Medical Debt Soars, Despite 340B Purchases Passing $100 Billion

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

Drug purchases under the 340B Drug Pricing Program exceeded $100 billion for the first time in 2025—an increase from 2024 of 22.8%—according to the Health Resources and Services Administration (HRSA), with hospitals accounting for a combined $83,936,162,423 (83.9%) across all hospital types (HRSA, 2026). Yet despite this program’s explosive growth and its inherent promise to expand access to care and treatment for low-income patients, medical debt in the United States now tops $220 billion (Macsata, 2025). Could this be the true reason why patient advocates increasingly find themselves aligned with drug manufacturers on the need to rein in and reform the 340B Program?

Photo Source: ADAP Advocacy | YouTube

Among hospital covered entities (CEs), Disproportionate Share Hospitals (DSHs)—hospitals that serve low-income patients and receive payments from the Centers for Medicare & Medicaid Services (CMS) to cover the costs of providing care to uninsured patients—accounted for $79,235,079,126 (79.2%). Yet despite this influx of cash, nearly two-thirds of adults who carry past-due medical bills owe money directly to hospitals (Macsata, 2025).

By comparison, all Ryan White HIV/AIDS Program (RWHAP) CEs combined accounted for just $3,092,689,404 (3.1%) of all 340B Program drug purchases. State AIDS Drug Assistance Programs (ADAPs) are widely regarded as the Gold Standard among these CEs, and most have operated under a rebate model for decades.

On the heels of HRSA’s new data release, Patients Rising—a national patient advocacy and education group based in Washington, DC—released a report in which they examined over 900 bankruptcy filings across six states (Colorado, Louisiana, Maine, Virginia, Washington, and Wisconsin) and found that 45% of filings listed verified 340B hospitals as creditors, totaling $6.62 million in debt. In some filings, debt accrued at a single 340B hospital accounted for as much as 98% of the household’s total debt. In that specific example, the household's monthly income was just $1,800, while the total debt from Christus Highland was $386,758 (Patients Rising, 2026).

Upon seeing these data, Dr. Adam J. Fein, President of Drug Channels Institute, argues that, due to the unwieldy, undermanaged, and largely unregulated nature of the 340B Program, reform may, in fact, never occur (Fein, 2026).

Dr. Fein argues that this monstrous growth in 340B drug purchases has reached a compound annual growth rate of ~22% per year over the last 15 years (Figure 1), while manufacturer sales have grown by just 7.3%, making 340B the single largest source of manufacturer discounts in the U.S.

Figure 1 – 340B Drug Program Prices: Purchases by Covered Entities, 2010 to 2025

 

Photo Source: Drug Channels Institute

While Dr. Fein does show that pharmaceutical list prices have also grown exponentially, he points to peer-reviewed research that used price-volume-mix decomposition to examine the relative importance of list prices vs. drug utilization (i.e., the number of pills, capsules, syringes, etc. purchased and distributed) to determine whether price increases or utilization were driving the growth of the 340B Program. Zeng et al. found that utilization accounted for an average of 79.6% of 340B growth based on list price, and nearly 100% of growth based on 340B drug prices (Zeng et al., 2025).

Similar to Dr. Fein, ADAP Advocacy has recently argued that CMS, rather than HRSA, should assume control of the 340B Program, in no small part because it has significant regulatory and enforcement staffing resources on hand to administer a program the size of 340B.

But while Dr. Fein’s concern is that Congress will not adequately take up the mantle of reform in the face of the program's enormity, ADAP Advocacy believes it is imperative that they do so. Since March 2025, we've argued that the program is now too big to fail.

In our recent policy paper, "340B Program: The Glue That Should Hold Our Healthcare System Together", we argue that Congress should reform the 340B program to implement a system-wide rebate model (similar to those currently working for state ADAPs), as well as mandating wholly transparent reporting, clearly defining who qualifies as a “patient” eligible to receive 340B discounted drugs, and establishing compliance and enforcement standards that require all covered entities to open disclose how much in rebates they receive and how those revenues are spent in alignment with both the letter and the spirit of the 340B statute.

Photo Source: ADAP Advocacy

ADAP Advocacy stands firmly in our conviction that the 340B Program must be fundamentally reformed. To be clear, no one side—save for patients in need of care—is faultless in allowing this program to spin wildly out of control. There is culpability to go around; but only one side—drug manufacturers—is required to provide discounted prices and rebate revenues to covered entities, and it is far easier for pundits, politicians, and even patients to paint pharmaceutical companies as the bad guys for drug pricing while holding hospitals and other covered entities blameless.

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] ADAP Advocacy. (2026, July 27). ADAP Advocacy Calls for CMS to Oversee 340B Drug Pricing Program. Washington, DC: ADAP Advocacy. Press Room. https://www.adapadvocacy.org/s/2026_ADAP_Press_340B_Oversight_CMS_072726.pdf

[2] Fein, A. J. (2026, July 15). The 340B Program Hit $100 Billion in 2025: Has It Become Too Big to Reform? Philadelphia, PA: Drug Channels Institute: Drug Channels. https://www.drugchannels.net/2026/07/the-340b-program-hit-100-billion-in.html

[3] Health Resources and Services Administration. (2026, July). 2025 340B Covered Entity Purchases. Rockville, MD: United States Department of Health and Human Services: Health Resources and Services Administration: Office of Pharmacy Affairs: 340B Drug Pricing Program: Program Updates. https://www.hrsa.gov/opa/updates/2025-340b-covered-entity-purchases

[4] Macsata, B. M., Laws, J., Hopkins, M. J. & Sosa, J. (2025, April). Patient Medical Debt: Findings from Quantitative Patient Survey in the United States. Washington, DC: ADAP Advocacy. https://static1.squarespace.com/static/698f8fa09fc8884466a1becd/t/69d85991b19c033c07b2a52b/1775786385556/2025_ADAP_Project_RW_340B_Asset_17_Medical_Debt_Survey_Report_04-23-25.pdf 

