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

New House Bill Would Require Insurers to Count Direct-to-Consumer Drug Purchases

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

A bill introduced by Representative Greg Murphy, M.D. (R-NC-03), would require insurers to count the cost of prescription medications purchased through direct-to-consumer platforms, such as the TrumpRX website (Hopkins, 2026), toward both deductibles and out-of-pocket maximums (Minemeyer, 2026).

Photo Source: Rep. Greg Murphy

The "Every Dollar Counts Act" (H.R. 8270), introduced in April 2026, would amend title XXVII of the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Service Code of 1986 to require out-of-pocket expenditures for drugs to count towards an individual’s deductible and out-of-pocket maximums. It does come with some caveats:

To count, the medication must be on the individual’s health plan’s formulary, meaning it would otherwise be covered by the insurance plan with a co-pay (Goldman, 2026).

"Direct-to-patient platforms have the potential to radically transform the drug marketplace, applying much-needed downward pressure on the extraordinary cost of lifesaving medicines. However, patients who are set to benefit most cannot apply their expenditures on drugs purchased through these platforms to their health insurance out-of-pocket contribution requirements. By making this possible, we are putting patients first and promoting competition to drive down costs further" (Murphy, 2026).

Photo Source: Congress.gov

Direct-to-consumer/patient platforms are becoming increasingly common since 2024, with numerous pharmaceutical companies and organizations, including Amgen (maker of Repatha), Eli Lilly (Zepbound), Novo Nordisk (Wegovy), Pfizer (Eliquis), AstraZeneca (Farxiga), Novartis (Cosentyx), Bristol Myers Squibb (Sotyktu), and PhRMA, the U.S. pharmaceutical lobbying group based in Washington, DC, going live with websites offering medications directly to patients, often at lower prices than what they would pay when using their commercial insurance (Constantino & Coombs, 2025).

The concept of direct-to-consumer sales isn’t new; but in an age when almost every medication purchase (in the United States) goes through complex chains of manufacturers, wholesalers, pharmacy benefits managers (PBMs), and pharmacies that then get filtered through another round of payors (e.g., commercial and public health insurers), consumers often have little idea of the true cost of their medications. More to the point, tiered prescription co-pays and the availability of manufacturer and commercial drug coupons, such as manufacturer patient assistance programs (PAPs) and GoodRx, make it difficult for patients to make informed decisions about the most affordable way to obtain their medications.

Patients have been sharing their stories on social media and in the press with their anecdotal encounters where they face a high-dollar sticker shock at the pharmacy register, only for their pharmacist to scan a different barcode behind the counter and come back with a significantly lower dollar amount (Fottrell, 2026).

Photo Source: Elements Magazine

GoodRx, founded in 2011, provides patients with a relatively easy-to-use website and smart phone app that allows patients to explore drug prices at various local pharmacies based on zip code. They also offer a subscription service, GoodRx Companion, that offers low-cost medications and savings on various medical services (GoodRx, 2026).

For consumers, this may seem like insurance, but GoodRx is quick to remind patients at every step that it is not health insurance; it is a collection of co-pay assistance coupons.

And this is the rub for many consumers: if they can get their prescription drugs this cheaply by scanning a QR Code, why should they ever have to pay a higher price?

This is an excellent question.

Why should American consumers be required to pay higher prices than any other nation for medications (Editor’s Note: Asking this question is not an endorsement of the deeply flawed Most Favored Nations proposed policy change)? Why should American consumers have copay accumulator programs that prohibit patient assistance program assistance from counting toward their deductibles? Why should American consumers be held captive in an endless labyrinth of ever-changing co-pays, surprise bills, and coverage denials for medications listed as being “covered”?

The answer is simple: because the “system” allows it.

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] Constantino, A. K. & Coombs, B. (2025, October 07). Healthy Returns: Amgen joins a growing list of drugmakers selling directly to consumers. Englewood Cliffs, NJ: CNBC: Health Returns. https://www.cnbc.com/2025/10/07/healthy-returns-amgen-other-drugmakers-launch-dtc-programs.html

[2] Every Dollar Counts Act, The, H.R. 8270, 119th Cong. (2026). https://www.congress.gov/bill/119th-congress/house-bill/8270

[3] Fottrell, Q. (2026, June 23). ‘It feels like a medical miracle’: How did a single QR code coupon cut my $618 Walgreens prescription to $15? New York, NY: MarketWatch: Personal Finance: The Moneyfist. https://www.marketwatch.com/story/it-feels-like-a-medical-miracle-how-did-a-single-qr-code-coupon-cut-my-618-walgreens-prescription-to-15-524a1151

