, including:

• The expansion of eligibility categories;
• The expansion of large health systems;
• The growing utilization by CEs of off-site clinics and child sites; and
• The explosive growth of Pharmacy Benefit Managers (PBMs) and contract pharmacies operating in the American healthcare space as third-party administrators for CEs

Policy Proposals

ADAP Advocacy also recommended several policy proposals to address the myriad issues facing the program, including:

• The implementation of a program-wide rebate model, in which drugs are purchased at full price up front, and rebates are provided by manufacturers at a later date;
• The consideration of a rebate “sales draw” under the program-wide rebate model that accounts for agencies with smaller annual operating revenues (e.g., those with less than $2 million);
• Mandatory reporting requirements for CEs, including how revenues have been used to improve patient care, reduce drug costs, or expand community services;
• Clearly defining “patient” in the statute—who qualifies as a patient, and which purchases qualify for 340B rebates; and
• Establishing an enforcement mechanism with real teeth and penalties ranging from civil monetary penalties to loss of 340B eligibility.

Each proposal is designed to ensure 340B revenues are used for patients in need, as intended by those who created the program. And these changes are long overdue.

Source: ADAP Advocacy | iStock

In 2025, 340B drugs exceeded $179.5 billion in list prices, with hospitals as the biggest cost driver (Martin et al, 2026). The 340B Program is immensely significant, and rising waste, fraud, and abuse pose an increasing risk. Because the American healthcare system is highly interdependent, a weakness in one sector can have widespread repercussions, making the 340B Program's impact especially important. 

Research published in September 2026 by the Pioneer Institute found that hospitals participating in the 340B Program spent an average of just 2.16% of their operating expenses on charity care, compared to 2.82% at non-340B hospitals. It also found that 340B hospitals spent just 1.6% of operating expenses on care for uninsured patients, compared with 2.26% at non-340B hospitals (Popovian et al., 2026).

Popovian et al. are quick to point out that their findings do not suggest that participating in the 340B Program “causes” hospitals to provide less charity care or care at cost; rather, their findings demonstrate that the 340B Program’s drug discounts, savings, and revenues do not reliably translate into providing more help for patients (either in terms of healthcare provision or lower costs), and that current reporting requirements are insufficient to ensure that 340B revenues are being appropriately utilized in ways that comport with either the letter or intent of the statute.

Source: Pioneer Health

Last month, ADAP Advocacy launched a national advocacy campaign focused on the data and findings of its most recent 340B white paper, including infographics, social media posts, op-eds, and video content. The campaign is patient-centric in that it informs patients, regardless of their chronic health condition or rare disease, why they can no longer sit on the sidelines and watch the pharmaceutical industry and big hospital systems duke it out over what is in our best interest. Nothing about us, without us!

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] Macsata, B. M., Anthony, G., Hopkins, M. J., Sosa, J. (2026, June). 340B Program: The Glue That Should Hold Our Healthcare System Together. Nags Head, NC: ADAP Advocacy: Policy Center: 340B: Policy Papers. https://www.adapadvocacy.org/s/2026_ADAP_Project_RW_340B_Asset_32_340B_Glue_Should_Hold_Healthcare_Together_061526.pdf

[2] Martin, R., Karne, H., Zen, S. (2026, June), The Size and Growth of the 340B Program in 2025. IQVIA. https://www.iqvia.com/-/media/iqvia/pdfs/us/white-paper/2026/iqvia-size--growth-of-340b-in-2025-white-paper-2026.pdf

[3] Popovian, R., Sydor, A. M., Czubaruk, K., Walker, M., & Smith, W. (2026, September 24). The 340B Accountability Gap: Charity Care, Uncompensated Care, and Medicaid Patient Volume Among 340B and Non-340B Hospitals: What the Data Mean for 340B Accountability and Reform. Boston, MA: The Pioneer Institute: Pioneer Health. https://pioneerinstitute.org/wp-content/uploads/2026/09/2026-09-08-Cancer-Care-340B-Paper.pdf

CDC Releases New Information About People Living With HIV/AIDS

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy

The Centers for Disease Control and Prevention (CDC) released its latest update to the Behavioral and Clinical Characteristics of Persons with Diagnosed HIV Infection in September 2026. These data represent findings from people living with HIV/AIDS (PLWHA) collected in 2024, and could point to significant trouble ahead for PLWHA (CDC, 2026).