[5] Macsata, B. M., Anthony, G., Hopkins, M. J., & Sosa, J. (2026, July 08). 340B Program: The Glue That Should Hold Our Healthcare System Together. Washington, DC: 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

[6] Patients Rising. (2026, July). Medical Bankruptcy in the United States. Washington, DC: Patients Rising. https://6015202.fs1.hubspotusercontent-na1.net/hubfs/6015202/01-PatientsRising-u4m/Research%20Papers/Medical-Bankruptcy-in-America-and-340B_6-State-Analysis-White%20Paper-email..pdf

[7] Zeng, S., Sarraille, W., & Martin, R. (2025, May 21). What is driving 340B growth: utilization or price? Health Affairs Scholar, 3(6), qxaf104. https://doi.org/10.1093/haschl/qxaf104

The Opacity Behind the 340B-Eligible Hospital Transparency

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

What happens when one of the only ways a 340B Drug Pricing Program-eligible Covered Entity (CE) can be evaluated relies on a single line item on a federal tax form? This is one of the primary questions that 340B reform advocates must grapple with, and a point that 340B-eligible hospitals consistently rail against (American Hospital Association, 2025). The debate over what hospitals hide from consumers of healthcare services... patients... is a growing storm inside the Washington Beltway and across the nation.

At present, the Financial Assistance at Cost line item in Schedule H on federal Form 990 tax returns is the only way to measure how 340B-eligible hospitals use the revenues generated by 340B drug rebates (Figure 1).

Figure 1 – An Example of the Financial Assistance at Cost Line Item in Schedule H on the federal Form 990 Tax Return

Photo Source: ProPublica, 2026

In the example in Figure 1, Oroville Hospital, located in Oroville, CA, reported that, in tax year 2022, it provided $9,027,670 in healthcare services at no cost to patients, accounting for 2.28% of its $397,658,853 in annual revenue (ProPublica, 2026).

This is slightly above the national average of charity care provision of 2.2% in 2023 (Levinson et al., 2025) and higher than the charity care expenditures reported by 75 of the 98 hospitals (76.5%) whose 990s ADAP Advocacy has examined for its 340B Map, the average of which is just 0.93% of their annual revenues.

So, what does that mean?

Because there are virtually no public reporting requirements for most 340B CEs, determining how those CEs reinvest 340B-generated revenues in patient care is virtually impossible. This is incredibly problematic because, while there are statutory requirements that dictate the purpose of those revenues, the inability to ensure CEs are using those revenues properly means that a huge percentage of the revenues generated by nearly $200 billion in 340B-eligible drug purchases in 2025 are untraceable and may be misspent (IQVIA, 2026).

Hospitals argue that:

Charity care is only indicative of the amount of care provided to patients who qualify for the hospital’s financial assistance policy and is therefore provided to the patient free of cost. It does not account for costs that hospitals incurred for services where payment was expected but not received (bad debt) or payment shortfalls from public payers like Medicaid (underpayments). Therefore, it is more accurate to look at a hospital’s total uncompensated care (bad debt and charity care) and their total community benefits, which among other costs includes uncompensated care costs as well as payment shortfalls. 340B hospitals are providing high levels of uncompensated care and community benefits despite many of these hospitals operating on razor-thin margins (American Hospital Association, 2025).

Hospitals, the American Hospital Association argues, are being transparent about their expenditures through federal tax filings and public reporting by individual hospitals. Ask them to quantify exactly how 340B revenues are being spent, however, and they will tell you they’re not required to disclose that information.

In a June 18th Substack report from The Rojas Report, Dutch Rojas states that Yale New Haven Hospital spends just 0.69% of its total expenses on the provision of charity care. This information is gleaned from his examination of federal Form 990s for both Yale New Haven Hospital and Yale New Haven Health Services Corporation, the latter of which does not file a Schedule H. Rojas argues that:

In fiscal 2021, Yale New Haven Hospital spent 0.69 percent of its total expenses on charity care.

Read that again.

Not 6.9 percent.

Not even one percent.

Sixty-nine hundredths of a single percent.

This is an organization the Internal Revenue Service classifies as a charity. A 501(c)(3). Tax-exempt on the theory that it exists to serve a public so underserved that the rest of us agree to forgo the taxes it would otherwise owe. That is the deal. That is the entire justification for the exemption.

Now set the charity number against the size of the enterprise. Yale New Haven Health is Connecticut’s largest health system. It reported total operating revenue of $7.24 billion in fiscal 2024 and $7.58 billion in fiscal 2025. A charity does not operate at that scale. A Fortune 500 company does (Rojas, 2026).

Photo Source: The Rojas Report

Additional research led by Robert Popovian, visiting health policy fellow at the Pioneer Institute, currently awaiting peer review, has found that, among the 3,999 hospitals analyzed, 340B hospitals actually provided lower levels of charity care compared to non-340B hospitals (2.16% compared to 2.82%), with Critical Access Hospitals (CAH) providing the lowest average percentages of charity care (1.69%). These researchers conclude that participation in the 340B program does not consistently correlate with higher levels of charity care, suggesting a misalignment between the program’s intent and its outcomes (Popovian et al., 2026).

This aligns largely with what ADAP Advocacy has discovered over the course of its multi-year 340B Executive Compensation project. We examined the federal Form 990s of over 100 hospitals, looking at 990s dating to the year prior to each hospital’s admission to the 340B program, the year immediately after becoming a covered entity, five years after eligibility, ten years after, and the most recently available 990 at the time of research.

In our most recent supplemental report released in December 2025, we found that, across the 98 hospitals with examinable Schedule H filings, the provision of charity care as a percentage of annual revenues decreased by an average of 20.06% from the earliest Schedule H filing to the most recent. In fact, just 27 of those hospitals increased charity care provision, while 41 saw decreases of 50% or greater (Figure 2, Hopkins & Macsata, 2025).