[4] Goldman, M. (2026, April 14). Exclusive: GOP pushes sweetener for cash-pay drugs. Arlington, VA: Axios: Health. https://www.axios.com/2026/04/14/gop-cash-pay-drug-deductible

[5] GoodRx. (2026). GoodRx Companion. Santa Monica, CA: GoodRx: Companion. https://www.goodrx.com/companion

[6] Hopkins, M. J. (2026, January 22). Trump Administration Applauds Itself for Rx Access Agreements, But Will They Help Patients? Nags Head, NC: ADAP Advocacy: ADAP Blog. https://adapadvocacyassociation.blogspot.com/2026/01/trump-administration-applauds-itself.html

[7] Minemeyer, P. (2026, April 14). Bill would force payers to apply DTC drug purchases to patient deductibles. New York NY: Fierce Healthcare: Regulatory. https://www.fiercehealthcare.com/regulatory/bill-seeks-force-payers-apply-dtc-drug-purchases-patient-deductibles

[8] Murphy, G. F. (2026, April 14). Murphy Introduces Legislation to Lower Out-of-Pocket Costs for Drugs. Mantea, NC: U.S. Congressman Gregory F. Murphy, M.D.: Media: Press Releases. https://murphy.house.gov/media/press-releases/murphy-introduces-legislation-lower-out-pocket-costs-drugs

The Growing Access Barrier Facing Patients: Private Equity

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

The acquisition of hospitals and healthcare practices by private equity (PE) firms has increased dramatically over the past two decades, with PE deals involving healthcare businesses tripling from 2009 to 2016, and acquisitions of healthcare-related operations reaching a staggering $79 billion in 2019 (Halabi et al., 2025). This explosive growth in acquisitions has resulted in astonishing profits for PE firms, slashed salaries for PE-owned employees, and worse outcomes for patients.

Photo Source: Purchaser Business Group on Health

According to the Private Equity Stakeholder Project (PESP), approximately 488 hospitals in the U.S. are owned by PE firms, including 8.5% of all private hospitals and 22.6% of all proprietary for-profit hospitals. At least 27.7% of PE-owned hospitals serve primarily rural patients, and nearly a quarter (22.6%) of PE-owned facilities are psychiatric hospitals (PESP, 2025b).

The healthcare sector is particularly attractive to PE firms as healthcare spending accounts for nearly one-sixth (18%) of the U.S. gross domestic product (GDP), growing 7.2% in 2024, and reaching $5.3 trillion or $15,474 per person (CMS, 2026). With spending at those levels, PE firms can very easily increase profitability, which they largely achieve by decreasing expenditures, particularly those related to salaries, and increasing the number of services provided and billed.

Research published in the Annals of Internal Medicine found that emergency department salaries were cut by 18.2% compared with control hospitals, by 15.9% in intensive care units (ICUs), and by 16.6% hospital-wide, reducing the number of full-time hospital employees by 11.6% (Kannan et al., 2025).

These cuts in staffing come with a cost. Using Medicare Part A and B claims and Cost Report data from 2009-2019, Kannan et al. found that, while there was no observable increase in ICU mortality rates, deaths in PE-owned emergency departments increased by 13.4%. In addition, patient transfers to other acute care hospitals from emergency departments increased by 4.2% and from ICUs by 10.6% (Kannan et al., 2025).

Photo Source: PESP Private Equity Hospital Tracker

A study published in Health Affairs found that claims billed by PE-owned hospitals to Medicare increased by 30.5% after acquisition, resulting in a 14.9% increase in Medicare spending per physician over five quarters. Similarly, patients at PE-acquired primary care practices saw a 12.9% increase in the number of services received, including an 11.1% increase in laboratory tests and an 11.3% increase in preventive and screening services (Singh et al., 2026).

These increases in services, when combined with significant decreases in salaries and staffing, result in huge profits for PE firms just from Medicare payments alone. It is harder, however, to quantify any increases in revenues related to the 340B drug pricing program at these practices or hospitals for a few of reasons:

• According to the Private Equity Stakeholder Project (PESP), some hospitals are operated by PE firms through complex ownership structures, often masking who owns, operates, or oversees them (PESP, 2025b).
• Some non-profit hospitals, while not directly owned by PE firms, are managed by companies that are owned by PE firms. Many of these arrangements are not publicly disclosed (PESP, 2025b);
• Providers are not currently required by either the Health Resources & Services Administration (HRSA), the Center for Medicare & Medicaid Services (CMS), or the Internal Revenue Service (IRS) to report annual 340B revenues to the public or on any tax documents.