Source: CDC

Key Findings and Discussion:

While 80% of respondents were prescribed antiretroviral therapy (ART) to treat their HIV, only 63% reported taking every dose as prescribed. Among those who missed doses, 22.7% missed doses for 1 to 2 days, 10.2% for 3 to 5 days, 1.5% for 6 to 10 days, and 2.3% for 11 or more days. The most commonly reported reasons for not taking medications included:

• Forgetting to take them (69.1%)
• Changes in daily routines or travel (42.3%)
• Falling asleep early or oversleeping (38.4%)
• Feeling depressed or overwhelmed (21%)
• Problems getting prescriptions or refilling medications (18.5%)
• The person didn’t feel like taking them (14.1%)
• Alcohol or drug use (10.3%)
• Problems paying for medications (6.9%)
• In the hospital or too sick to take medications (6.6%)
• Difficulties with medication side effects (5.8%)

When disaggregated by sex, Female respondents were slightly more likely to be adherent to treatment (66.2%), while 62.5% of Males reported being adherent.

When disaggregated by race, Multiracial Americans were the least likely to be treatment adherent (59.5%), followed by Black Americans (62%), Hispanic/Latine Americans (63.1%), and White Americans (65.6%). Asian Americans had the highest rate of treatment adherence, at 70.6%.

When disaggregated by age, adults aged 50+ were most likely to be treatment adherent (69.9%), followed by those aged 40-49 (58.3%) and those aged 18-29 (53.6%). Adults aged 30-39 were the least adherent, at 50.6%.

These data are particularly problematic, as failure to adhere to treatment regimens can result in the mutation of the virus to become resistant to specific ARTs or drug classes, making HIV harder to treat and limiting future treatment options. Additionally, nonadherence to ART regimens can leave the virus unsuppressed, increasing the likelihood of transmitting it to others (HIV dot Gov, 2026).

Source: Marley Drug

How to Improve Treatment Adherence

The HIV treatment landscape has changed significantly over the past twenty years. While treating HIV once required patients to take and keep track of multiple pills a day (or daily injections), single-pill oral regimens became the norm in the 2010s, and now, we have long-acting injectable (LAI) medications that can be delivered monthly or every other month.

A recent study published in The New England Journal of Medicine found that patients treated with LAIs were significantly less likely to experience regimen failure (n = 29; 19%) than patients taking a standard oral regimen (n = 55; 36%). While most regimen failures in the standard group resulted from virologic failure (58.2%), treatment discontinuation or abandonment caused regimen failure in the LAI group (82.6%). At the 48-week mark, regimen failure was 22.8% in the LAI group and 41.2% in the standard oral regimen group, indicating that LAIs are a key component to improve treatment adherence and virologic suppression (Rana et al., 2026)

ADAP Advocacy’s own research found that 52.3% of patients who responded to a 2024 survey would prefer LAI treatment regimens over oral regimens (Johnson et al., 2024).

Source: ADAP Advocacy

Quality of Life and HIV

Additional findings of the MMP found that structural challenges continue to negatively impact PLWHA, with respondents reporting hunger or food insecurity (22%), unstable housing or homelessness (20%), and unemployment (15%) as being primary drivers of poor physical, mental, and emotional health. Moreover, many PLWHA reported unmet needs for ancillary services that could improve living conditions and well-being, including access to dental care (24%), meal or food service assistance (15%), and stable sheltering or housing services (15%).