Figure 2 - Largest Decreases in the Provision of Charity Care as a Percentage of Annual Revenue in Hospitals After Receiving Eligibility for the 340B Drug Rebate Program: Updated for 2025 Supplemental Report #2

Photo Source: ADAP Advocacy

Federal legislators are also expressing concern over the relative ungovernability of hospitals, particularly large hospital systems. In the current 119th Congress, Representative Gregory Murphy, M.D. (R-NC-03) introduced the Tax Exempt Hospital Transparency Act (H.R. 9504), which would require every tax-exempt hospital to include the following information in their annual tax filings:

• A description of how each organization is addressing the needs identified in the most recent community health needs assessment conducted under section 501(r)(3), and a description of any such needs that are not being addressed together with the reasons why such needs are not being addressed,
• The audited financial statements of such organization (or, in the case of an organization the financial statements of which are included in a consolidated financial statement with other organizations, such consolidated financial statement),
• The Centers for Medicare & Medicaid Services (CMS) certification number of the organization (or such other identifying information as the Secretary may require),
• The value, at cost, of the financial assistance provided during such taxable year pursuant to the organization’s financial assistance policy (as described in section 501(r)(4)), and
• The number of completed financial assistance applications received, granted, and denied during the taxable year pursuant to the organization’s financial assistance policy (as described in section 501(r)(4)).

Specific to the 340B Program, high revenue tax-exempt hospitals would have to report:

• (A) IN GENERAL.—For purposes of this subsection, the term ‘specified Federal 340B drug discount program information’ means—
• (i) the total number of individuals, by their type of insurance coverage, who were dispensed or administered covered outpatient drugs during the taxable year that were subject to an agreement under section 340B of the Public Health Service Act,
• (ii) the aggregate net 340B payment amount with respect to such drugs subject to such an agreement dispensed or administered by the organization during such taxable year, and
• (iii) the aggregate costs incurred by the organization during such taxable year that were necessary for such organization to participate in the program under such section and to comply with such program’s requirements (including program-related compliance, legal, educational, and administrative costs, and compensation paid to independent contractors to carry out program-related functions).
• (B) COVERED OUTPATIENT DRUG.—For purposes of this paragraph, the term ‘covered outpatient drug’ has the meaning given such term in section 340B(b) of the Public Health Service Act.
• (C) AGGREGATE NET 340B PAYMENT AMOUNT.—For purposes of this paragraph, the term ‘aggregate net 340B payment amount’ means, with respect to a covered outpatient drug purchased by an organization under an agreement under section 340B of the Public Health Service Act and dispensed or administered to an individual by such organization, the excess (if any) of—
• (i) the total amount of payments received from any payor by the organization for such drug, over
• (ii) the ceiling price (as described in subsection (a)(1) of such section) for such drug (or, if less, the price at which such organization acquired such drug) (H.R. 9504).

H.R. 9504 was passed by the House Committee on Ways and Means to the full House on July 1st, 2026, on a party-line voice vote (Republicans in favor; Democrats opposed). Democratic opposition to the bill largely centered on the addition of new administrative burdens placed on hospitals in the wake of over $1 trillion in cuts to healthcare programs in the One Big Beautiful Bill Act of 2025. The American Hospital Association, predictably, came out in opposition to the bill (McAuliff, 2026).

Photo Source: The New York Times

The reality is this:

Until such time as the public and legislators are able to examine how 340B drug rebate revenues are being utilized by covered entities, in general, and by hospitals specifically, accusations of malfeasance on the part of large health systems are going to continue, particularly with the growing threats posed to patients by private equity firms and managers (Hopkins, 2026).

In the meantime, unless hospitals voluntarily disclose how those 340B revenues are being reinvested, they’ll simply have to deal with their lack of charity serving as the primary metric by which they’re judged.

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] American Hospital Association. (2025, October). Fact Sheet - 340B Drug Pricing Program: Fact vs. Fiction. Chicago, IL: American Hospital Association. https://www.aha.org/system/files/media/file/2025/10/fact-sheet-340b-drug-pricing-program-fact-vs-fiction-R.pdf

[2] Hopkins, M. J. & Macsata, B. M. (2025, December). The 340B Drug Rebate Program and its Potential Impacts on Annual Revenues, Executive Compensation, and Charity Care Provision in Eligible Covered Entities: Supplemental Report Two – December 2025. Washington, DC: ADAP Advocacy: Policy Center: 340B: Policy Papers. https://static1.squarespace.com/static/698f8fa09fc8884466a1becd/t/6a0b59ad218bcc00c30a3017/1779128749408/2025_ADAP_Project_RW_340B_Asset_30_ExecComp_Supplemental_Report_2_%2812.22.25%29.pdf

[3] Hopkins, M. J. (2026, June 18). The Growing Access Barrier Facing Patients: Private Equity. Washington, DC: ADAP Advocacy: Blog. https://adapadvocacyassociation.blogspot.com/2026/06/the-growing-access-barrier-facing.html

[4] IQVIA. (2026, June 04). The Size and Growth of the 340B Program in 2025. Durham, NC: IQVIA: United States: Library: White Papers. https://www.iqvia.com/locations/united-states/library/white-papers/the-size-and-growth-of-the-340b-program-in-2025

[5] Levinson, Z., Hulver, S., Godwin, J., & Neuman, T. (2025, February 19). Key Facts About Hospitals. San Francisco, CA: KFF: Health Costs. https://www.kff.org/health-costs/key-facts-about-hospitals/?entry=the-hospital-industry-number-of-hospitals

[6] McAuliff, M. (2026, July 01). Tax-exempt hospitals targeted in bill demanding more disclosure. Chicago, IL: Modern Healthcare: Politics & Regulation. https://www.modernhealthcare.com/politics-regulation/mh-house-tax-exempt-hospital-transparency-act/

[7] Popovian, R., Sydor, A. M., Czubaruk, K., Walker, M., & Smith, W. (2026, February 17). Financial Outcomes and Community Benefit in the 340B Program: Comparing 340B and Non-340B Hospitals. medRxiv. https://doi.org/10.64898/2026.02.12.26346191

[8] ProPublica. (2026). Full text of "Full Filing" for fiscal year ending Nov. 2023. New York, NY: ProPublica: Nonprofit Explorer: California: Oroville Hospital. https://projects.propublica.org/nonprofits/organizations/941634554/202402859349301695/full

[9] Rojas, D. (2026, June 18). Yale New Haven Spends 0.69% of Its Budget on Charity Care. Where the Rest Goes Is the Real Story. New York, NY: The Rojas Report. https://read.rojasreport.com/p/yale-new-haven-spends-069-of-its

[10] Tax Exempt Hospital Transparency Act, H.R. 9504, 119th Cong. (2026). https://www.congress.gov/bill/119th-congress/house-bill/9504

Extraction Dressed Up as Care: Why the 340B Program Needs to Answer to Patients

By: Ryan Alvey, Executive Director & Founder, Positive Change Movement, and member of the ADAP Advocacy 340B Patient Advisory Committee

The 340B Drug Pricing Program was created with a simple moral promise: to help safety-net providers stretch limited resources so vulnerable patients could get care, medication, and support. What happened to that promise?