That does not, however, mean that PE firms don’t have 340B in their sights. In May 2026, Quorum Health, based in Brentwood, TN, announced that they would be abandoning their for-profit business model and switching to a non-profit model under the pretense of ‘…deliver[ing] quality care in rural and mid-sized communities.” Quorum admits that doing so will result in $13 million in annual savings from tax exemptions alone, and that the expected acquisition of eligibility for the 340B Program will result in $11 million in additional revenues. While this shift must be approved by regulators, it’s expected to be approved by Fall 2026 (Van Alstin, 2026).

These negative consequences have not gone unnoticed. The Private Equity Stakeholder Project—a Chicago-based non-profit watchdog organization founded in 2017 to monitor and address the growing impact of private equity and private fund managers in the climate & energy, workers & jobs, housing, healthcare, and detention & surveillance industries (PESP, n.d.)—began tracking hospitals owned by PE firms, creating an easily searchable list for public examination (PESP, 2025a) and an interactive map (PESP, 2025b).

Photo Source: Quartz

While nonprofit organizations and researchers are closely monitoring the impacts of PE firm ownership in the healthcare industry, state and federal legislators and regulators have struggled to keep pace with the pace of PE acquisitions. A recent article published in The American Journal of Managed Care has called on policymakers to “…pursue innovative regulatory solutions, including health care–specific PE law, alignment of state and federal oversight, adoption of alternative payment models, and strengthened patient protections against PE-associated clinical and nonclinical risks (Berman et al., 2026).

ADAP Advocacy echoes this call. Aside from the risks to patients, PE firms represent real and present dangers to the communities being served by the providers and hospitals they own and loot. They raid safety-net hospitals (O’Grady, 2022), bankrupt hospitals and sell off their property (DePillis, 2019), roll back or eliminate essential but less profitable services (Spegele, 2021), and leave communities with few, if any, options for accessing healthcare services. Those PE firms that have managed to worm their way into the non-profit provider sectors are also very likely reaping 340B revenues while patients suffer.

It’s time to curtail PE ownership in the healthcare sector, regardless of how much money it makes for owners and investors.

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] Berman, M. E., Tamirisa, K., Rahim, F. O., Khachadoorian-Elia, H., & Witkowski, M. L. (2026, May 11). Regulating Private Equity in Health Care: A Strategic Policy Agenda. American Journal of Managed Care, 32(5), e138-e140. https://doi.org/10.37765/ajmc.2026.89938

[2] Centers for Medicare and Medicaid Services. (2026, January 14). National health expenditure data: Historical. Washington, DC: United State Department of Health and Human Services: Centers for Medicare and Medicaid Services: Data and Research: Statistics, Trends, and Reports: National Health Expenditure Data. https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/historical

[3] DePillis, L. (2019, July 29). Rich investors may have let a hospital go bankrupt. Now, they could profit from the land. Atlanta, GA: CNN: CNN Business: Economy. https://www.cnn.com/2019/07/29/economy/hahnemann-hospital-closing-philadelphia/index.html

[4] Halabi, S., Belani, S., & O’Hara, G. (2025). Private Equity and Non-Profit Status in the US Healthcare System. Akron Law Review, 58(4), 687-715. https://ideaexchange.uakron.edu/akronlawreview/vol58/iss4/4?utm_source=ideaexchange.uakron.edu%2Fakronlawreview%2Fvol58%2Fiss4%2F4&utm_medium=PDF&utm_campaign=PDFCoverPages

[5] Kannan, S., Bruch, J. D., Zubizarreta, J. R., Stevens, J., & Song, Z. (2025, September 23). Hospital Staffing and Patient Outcomes After Private Equity Acquisition. Annals of Internal Medicine, 178(11), 1,528-1,538. https://doi.org/10.7326/ANNALS-24-03471

[6] O’Grady, S. (2022, November). How Private Equity Raided Safety Net Hospitals and Left Communities Holding the Bag: A Case Study on Leonard Green & Partners’ Ownership of Prospect Medical Holdings. Chicago, IL: Private Equity Stakeholder Project: PESP Private Equity Hospital Tracker. https://pestakeholder.org/wp-content/uploads/2022/11/Prospect_Primer_Nov-2022.pdf

[7] Private Equity Stakeholder Project. (2025a, April). PE hospital tracker. Chicago, IL: Private Equity Stakeholder Project: PE Hospital Tracker. https://airtable.com/appZYwbt3vioNrb95/shricxhAQSjpv5ec8/tbl058jjL6qNMqzkM