Trouble Ahead

The real concern in these data is not the data themselves, but that they were gathered before the Trump Administration took wrecking balls to nearly every aspect of public health provision and services. With state ADAP programs facing increasing budgetary shortfalls that could result in constriction of state programs (Hopkins, 2026), the forthcoming Medicaid implosion that the Trump Administration and its allies in Congress forced through in the One Big Beautiful Bill Act (Hopkins, 2025), and exploding costs of living related to the ongoing war against Iran and nonsensical tariffs, including skyrocketing costs of fuel, diesel, food, goods, and services (Wile & Murphy, 2026; Zahn, 2026), PLWHA are going to be squeezed more than ever. The reality is that patients living with HIV are going to be significantly worse off financially and are likely to face significantly higher barriers to accessing not only HIV care and treatment, but basic necessities, like food, shelter, and transportation.

While we should have been preparing for this for a while, many of us were caught flat-footed by the wholesale destruction being wrought by the Trump Administration. Hopefully, we will be able to course correct enough to avoid the majority of the devastation many are predicting.

Disclaimer: All funders of the ADAP Advocacy Association are publicly listed on our website. 

Disclaimer: Guest blogs do not necessarily reflect the views of the ADAP Advocacy Association; rather, they provide a neutral platform for the author to promote open, honest discussion of public health-related issues and updates.

References:

[1] Centers for Disease Control and Prevention. (2026, September 10). Behavioral and Clinical Characteristics of Persons with Diagnosed HIV Infection. Atlanta, GA: United States Department of Health and Human Services: Centers for Disease Control and Prevention: National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention: Division of HIV Prevention: HIV Data: Medical Monitoring Project. https://www.cdc.gov/hiv-data/mmp/behavioral-clinical-characteristics-pwh.html

[2] HIV dot Gov. (2026, September 24). Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV. Rockville, MD: United States Department of Health and Human Services: Office of Infectious Disease and HIV/AIDS Policy: HIV dot Gov: Clinical Info: Guidelines. https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/interruption-antiretroviral-therapy

[3] Hopkins, M. J. (2025, July 30). Preparing for One Big Beautiful Disaster. Washington, DC: PlusInc: Blog. https://www.plusinc.org/blog/one-big-beautiful-disaster

[4] Hopkins, M. J. (2026, September 24). ADAP: A House of Cards Waiting to Fall. Nags Head, NC: ADAP Advocacy: ADAP Blog. https://adapadvocacyassociation.blogspot.com/2026/09/a-house-of-cards-waiting-to-fall.html

[5] Johnson, R. D., Hopkins, M. J., Laws, J., & Macsata, B. M. (2024). HIV Long-Acting Injectables: Patient access considerations for injectable HIV therapies and injectable HIV Pre-Exposure Prophylaxis. Nags Head, NC: ADAP Advocacy. https://www.adapadvocacy.org/s/2024_ADAP_Project_Long_Acting_Injectables_Final_Report_062524-wgxy.pdf

[6] Rana, A. I., Zheng, L., Castillo-Mancilla, J., Bao, Y., Sieczkarski, S., Brooks, K. M., Lake, J. E., Fichtenbaum, C., Heath, S. L., Belaunzaran-Zamudio, P. F., Klingman, K., Fox, L., Morton, T., Stirratt, M., Li, J. Z., Acosta, E. P., Venuto, C., Galárraga, O., Shoptaw, S., Wohl, D., … ACTG A5359 LATITUDE Trial Team. (2026). Cabotegravir plus Rilpivirine for Persons with HIV and Adherence Challenges. The New England journal of medicine, 394(9), 858–871. https://doi.org/10.1056/NEJMoa2508228

[7] Wile, R. & Murphy, J. (2026, September 23). The U.S. economy before and after the Iran war, in five charts. New York, NY: NBC News: Business: Economy. https://www.nbcnews.com/business/economy/us-economy-iran-war-five-charts-rcna598412

[8] Zahn, M. (2026, August 25). Tariffs will cost US households over $1,000 a year, Yale Budget Lab says. Burbank, CA: ABC: ABC News: Business. https://abcnews.com/Business/tariffs-cost-us-households-1000-year-yale-budget/story?id=135945432