Photo Source: ADAP Advocacy

As a person living with HIV in rural Kentucky, I know exactly what that promise is supposed to mean. It is supposed to mean that someone like me does not have to beg for care. It is supposed to mean that HIV service organizations exist for people living with HIV, not merely because of us. It is meant to mean that the money generated by our diagnoses, our prescriptions, our labs, and our lives comes back to the communities it was intended to serve. 

But too often, that is not what patients experience. 

I am not writing this as an outsider looking at a policy chart. I am writing this as a gay man living with HIV and numerous comorbidities who became an advocate because I had no choice. I have sat in rooms where people talk about ending the HIV epidemic while people living with HIV are missing from leadership. I have watched organizations build budgets, salaries, reputations, and public-relations campaigns around our suffering, while those most affected are treated as inconvenient whenever we ask questions.

And I have lived the consequences of a system where the provider holds all the power.

In rural communities, there may be only one HIV provider within reach. If that provider refuses  care, delays care, restricts access, or retaliates against a patient who speaks up, the patient does  not simply "go somewhere else." Somewhere else may require half a day of travel. Somewhere else may require transportation that the patient does not have or fuel that the patient cannot afford. Somewhere else may mean months without consistent care. Somewhere else may mean choosing between dignity and survival.

That is why 340B transparency is not an abstract policy issue. It is a patient safety issue.

The 340B Program is now enormous. IQVIA reported that in 2025, drug sales under the program topped $179.2 billion, which represented a year-over-year increase of 20% (IQVIA, 2026). The federal agency charged with policing the program describes it as a way for healthcare providers to “stretch scarce federal resources,” reach more eligible patients, and provide more comprehensive services.

That purpose matters. But purpose without accountability is just branding. 

An ADAP Advocacy report, "Is the 340B Drug Pricing Program the Next 'Too Big to Fail'?", asks the question many patients have been asking quietly for years: where are the savings going?  The report argues that 340B has grown without sufficient transparency and highlights an analysis of 102 providers in which annual revenues increased dramatically after joining 340B, CEO compensation rose, and hospital charity care declined.

Photo Source: ADAP Advocacy

This issue should concern everyone who cares about the future of HIV care. Charity care isn't just limited to hospitals; it's really about supporting people. The truth is, individuals with untreated, symptomatic HIV or advanced AIDS tend to use hospitals more often, facing higher admission rates and longer stays (NIH, 2018).

To be clear, 340B should not be destroyed or weakened. For HIV care, it can be essential. State AIDS Drug Assistance Programs (ADAPs) and Ryan White grantees depend heavily on drug rebates and savings to keep people insured, medicated, and...alive. The National Alliance of State and Territorial AIDS Directors (NASTAD) reported that in calendar year 2024, ADAPs achieved an 87% viral suppression rate among clients served, compared with an estimated 67% among all people living with diagnosed HIV in the United States.

That is exactly why reform matters.

When a program is this important, patients cannot afford blind trust. We cannot afford vague assurances that “the money helps the mission.” We need to know how. We need to know whether 340B revenue is paying for direct patient assistance, transportation, housing stabilization, peer navigation, rural access, mental health support, and culturally competent care — or whether it is being absorbed into executive salaries, expansion strategies, branding, buildings, and bureaucracy. 

People living with HIV should not have to file records requests, complaints, lawsuits, or whistleblower reports just to understand whether money intended to help us is actually reaching us.

Despite the Denver Principles, our community has been told for decades to trust institutions. Trust the nonprofit service provider. Trust the grant recipient. Trust the volunteer board. Trust the same systems that too often exclude the very people whose lives justify their funding.

I do not trust systems that refuse to be transparent.

Photo Source: ADAP Advocacy | iStock

If an HIV service organization receives funding from the Ryan White HIV/AIDS Program and benefits from 340B Program-related revenue, and claims to exist for people living with HIV, then it should be able to answer basic questions.

How much 340B revenue did it generate? How much was spent on direct patient assistance? How many patients received help with rent, utilities, transportation, food, insurance premiums, or emergency needs? How many people living with HIV serve on its board? How many people living with HIV hold paid leadership positions? How many complaints were filed by patients, applicants, employees, or community members? And how many of those complaints were independently investigated?

These questions are not attacks. They are the bare minimum.

The 340B Program's future cannot be decided only by hospitals, pharmaceutical companies, lobbyists,  providers, and trade associations. People living with HIV must be at the center of the conversation. Not as testimonials. Not as photos in annual reports. Not as an advisory board decoration. As decision-makers.  

Because we know what happens when accountability is optional.

We know what it feels like to be reduced to a funding category. We know what it feels like to see organizations praised publicly while patients go without help privately. We know what it feels like to be told that a program exists for us, only to be treated as a problem when we demand access, equity, and dignity.

The phrase “too big to fail” entered the public consciousness after the 2008 financial crisis, describing institutions so deeply embedded in the economy that their collapse could threaten the entire system. Julie Young’s definition of "too big to fail” is useful here because the 340B Program has become embedded in the healthcare financing system in much the same way: too large to ignore, too important to casually dismantle, and too dangerous to leave without accountability.