[8] Private Equity Stakeholder Project. (2025b, April). PESP Private Equity Hospital Tracker. Chicago, IL: Private Equity Stakeholder Project. https://pestakeholder.org/pesp-private-equity-hospital-tracker/

[9] Private Equity Stakeholder Project. (n.d.). About us. Chicago, IL: Private Equity Stakeholder Project: About Us. https://pestakeholder.org/about-us/

[10] Singh, Y., Dixit, M. N., & Whaley, C. M. (2026, May 20). Private Equity Acquisitions In Primary Care: Changes In Utilization, Spending, And Workforce. Health Affairs, 45(6), 629-636. https://doi.org/10.1377/hlthaff.2025.01703

[11] Spegele, B. (2021, April 11). A City’s Only Hospital Cut Services. How Locals Fought Back. New York, NY: The Wall Street Journal: Health: Healthcare. https://www.wsj.com/health/healthcare/a-citys-only-hospital-cut-services-how-locals-fought-back-11618133400

[12] Van Alstin, C. (2026, May 24). Nationwide private-equity backed hospital chain announces shift to nonprofit business model. Providence, RI: Innovate Healthcare: Health Exec: Business Intelligence. https://healthexec.com/topics/healthcare-management/business-intelligence/nationwide-private-equity-backed-hospital-chain-announces-shift-nonprofit-business-model

HIV Advocacy: Why Stories Change More Than Hearts

By: Michelle Anderson, MA, Grassroots Advocacy & Patient Storytelling Consultant, ADAP Advocacy

**First-Person Perspectives**

I have been in advocacy for more than 20 years, and for years, I have sat in rooms where decisions were being made for people like me without including people like me in the conversation. I have listened to presentations filled with statistics, charts, and research findings that spoke completely over my head. I have listened to reports that described the disparities affecting Black women living with HIV, but those reports were not always an accurate depiction because they did not provide a complete narrative of Black women's experiences when faced with the systemic pressures that create risk for HIV beyond behavior. Although the data is important and research matters, something is still missing.

Photo Source: Narrative Power Institute

I often say that stories are more than personal experiences. They are a form of knowledge that speaks beyond what data cannot convey. They help us understand how policies, systems, and institutions impact real lives. They reveal the human reality behind data and create opportunities for change that numbers alone often cannot achieve because they connect the numbers to human impact.

For instance, when a Black woman living with HIV shares her experiences, it brings context to the conversation. It helps people understand that HIV is not a single issue. It is often connected to issues like poverty, trauma, housing insecurity, gender-based violence, lack of healthcare access, and systemic racism. These are realities that cannot be fully captured in a report because statistics only tell the story of the disproportionate impact of HIV.

Storytelling makes systems visible. It helps us move away from stigmatizing rhetoric that blames individuals and toward examining the conditions that shape people's realities. Instead of asking why someone did not make a different choice, storytelling helps us understand why the decision was made, given the options available to them and the conditions that shaped those options.

I have seen firsthand how stories can change a room. I have watched policymakers lean in when they hear someone describe the choice between paying rent and paying for healthcare. I have seen healthcare providers reconsider their assumptions after listening to a patient who may have fallen out of care due to transportation barriers. I have watched community members connect with issues they previously viewed as distant or unrelated to their own lived experiences. Stories create understanding, empathy, accountability, and, most importantly, they create movement.

Photo Source: ADAP Advocacy

That same principle is at the heart of the work currently underway through the "ADAP Saves Lives: End the Wait" campaign, which was launched in response to the reemergence of ADAP waiting lists and restrictions in some parts of the country. For those of us who have been in this fight nearly 20 years ago, the thought of people once again waiting for access to life-saving HIV medication is deeply concerning. Storytelling is an essential advocacy tool because behind every policy decision is a person whose health may be affected. By elevating the voices of persons living with HIV, storytelling helps policymakers and communities understand what is truly at stake when access to care is threatened.

Meaningful Involvement of People Living with HIV/AIDS (MIPA) recognizes that people living with HIV should be involved, utilizing our lived expertise as leaders, decision makers, and partners in shaping the policies and programs that impact our lives. When people share their experiences in legislative hearings, advisory boards, advocacy campaigns, and community discussions, they provide evidence-informed solutions grounded in real-time experiences. This is when narrative begins to build power.