But Duncan Watts pushed the idea even further in the Harvard Business Review, asking whether some systems are not just “too big to fail” but “too big to exist” in their current form.  That is the question 340B now forces us to ask. Not whether the program should disappear, but whether a program this large should continue operating with so little transparency about where the savings actually go.

Photo Source: Third Way

Recent policy analysis from Third Way has also warned that hospitals can use 340B pricing advantages to increase revenue without ensuring patients receive the benefit.  That is exactly why patients should not be asked to accept vague promises. If providers are generating savings in the name of low-income, uninsured, underinsured, and chronically ill patients, then those patients deserve proof that the money is reaching them.

If the 340B Program is truly a safety-net program, then patients should be able to see the net. We should be able to touch it. We should know it will hold us when we fall.

Anything less is not safe. 

It is extraction dressed up as care.

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] Health Resources and Services Administration. (n.d.). 340B Drug Pricing Program. U.S. Department of Health & Human Services. Retrieved online at https://www.hrsa.gov/opa

[2] Health Resources and Services Administration. (2025, December 10). 2024 340B Covered Entity  Purchases. U.S. Department of Health & Human Services. Retrieved online at https://www.hrsa.gov/opa/updates/2024-340b coveredentity-purchases 

[3] Macsata, B.M., Anthony, G., & Hopkins, M.J. (2025, February). Is the 340B Drug  Pricing Program the Next “Too Big to Fail”? Washington, DC: ADAP Advocacy.  https://www.adapadvocacy.org/s/2025_ADAP_Project_RW_340B_Asset_16_Too_Big_To_Fail  _03-07-25.pdf 

[4] Martin, R., Karne, H., and Zeng, S. (2026, June 4). The Size and Growth of the 340B Program in 2025. IQVIA. Retrieved online at https://www.iqvia.com/-/media/iqvia/pdfs/us/white-paper/2026/iqvia-size--growth-of-340b-in-2025-white-paper-2026.pdf

[5] NASTAD. (2026). 2026 National Ryan White HIV/AIDS Program Part B ADAP Monitoring  Project Annual Report. Retrieved online at https://nastad.org/2026-rwhap-part-b adapmonitoring-report 

[6] Thune, J. (2024). SUSTAIN 340B Act Discussion Draft Explanatory Statement and Supplemental Request for Information. Bipartisan 340B Senate Working Group. Retrieved online at  https://www.thune.senate.gov/wp-content/uploads/media/doc/340B%20Discussion%20Draft%20Explanatory%20Document%20and%20Subsequent%20RFI.pdf 

[7] Rowell-Cunsolo TL, Liu J, Shen Y, Britton A, Larson E. The impact of HIV diagnosis on length of hospital stay in New York City, NY, USA. AIDS Care. 2018 May;30(5):591-595. doi: 10.1080/09540121.2018.1425362. Epub 2018 Jan 17. PMID: 29338331; PMCID: PMC5860957.

[8] Watts, D. (2009, June). Crisis Management – Too Big to Fail? How About Too Big to  Exist? Harvard Business Review. Retrieved online at https://hbr.org/2009/06/too-big-to-failhow about-too-big-to-exist 

[9] Wofford, David. (2025, February 12). How Hospitals are Raising Drug Prices. Third Way: Report. Retrieved online at https://www.thirdway.org/report/how-hospitals-are-raising-drug-prices 

[10] Young, Julie. (2023, November 13). Too Big to Fail: Definition, History, and Reforms. Investopedia: Terms. Retrieved online at https://www.investopedia.com/terms/t/too-big-tofail.asp

National Oncology Group Realigns 340B Priorities Away from Patient-First

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

The American Society of Clinical Oncology (ASCO) released its latest policy position statement on the 340B Drug Pricing Program on May 5th, 2026 (ASCO, 2026). ASCO President, Eric J. Small, MD, FASCO, states, “…reforms focused on eligibility, transparency, and accountability are needed to reflect modern healthcare delivery and to ensure the program continues to benefit the vulnerable people it was designed to help.” But why?

Despite this statement, some of their new positions have raised eyebrows among 340B reform advocates, staking out positions that seem less designed to deliver on transparency and accountability, and more aligned with profitability. Ted Okon, who serves as the executive director of the Community Oncology Alliance, and Dr. Lucio Gordan, a medical oncologist and hematologist with Florida Cancer Specialists & Research Institute, expressed their disagreement in a strongly worded op-ed published in The Wall Street Journal only days after ASCO’s announcement, which reads, in part:

“Expanding participation in a flawed program isn’t reform. It simply broadens access to the same distorted financial incentives that have fueled consolidation, higher costs and migration of cancer care into more expensive hospital settings.”

Photo Source: The Wall Street Journal

One ASCO’s “new” positions involve the proliferation of child sites—standalone locations affiliated with a larger healthcare provider but not on its main campus.

In its statement, ASCO asserts that, “Independent oncology practices with multiple locations should be able to register a child site for the 340B program if they bill under the same Tax ID number as the eligible parent practice.”

The problem with this is that child sites are not always located in areas that serve the populations that 340B covered entities are obligated to serve: lower-income, uninsured, and underinsured patients.

For example, Bon Secours Mercy Health’s Richmond Community Hospital in Richmond, VA, closed its intensive care unit in 2017, yet it still managed to have the highest profit margins of any hospital in Virginia. While cutting services and supplies, former Bon Secours executives, doctors, and nurses accused the company of reaping the 340B revenue profits from communities like Richmond and reinvesting them in wealthier—and Whiter—communities (Thomas & Silver-Greenberg, 2022).

Photo Source: ADAP Advocacy

Proving this, however, is difficult when it comes to hospital systems, as there are zero public reporting requirements for 340B revenues for hospitals, and it becomes even more labyrinthine when 340B eligibility is extended across child sites.

ADAP Advocacy argues that each child site should be able to prove its eligibility on its own merits, without those revenues being redirected to a larger organization that can then redistribute those funds to areas outside the 340B remit.

Another area where ASCO runs its transparency argument afoul relates to its call to allow unlimited numbers of contract pharmacies:

“Covered entities should be able to contract with multiple pharmacies, with caps on administrative fees, to support rural and underserved areas and ensure savings are preserved for patient care.”

The recent explosion in the number of covered entities and contract pharmacies has exacerbated the issue of manufacturers encountering duplicate discounts. Duplicate discounts occur when drugs provided to Medicaid beneficiaries (i.e., patients) are subject to discounted prices under the 340B program and are also eligible for Medicaid rebates—when drug manufacturers pay rebates to states as a condition for the federal contribution to Medicaid spending for the manufacturers’ outpatient drugs (Nguyen & Suresh, 2024). This overlap means manufacturers risk providing duplicate discounts when they are legally required to provide either a 340B program drug price or a rebate to state Medicaid programs (Health Resources & Services Administration, 2020).

Photo Source: HRSA | Paul Shank

To combat this risk, the U.S. Department of Health and Human Services (HHS) and CMS created the Medicaid Exclusion File (MEF)—a list of covered entities that use 340B drugs for Medicaid beneficiaries under the Fee-For-Service (FFS) model. Once registered on the MEF, covered entities must notify the agency if they intend to use 340B drugs for Medicaid beneficiaries, and states then exclude claims from those registered providers from their rebate invoices to manufacturers.

The problem, however, is that the MEF applies only to FFS Medicaid models, and not to Medicaid MCOs. Unlike FFS models, which are based on reimbursement for individual services, MCOs are generally paid under a capitated model that pays each plan a set amount per beneficiary each month. As states increasingly contract with MCOs to manage their state Medicaid benefits, the expansion of drug dispensing by contracted pharmacies under the MCO model makes it more difficult for states to identify patients covered by MCOs and to track whether a 340B-discounted drug was dispensed to those patients (Nguyen & Suresh, 2024).

In addition to these changes, ASCO also proposes a new eligibility formula, called the Indigent Care Ratio (ICR). This ratio, they argue, would allow 340B eligibility to be extended to community-based, non-hospital-affiliated providers, such as independent oncology practices:

More than half of Americans receive cancer care in community-based oncology practices,” said Dr. Small. “These practices form the backbone of cancer care delivery in many rural and underserved areas, where they are often patients’ only access to such care (ASCO, 2026).

Using an ICR, ASCO argues, would allow practices to meet a specific threshold for providing care to Medicaid, uninsured, and dual-eligible patients. While the ICR makes sense in theory, its impacts definitely need further study before any implementation. ADAP Advocacy is concerned that this proposed formula, like most other formulas designed to expand access under the 340B Program, will run amok by entities trying to scheme profitability. It could further compound an existing problem by driving up the cost of cancer care, as “the current financial incentives within the 340B program may be driving higher utilization of specific outpatient medications” (Access Forum, 2026).

Photo Source: American Journal of Managed Care

There is significant overlap in advocacy values and policy priorities between the HIV and oncology patient communities, fostering greater collaboration. It has led to greater alignment on key issues, such as protecting Medicare’s six protected classes, outlining concerns about the adverse impact of Medicare’s Drug Pricing Negotiation Program on patient access, and reforming the 340B Program. In each case, that alignment has maintained one paramount priority: patients. Sadly, ASCO’s revised 340B priorities fall outside of that patient-first priority.

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] Access Forum. (2026, February 15). The Hidden Cost of 340B: How Drug Pricing Programs Impact Cancer Care. https://theaccessforum.org/learning-hub/the-hidden-cost-of-340b-how-drug-pricing-programs-impact-cancer-care/ 

[2] American Society of Clinical Oncology. (2026, May 05). ASCO Updates Policy Statement on 340B Drug Pricing Program. Alexandria, VA: American Society of Clinical Oncology: News & Initiatives: Policy New Analysis. https://www.asco.org/news-initiatives/policy-news-analysis/asco-updates-policy-statement-340B-drug-pricing-program

[3] Health Resources and Services Administration. (2020, July). Duplicate Discount Prohibition. Washington, DC: United States Department of Health and Human Services: Health Resources Services Administration: 340B Drug Pricing Program: Program Requirements: Duplicate Discount Prohibition. https://www.hrsa.gov/opa/program-requirements/medicaid-exclusion

[4] Nguyen, T. & Suresh, R. (2024, March 04). What You Need to Know About 340B Duplicate Discounts. Washington, DC: Edgeworth Economics: The Antitrust Prescription. https://www.edgewortheconomics.com/antitrustprescription-340B-duplicate-discounts

[5] Okon, T. & Gordan, L. (2026, May 15). Expanding 340B Won’t Fix a Broken System. The Wall Street Journal. https://www.wsj.com/opinion/expanding-340b-wont-fix-a-broken-system-8c621229?st=BPngEs&reflink=desktopwebshare_permalink 

[6] Thomas, K. & Silver-Greenberg, J. (2022, September 24). How a Hospital Chain Used a Poor Neighborhood to Turn Huge Profits. New York, NY: The New York Times: Health. https://www.nytimes.com/2022/09/24/health/bon-secours-mercy-health-profit-poor-neighborhood.html

When Will 'Big' Enough Be Enough for Big Hospital Systems?

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

Just four hospital systems control over 600 (~10%) of the 6,100 hospitals in the United States (Dyrda, 2026; American Hospital Association, 2026), and each of those four companies owns over 100 hospitals. There are 34 more private companies that own a combined 1,461+ additional hospitals, many if not most of which are regional systems.

Another report issued by Yale University in 2026 found that in 32 states, 50% or more of the hospitals are either highly concentrated in single areas or exist in a monopoly where one system is the only hospital provider available in a given state, including 19 states where two-thirds or more of the hospitals meet those criteria (Figure 1, Cooper et al., 2026).