Narrative power is the ability to shape how people understand an issue. It is the ability to influence systems by challenging stigma, exposing data gaps, and moving conversations beyond awareness to impact. By shifting the narrative, our stories change perspectives, influence policy, and become the power that shapes how systems operate and whose voices are valued within them.

Photo Source: ADAP Advocacy

I believe that the people closest to the issues are often closest to the solutions. Lived experiences belong at decision-making tables because stories are more than personal testimonies. They are tools for leadership, advocacy, and systems change. Stories do change hearts, but they also change how people understand issues, how policies are shaped, and how systems respond to the communities they serve.

Stories do change hearts, but the power does not stop there. They help people understand, in real time, the realities behind data and the impact systems have on people’s lives. When we share our stories, we are challenging stigma, educating communities, informing policy, and creating opportunities for change. We move beyond awareness and into action. We transform our lived experiences into narrative power. This month marks the beginning of ADAP Advocacy’s narrative power to combat the resurgence of those dreading AIDS Drug Assistance Program waiting lists. Patient’s lives depend on it!

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.

Lies, Damned Lies, and 340B Matters Lies

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

The 340B reform denialists, in chorus, obfuscate the truth: namely, that the 340B Drug Pricing Program is doing "just fine" and needs no changes, no matter how big or small. In a recent social media post, an organization that professes to care about patients, “340B Matters”, posted the following on X:

Welcome to Friday Pharma Lies, a series debunking the drug industry’s falsehoods about the 340B Program.

Lie: 340B discounts are supposed to be passed along to patients.

Truth: Congress created 340B “to stretch scarce federal resources as far as possible, reaching more eligible patients and providing more comprehensive services.” Accordingly, covered entities use 340B to fund safety net healthcare services they otherwise could not afford to offer. Many covered entities use 340B discounts to connect patients with discounted drugs, but there is no requirement for them to do so (Figure 1; 340B Matters, 2026).

Figure 1 – 340B Matters Social Media Post

Photo Source: 340B Matters

This post, while technically accurate, is arguably one of the most craven positions one can take on the sprawling, virtually unregulated funding mechanism we call the 340B Program.

Moreover, it is a position being taken by an “org” that is almost entirely devoid of information about who they are.

When looking into the history of 340B Matters, what ADAP Advocacy was able to find was the following:

1. 340B Matters is not, according to the federal government, a 501(c) non-profit organization. While this is not, in and of itself, illegal, the “.org” URL domain was originally intended for non-commercial ventures and organizations. As such, when a website is created using the “.org” extension, the safe assumption is that the website one is visiting is that of a non-profit or charitable organization. Instead, the website is owned by Han Kingler, a partner at the lobbying firm Black Diamond Strategies, who, according to the 340B Matters website’s privacy policy, serves as the Executive Director of the organization (340B Matters, 2016).
2. In addition to not being a registered non-profit, 340B Matters is “proudly sponsored” by The Craneware Group, a for-profit organization that specializes in “340B solutions”—a fanciful way of saying, “Maximizing 340B revenues for providers and increasing profits” (The Craneware Group, 2026). This, of course, runs counter to the 340B Matters tagline, “Patients Over Profits. The Craneware Group, while legally domiciled in Scotland, has a U.S. headquarters in Deerfield Beach, FL, part of the greater Boca Raton/Ft. Lauderdale area. The “solutions” they offer are software-based applications that focus on maximizing profits and decreasing overhead costs, including margins, revenues, and workforce.
3. 340B Matters obfuscates its ownership and operational team by creating a “Who We Are” page that provides the following explanation of the organization: “340B Matters seeks to protect this vital program for nonprofit healthcare facilities from those that would severely restrict access to the 340B program. We support patients over profits” (340B Matters, 2025). This page includes no information about who founded the organization, whether the organization has a Board of Directors, nor mentions any employees, contractors, or executive leadership. Nor does their website indicate that any healthcare providers or patient advocacy groups are affiliated with 340B Matters.

Essentially, what ADAP Advocacy found is that every aspect of the 340B Matters “organization” operates for one purpose:

To continue the unchecked growth of the 340B program. That explosive growth is concerning because it hasn't alleviated the medical debt crisis in this country, but also because it sets the stage for a program that is too big to fail.

Photo Source: ADAP Advocacy

Again, the aforementioned social media post is technically correct: there is no statutory obligation for 340B covered entities to provide discounted medications to the patients they purport to serve.

And this is just one of myriad problems with the 340B Program.

The program was designed to ensure that patients who could otherwise neither access nor afford healthcare services, particularly those living with HIV/AIDS, hemophilia, and Black Lung disease.