Figure 1 - Share of hospitals that are in a highly concentrated market or are part of a monopoly, 2025

Photo Source: Owens, 2026

While hospital mergers can have positive outcomes, including financial and operational stability for the hospitals and the addition of new services at hospitals offered to patients after mergers, repeated evidence has demonstrated that hospital consolidation—the practice of hospital or healthcare systems purchasing existing hospitals and/or medical practices—creates more barriers to accessing healthcare services by:

• Reducing or eliminating competition, which strengthens the ability of large hospital systems to demand higher reimbursement rates, thereby increasing prices and introducing cost barriers
• Limiting the ability of patients to access healthcare services outside of those systems by locking them into provider networks through their public or commercial insurance providers (e.g., Medicaid, private, or employer-sponsored health insurance programs)
• Shuttering hospitals, clinics, and other providers that do not generate sufficient revenues for the hospital system to keep them in operation, thereby introducing distance, transportation, and cost barriers (Phillips, 2023).

In some cases, hospital systems, such as Bon Secours, will rake in 340B Drug Pricing Program rebate revenues from hospitals and practices serving lower-income neighborhoods, but choose to reinvest those dollars in more affluent communities where reimbursement rates are likely to be higher.

What Can Be Done?

Hospital consolidations, along with other types of business acquisitions, should fall under scrutiny by federal agencies whose remits include investigating, prosecuting, and breaking up sector monopolies. However, an analysis published in American Economic Review: Insights found that the Federal Trade Commission (FTC) took enforcement actions against just 13 of the 1,164 hospital mergers that occurred between 2002 and 2020, despite 238 of those transactions (20.4%) could have been flagged by the FTC using standard merger screening tools as being likely to increase prices by decreasing competition. Further examination of mergers that occurred between 2010 and 2015 found that 97 could have been flagged by the FTC as likely to increase prices by reducing competition. The FTC intervened in just 8 of these cases (Brot-Goldberg et al., 2024).

Photo Source: NPR | KUNR

It has long been speculated that both the FTC and the U.S. Department of Justice (DOJ) are not only susceptible to political interference in their activities by bad actors, but easily fall prey to those manipulations through the appointments of officials who lack qualifications, serve the whims of the sitting President, or fail to ensure that the agencies they lead remain independent of administration officials and/or corporate interests/lobbying.

This essentially leaves individual states to pursue antitrust charges against these mergers. Again, these state entities are as susceptible to administrative and business-interest interventions aimed at preventing enforcement. The sad reality is these Big Hospital Systems will continue to expand, and patient access and choice will continue to deteriorate.

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] American Hospital Association. (2026). Fast Facts on U.S. Hospitals, 2026. Chicago, IL: American Hospital Association: Statistics. https://www.aha.org/statistics/fast-facts-us-hospitals

[2] Brot-Goldberg, Z., Cooper, Z., Craig, S., & Klarnet, L. (2024, December). Is There Too Little Antitrust Enforcement in the US Hospital Sector? American Economic Review: Insights, 6(4), 526-542. https://tobin.yale.edu/sites/default/files/2024-02/Hospital_Merger_Heterogeneity_manuscript.pdf

[3] Cooper, Z., Harris, A., & Hill, M. (2026, March 09). A Ranking of All 50 States by Hospital Consolidation. New Haven, CT: Yale University: Health Care Affordability Lab: Commentary. https://www.healthcareaffordabilitylab.org/commentary-press-release-posts/a-ranking-of-all-50-states-by-hospital-consolidation

[4] Dyrda, L. (2026, February 25). 100 of the largest hospitals and health systems in the US: 2026. Chicago, IL: Becker’s Hospital Review: Rankings and Rating. https://www.beckershospitalreview.com/rankings-and-ratings/100-of-the-largest-hospitals-and-health-systems-in-the-us-2026/

[5] Owens, C. (2026, March 09). The states where hospitals are most concentrated. Arlington, VA: Axios: Health. https://www.axios.com/2026/03/09/hospital-concentration-states-health-costs

[6] Phillips, A. (2023, November 15). The consequences of U.S. hospital consolidation on local economies, healthcare providers, and patients. Washington, DC: Competition. Washington Center for Equitable Growth. https://equitablegrowth.org/research-paper/the-consequences-of-u-s-hospital-consolidation-on-local-economies-healthcare-providers-and-patients/

Ryan White Programmatic Funding Balances on a Precarious Precipice

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

When then becomes now. In 2013, a large group of HIV advocates, activists, care providers, community organizations, pharmaceutical companies, and patients living with HIV/AIDS (PLWHA) gathered in Washington, DC, to address what they saw as a crisis: that the Ryan White Cares Act would be reopened and gutted by the then-Republican-majority.

Photo Source: ADAP Advocacy

Those fears never came to pass, in no small part because of a mutual agreement to simply not mention that the act needed to be reauthorized because there was no sunset provision—a provision that automatically repeals or terminates a law—and just pray that it would be forgotten. Disagreements aside, stakeholders agreed that with no clear path ahead, the best strategy was “keeping our heads down and pray no one notices us,” as the late Bill Arnold summarized.

It’s now 2026, and once again, the specter of a collapse is once again upon us. This time, political inaction, combined with accusations of purported malfeasance, appears to be the culprit. What previously worked is no longer a viable option, since HIV-related services have been in the crosshairs since Elon Musk started gutting much of the safety-net under the guise of government “efficiency,” regardless of the harm being caused to patients, families, neighborhoods, and communities.

State AIDS Drug Assistance Programs (ADAPs) across the U.S. are facing unprecedented budgetary shortfalls, with multiple states opting to implement “cost containment” measures, including (but not limited to) cutting income eligibility levels, requiring in-person recertification, cutting formulary coverage, and introducing per-patient expenditure caps, in an effort to keep their programs open for as many people as possible (Hopkins, 2026). The HIV community has been in similar predicaments, such as the “ADAP Crisis” that impacted over 10,000 patients between 2010-2012, but something about this crisis just feels different.

Why?

Because the number of PLWHA continues to increase, while federal funding remains flat and state-level funding decreases. And they’re living longer

According to the most recent report from the National Alliance for State and Territorial AIDS Directors, an average of 52% of all state ADAP budgets is derived from pharmaceutical and manufacturer rebates (NASTAD, 2026). This is a significant change from 2008, when federal funding accounted for 51%, state funding for 21%, and rebates for 21% (Figure 1).