What it has become, however, is a revenue cash cow for unscrupulous hospitals, Federally-Qualified Health Centers, and other covered entities that, because of the fact that there are virtually no rules or enforcement mechanisms for the 340B Program itself, are able to get away with misappropriating 340B funds to support various endeavors that run counter to the statute’s intended purposes, including (but not limited to):

1. The inflation of executive compensation packages, as documented on 340bmap.org
2. The building, renovation, or upgrading of facilities in ways that do not improve access to healthcare services (e.g., adding water and other decorative features to existing hospitals)
3. The opening of new facilities or purchase of practices in higher-income areas that will generate greater revenue while simultaneously shuttering existing facilities and practices in lower-income areas
4. And not to mention, subsidizing a college football coach's salary, or funding electoral ballot initiatives, or purchasing private learjets

Photo Source: ADAP Advocacy

“Organizations” such as 340B Matters create content that is designed to make it seem that pharmaceutical companies and proponents of 340B reform are attempting to shut down healthcare facilities by taking away 340B revenues. They develop content like this to make it seem that only one side of the equation—the side of those who actually provide the 340B revenues to them in order to continue offering the medications through Medicare markets—are attempting to cut off your healthcare services just to make a profit.

What they consistently fail to mention is that, aside from AIDS Drug Assistance Programs and hemophilia clinics, 340B covered entities are not required to provide any transparency about the amount of their annual revenues the 340B Program accounts for, how those revenues are spent, or whether or not lower-income patients actually benefit from those revenues in any appreciable manner.

Disclaimer: All of the funders of the ADAP Advocacy Association are publicly available online at https://www.adapadvocacy.org/support.html. 

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] 340B Matters. (2016, June 01). Privacy policy. 340B Matters. https://340bmatters.org/Privacy-Policy/

[2] 340B Matters. (2025). Who we are. 340B Matters. https://340bmatters.org/who-are-we/

[3] 340B Matters. (2026, March 20). Welcome to Friday Pharma Lies, a series debunking the drug industry’s falsehoods about the 340B Program. Lie: 340B discounts are [Image attached] [Status update]. Facebook. https://www.facebook.com/share/v/1AwvuRMx8R/

[4] The Craneware Group. (2026). Our Story. Deerfield Beach, FL: The Craneware Group: 

Coverage You...Can’t...Count On

By: Marcus J. Hopkins, Health Policy Lead Consultant, ADAP Advocacy, and Matt Toresco, Chief Executive Officer, Archo Advocacy

Imagine a healthcare system where patients pay monthly premiums to maintain access to a plan. They pay co-pays before they see their physicians. They pay 100% of the cost of their visits and tests to meet a “deductible” before their insurance, which they pay to access, agrees to cover anything. Then they pay again at the pharmacy counter when they pick up medications. Over the course of a year, they end up spending more than $20,000 on healthcare costs. This scenario is the reality for many patients living in the United States, but it only gets worse.

Every step of the way, they meet resistance from the insurance company they pay to cover their healthcare costs. Prior authorization requirements. Drug formularies that exclude the medications their physicians prescribe. Denials of coverage for services contractually covered under their plans. A labyrinthine series of hoops and paperwork for which they are personally responsible, all to prove to the company that they pay that the care those insurers promised to cover should be covered.

Now, imagine living with a chronic disease and attempting to navigate all of these costs and hurdles while enduring the physical, mental, and emotional toll of just trying to survive, all while being told that this is the best healthcare system in the world and that they should feel lucky.

Those living in one of the 72 countries where leaders have refused to implement this “model” should consider themselves lucky (World Population Review, 2026).

In 2025, Americans who purchase health insurance from their respective marketplaces got the news that their health insurance premiums would be increasing by an average of 21.7% in 2026, while those who receive coverage through their employers saw increases ranging from 6% to 7% (Holahan, O’Brien, & Kennedy, 2025), not because those price increases were warranted, but because Congressional leaders failed to extend enhance premium tax credits they implemented at the height of the COVID-19 pandemic.

Those enhanced premium tax credits impacted roughly 22 million people—about 90% of those who enroll in insurance through the Affordable Care Act marketplaces (Iacurci, 2026)—a number that is both immense and yet just ~6% of the total U.S. population.

That’s correct:

A policy affecting just 6% of the U.S. population led to a nearly 22% increase in marketplace premiums.

According to recent polling by the Pew Research Center, 93% of respondents identified the cost of healthcare as their top economic concern (Figure 1).