Figure 1 - Total ADAP Budget, By Source, FY1996–FY2024

Photo Source: NASTAD, 2026

Meanwhile, state funding has decreased to just 4% across the country, while the federal funding has remained relatively flat for a decade. For many programs, this has the potential to spell doom, as baseline budgets make using a rebate model—where programs pay the list price of medications upfront and are reimbursed the difference between the list price and the 340B Drug Pricing Program purchase price—a precarious endeavor. If the funds aren’t available to front-load those purchases, how will the programs do so and continue to provide services?

The answer is increasingly looking to be, “They can’t.”

In addition to being hit hard by funding shortages, ADAP programs, which have been authorized to pay for enrollees’ commercial insurance premiums, deductibles, and co-pays rather than using a full-pay medication model, have been struggling to keep up with the exponential annual increases in insurance costs foisted upon patients as yet another result of political inaction and malfeasance.

Since 2014, the average premium for an Affordable Care Act (ACA) Marketplace benchmark plan has risen from $273/month to $625/month in 2026 (Figure 2).

Figure 2 - Marketplace Average Monthly Benchmark Premiums, 2014-2026

Photo Source: KFF, 2026

These marketplace benchmark trends coincide with the aforementioned flat federal funding, decreasing state funding, and increased ADAP enrollment following the winddown of the expanded Medicaid access allowed during the COVID-19 pandemic, which led to a roughly 30% increase in enrollment from Calendar Year 2022 (CY2022) to CY2024 (NASTAD, 2026).

Essentially, as premiums become increasingly unaffordable, enrollees who had previously relied on Ryan White and ADAP for co-pay assistance while paying their own premiums have, due to rising costs, been forced to turn to ADAP for assistance with premiums, deductibles, and co-pays.

What Does This Portend?

None of these circumstances on their own would be ideal, but in combination, ADAPs are, for the first time in over 12 years, considering implementing waitlists for services.

For those who don’t remember, ADAPs once resorted to leaving patients in need of treatment on state waitlists to gain access to funding. Essentially, the only way to get access was for someone to become ineligible or die. Over 10,000 PLWHA languished on waiting lists in 13 states, and several of them died; the community pleaded for help.

The threat of these once again becoming a reality has prompted concerns about the collapse of the program altogether, with a recently released analysis projecting over 117,000 new HIV diagnoses over 5 years if the program ends, and an additional 68,000+ diagnoses if the program is interrupted for 2.5 years (Haelle, 2026). No clearer example exists than what is happening in Florida.

A recent analysis present at the Conference on Retroviruses and Opportunistic Infections (CROI) found that, should the Ryan White HIV/AIDS Program collapse, the projected number of new HIV diagnoses is likely to increased by 73% in 30 states, with the hardest hit states being Colorado, South Carolina, Missouri, Tennessee, Kentucky, Alabama, Illinois, and Wisconsin (Schnure et al., 2026).

What Can Be Done?

At this point, most state legislative sessions have ended or are winding down, essentially making the prospect of securing state-level funding an unlikely avenue. Additionally, given the Trump Administration and the current composition of Congress, there is little evidence that positive momentum can be built to secure additional federal funding.

NASTAD is pushing for a $175 million increase in the federal appropriation to address the shortfalls. NASTAD's recent policy brief reads: "Of the $175 million increase, $75 million should be allocated through the ADAP base funding awards, and $100 million should be added to the ADAP Emergency Relief Funding, bringing those awards to a total of $175 million."

In the meantime, policy experts, advocates, and activists are working behind the scenes to mitigate the current and impending funding disasters. ADAP Advocacy will continue to monitor and report on circumstances as they develop.

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] Dawson, L. & Kates, J. (2026, March 02). Constrained Budgets Lead States to Restrict HIV Drug Access Through Ryan White. Washington, DC: KFF: HIV/AIDS. https://www.kff.org/hiv-aids/constrained-budgets-lead-states-to-restrict-hiv-drug-access-through-ryan-white/

[2] Haelle, T. (2026, February 27). Study Warns of Large Increase in New HIV Cases in U.S. if Ryan White Program Ends: Colorado and several Southern and Midwest states would see the biggest increases in incidence. New York, NY: MedPage Today: Meeting Coverage: CROI. https://www.medpagetoday.com/meetingcoverage/croi/120084

[3] Hopkins, M. J. (2026, March 12). NASTAD Releases 2026 ADAP Monitoring Report: Warning Signs Ahead. Nags Head, NC: ADAP Advocacy: Blog. https://adapadvocacyassociation.blogspot.com/2026/03/nastad-releases-2026-adap-monitoring.html

[4] KFF. (2026). Marketplace Average Monthly Benchmark Premiums. Washington, DC: KFF: State Health Facts: Affordable Care Act: Health Insurance Marketplaces. https://www.kff.org/affordable-care-act/state-indicator/marketplace-average-benchmark-premiums/?activeTab=graph&currentTimeframe=0&startTimeframe=12&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

[5] National Alliance of State and Territorial AIDS Directors. (2026a). 2026 National Ryan White HIV/AIDS Program Part B ADAP Monitoring Project Annual Report: Stabilizing the Safety Net: Stewardship and Outcomes in a Volatile Landscape. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/2026-rwhap-part-b-adap-monitoring-report

[6] National Alliance of State and Territorial AIDS Directors. (2026, February 27). ADAP Fiscal Year 2027 Funding Request. Washington, DC: National Alliance of State and Territorial AIDS Directors. https://nastad.org/resources/adap-fiscal-year-2027-funding-request

[7] Schnure, M., Forster, R., Jones, J. L., Lesko, C. R., Batey, D. S., Butler, I., Ward, D., Musgrove, K., Althoff, K. N., Jain, M. K., Gebo, K. A., Dowdy, D. W., Shah, M., Kasaie, P., & Fojo, A. T. (2026). HIV Incidence Could Rise by 73% in 30 States if Ryan White Ends: A Simulation Study, Abstract [Conference abstract]. 2026 Conference on Retroviruses and Opportunistic Infections, Denver, Colorado, United States. https://www.natap.org/2026/CROI/croi_100.htm