Figure 1 – The Cost of Health Care, Good and Housing Are Top Economic Concerns for Americans

Photo Source: Van Green, Cerda, & Shepard, 2026

Meanwhile, health insurance companies, such as CVS Health, UnitedHealth, and Elevance have seen annual revenue growth ranging from 7.8% (CVS) to 12% (UnitedHealth and Elevance), all while implementing artificial intelligence (AI) tools not to improve the quality of care, but to ensure that their profits are maximized by denying care (Mello et al., 2026).

The truth about the American healthcare system is that it does not ensure the health of those stuck in it but rather ensures profits for insurance companies. Worse still, the Affordable Care Act (ACA)—so blithely named by Congress to suggest that it would make healthcare affordable for Americans—was designed in such a way that the system was made worse.

In 2023, researchers at KFF discovered that health insurance companies providing coverage under Medicare Advantage plans denied 3.2 million prior authorization claims—roughly 6.4% of all prior authorization requests—and that just 11.7% of those denials were appealed. Of those appeals, 81.7% were successfully appealed in the patients’ favor (Biniek et al., 2025).

Research conducted in 2025 by PlusInc found that, of 36.7% of respondents who had appealed their insurers’ decision to deny coverage of a service, medication, or medical device, 70% reported that they were ultimately able to get that denial partially or fully reversed in their favor (Macsata, et al., 2025).

Photo Source: PlusInc

Despite this high success rate, health insurers don’t make the appeals process easy. Appeals often require multiple attempts, mounds of paperwork, and seemingly endless wrangling just to get a health insurance company to do what they promised.

So, what do American patients get for paying the equivalent of a minimum wage annual income—nearly twice as much as other comparable governments pay per patient?

When compared to eleven other comparable nations (Australia, Austria, Belgium, Canada, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom):

• The lowest life expectancy rates
• Exponentially higher maternal mortality (death) rates
• Exponentially higher hospitalization rates for congestive heart failure and diabetes
• Significantly lower percentages of residents who have a regular source of healthcare services
• Significantly lower physician-to-patient ratios (Telesford et al., 2025).

All of these outcomes indicate that our system isn’t working. Moreover, it hasn’t been working for a while. The data tell one story, but the lived experiences of American patients tell another.

The Number Nobody's Asking About

The West Health-Gallup survey published in November 2025 highlights 47% of Americans fear they can't afford healthcare. That's not a statistic. That's a system signaling collapse.

Photo Source: West Health-Gallup

The survey shows family premiums hit $26,993 this year, with workers contributing $6,850 from their paychecks. Most employees don't realize they're paying this hidden tax because they only look at their take-home amount.

Healthcare costs are rising by 6% annually, while general inflation is at 2.7% and wage growth is at 4%. The math doesn't work. It can't work. It was never designed to work for patients.

What "High-Performing" Actually Means

The survey ranked states by healthcare performance. Even in the top-performing states, 15% of residents can't afford their medications. In the lowest-ranked states, that number hits 29%.

Here's what nobody's saying: insurance coverage and patient outcomes are fundamentally disconnected.

The current model limits physicians to 5-7 minutes per patient. They see 40+ patients daily just to keep revenue flowing. There's no time to understand complicated issues or surgical histories. Physician apathy isn't a character flaw. It's a business model that no physician wants to practice but has no time or pull to do otherwise!

The Baseline Budgeting Trap

Baseline budgeting uses the previous year's budget as the starting point for next year, without evaluating fraud, waste, or abuse. It is a trap!

Patients are never part of these internal budgeting processes. Nobody asks how families fared paying for healthcare last year. The system expects you to shoulder the load and keep paying higher premiums.

Pricing gets set without patient insight. Financial constraints don't factor into the equation. The survey shows 35% of Americans—91 million people—report they couldn't access quality healthcare if they needed it today. That's financial toxicity at scale.

The Vertical Integration Stranglehold

Three PBMs now control 80% of all prescriptions in America. They're vertically integrated with major insurers—CVS/Caremark with Aetna, Express Scripts with Cigna, OptumRx with UnitedHealthcare.

These companies own the PBMs, specialty pharmacies, retail pharmacies, surgery centers, and even provider practices. They make tens of billions in quarterly profit while premiums climb year after year.

There is too little competition. The insurance companies have amassed so much power and lobbying money that they get everything they want. That's not in the best interest of patients or clinicians.

The ACA Perfect Storm

The Trump Administration and Congressional Republicans let the ACA subsidies expire. Their lapse will result in premiums doubling for more than 20 million Americans. The average subsidy recipient can expect to see annual premium payments jump 114%—from $888 to $1,904.

But here's the question nobody's asking: Why are premiums so high in the first place, and why have they continued to rise when the risk pool expanded post-ACA implementation?

The ACA was sold as competition and cost reduction. Instead, it guaranteed customers to insurance companies…subsidized by taxpayers. Since its founding, costs have only increased to insane levels. Nothing has gotten cheaper, even though everyone must now have health insurance by law.

Based on pure economics and math alone, that should not be. This clearly points to crony capitalism, where winners are allowed to win as much as they want, at the expense of everyone else.

What Happens When Fear Becomes Reality

The survey shows that 55% of Americans cite long wait times as a reason they do not seek care. Another 27% mention work schedule conflicts. One-third skipped recommended medical procedures due to cost.

When financial barriers become reality for millions simultaneously, people skip appointments or delay care. This leads to worsening symptoms, disease progression, and medication non-compliance.

All leading to worse health outcomes, decreased presenteeism at work, and decreased productivity. This isn't a healthcare crisis. It's an economic crisis. Healthcare in its current form is just economics. The American healthcare system needs a reboot!

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] Biniek, J. F., Sroczynski, N., Freed, M., & Neuman, T. (2025, January 28). Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023. Washington, DC: KFF. https://www.kff.org/medicare/nearly-50-million-priorauthorization-requests-were-sent-to-medicare-advantage-insurers-in-2023/

[2] Daniller, A. (2025, December 10). Most Americans say government has a responsibility to ensure health care coverage. Washington, DC: Pew Research Center: Reseach Topics: Politics & Policy: Political Issues: Health Policy. https://www.pewresearch.org/short-reads/2025/12/10/most-americans-say-government-has-a-responsibility-to-ensure-health-care-coverage/

[3] Gonya, D. (2017, January 10). From The Start, Obama Struggled With Fallout From A Kind Of Fake News. Washington, DC:  National Public Radio: All Things Considered. https://www.npr.org/2017/01/10/509164679/from-the-start-obama-struggled-with-fallout-from-a-kind-of-fake-news

[4] Health Affairs Research Brief. (2022, October 06). The Role Of Administrative Waste In Excess US Health Spending. Health Affairs. https://www.healthaffairs.org/content/briefs/role-administrative-waste-excess-us-health-spending

[5] Holahan, J., O’Brien, C., & Kennedy, N. (2025, December 18). Understanding the Extraordinary Increase in ACA Premiums in 2026. Washington, DC: Urban Institute: Research: Publication. https://www.urban.org/research/publication/understanding-extraordinary-increase-aca-premiums-2026

[6] Iacurci, G. (2026, February 24). The ACA health coverage subsidy lapse hit 22 million people. Here are some of their stories. Englewood Cliffs, NJ: CNBC. https://www.cnbc.com/2026/02/24/aca-enhanced-subsidy-expiration-effects.html

[7] Macsata, B. M., Hopkins, M. J., Lathan, V. & Laws, J. (2025, November). Navigating Healthcare: Findings from Quantitative Patient Survey in the United States. Washington, DC: PlusInc. https://www.plusinc.org/s/2025_PLUSINC_Project_Prior_Auth_Workplan_112425-FINAL-NAVIGATING-HEALTHCARE-ne7x.pdf

[8] Mello, M. M., Trotsyuk, A. A., Mahamadou, A. J. D., & Char, D. (2026, January). The AI Arms Race In Health Insurance Utilization Review: Promises Of Efficiency And Risks Of Supercharged Flaws. Health Affairs, 45(1), 6-13. ttps://doi.org/10.1377/hlthaff.2025.00897

[9]Telesford, I., Wager, E., & Cox, C. (2025, October 06). How does the quality of the U.S. health system compare to other countries? Peterson-KFF Health System Tracker. https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/

[10] Toresco, M. (2026, March 12). The Number Nobody's Asking About. Archo Advocate Brief. https://archo-advocate-brief.beehiiv.com/p/the-number-nobody-s-asking-about

[11] Van Green, T., Cerda, A., & Shepard, S. (2026, February 04). A Year Into Trump’s Second Term, Americans’ Views of the Economy Remain Negative. Washington, DC: Pew Research Center: Research Topics: Economy & Work. https://www.pewresearch.org/politics/2026/02/04/a-year-into-trumps-second-term-americans-views-of-the-economy-remain-negative/

[12] World Population Review. (2026). Countries with Universal Healthcare 2026. Walnut, CA: World Population Review: Country Rankings. https://worldpopulationreview.com/country-rankings/countries-with-universal-healthcare