How the Big, ‘Beautiful’ Bill Would Undermine Access to Life-Saving Substance-Use Disorder Treatment

The United States has struggled for decades to address the devastating toll of substance-use disorder (SUD), particularly with the opioid crisis that continues to claim tens of thousands of lives annually. In recent years, health insurance coverage expansions and improved access to treatment have helped millions of Americans both begin and sustain recovery. Remarkably, in 2024, drug overdose deaths fell by nearly 27 percent thanks, in part, to better access to care.

The House Republican “One Big, Beautiful Bill” proposes sweeping Medicaid cuts that threaten to undermine this fragile progress by causing 7.8 million people on the program to lose their insurance. Accordingly, the bill would jeopardize access to services that both prevent substance use and provide treatment for many people with SUD. A new Center for American Progress analysis estimates that, if the bill were to become law, more than 1.6 million individuals with Medicaid-receiving SUD treatment would become uninsured—cutting off their access to lifesaving care. While these estimates reflect the House-passed bill, the Senate’s more extreme Medicaid cuts could cause even greater coverage losses and disruptions to care.

Medicaid is a lifeline for people living with substance-use disorder

Medicaid is the largest payer of behavioral health services in the United States, including for SUD treatment. According to the latest available data, Medicaid covered nearly 60 percent of all national spending on SUD treatment in 2019—accounting for $17 billion out of the $30 billion spent across all payers. Medicaid covers a range of SUD treatments and services, including inpatient treatment; outpatient treatment, such as individual and group therapy; medication-assisted treatment; and some forms of naloxone, which can reverse opioid overdoses. Additionally, 36 states and the District of Columbia have approved Section 1115 Medicaid demonstration waivers that allow for expanded SUD treatment options and enable states to provide additional, wraparound services for individuals with SUD to achieve and sustain recovery. For example, one component of West Virginia’s waiver authorizes Medicaid coverage for quick-response teams that provide follow-up support to individuals who have experienced an overdose or an SUD-related emergency, ensuring they get connected to care. New Mexico’s waiver authorizes supportive housing services, including eviction prevention and move-in assistance for Medicaid enrollees with SUD.

The Affordable Care Act (ACA) improved SUD treatment access by making SUD services one of ten essential health benefits that nearly all insurers are required to cover. The ACA also allowed states to expand Medicaid eligibility to adults with incomes up to 138 percent of the federal-poverty level (FPL), providing millions of previously uninsured low-income adults with access to life-saving SUD treatment. One 2020 study found a 15.7 percentage point rise in the share of patients in SUD programs covered by Medicaid and a corresponding 13.7 point drop in the share of uninsured patients between 2013 and 2017 as a result of the ACA’s Medicaid expansion. In 2021, 4.9 million Medicaid enrollees were treated for SUD, 43 percent of whom were adults with coverage under Medicaid expansion.

Uninterrupted access to treatment is essential for individuals with SUD. People who discontinue SUD treatment—especially opioid-use disorder (OUD) treatment—are more likely to overdose or experience adverse health events. Loss of insurance coverage can cause people to discontinue care or force people to rely on costly and otherwise avoidable inpatient-care and emergency-department services.

House Republicans’ Big, ‘Beautiful’ Bill could strip coverage from more than 1.6 million Medicaid enrollees in substance-use disorder treatment

The House-passed budget bill would enact several cuts to the Medicaid program that would result in coverage losses. The bulk of those coverage losses would come from the bill’s proposed burdensome work-reporting requirements on adults enrolled in Medicaid through the ACA’s expansion option. Specifically, the bill would require nonpregnant, nondisabled, noncaregiver adults ages 19 to 64 to document at least 80 hours of work per month or other qualifying activities (such as job training or volunteering) in order to maintain their Medicaid coverage. Individuals unable to meet the requirement would risk losing coverage. The Senate Finance Committee text goes even further, eliminating the exemption and requiring compliance from parents with children older than age 14.

Evidence from previous state-level implementations, including in Arkansas and New Hampshire, shows that work-reporting requirements do not increase employment but, instead, result in large-scale coverage losses among people eligible for Medicaid. The nonpartisan Congressional Budget Office estimates that the bill’s work-reporting requirements would cause 4.8 million Medicaid enrollees to become uninsured.

Though the bill includes an exemption for individuals with SUD from work-reporting requirements, it remains unclear how states would implement or enforce that exemption. Past state implementation shows exemptions often fail to protect vulnerable populations from being tripped up by work requirements in practice. In 2018, Arkansas enrollees seeking work-requirement exemptions faced a complex, multistep process—and thousands lost coverage due to red tape.

Table 1 showcases CAP’s estimates that more than 1.6 million Medicaid expansion enrollees receiving SUD treatment could become uninsured under the bill, leading to disruption or discontinuation of care.

CAP estimates that the states with the largest coverage losses among Medicaid enrollees being treated for SUD include California (nearly 170,000), New York (nearly 166,500), Ohio (134,500), and Pennsylvania (nearly 118,000). These coverage losses reflect the size of each state’s Medicaid expansion population as well as each state’s rate of SUD treatment take-up among people with Medicaid.

Conclusion

Medicaid is the financial backbone of our nation’s behavioral health services infrastructure and provides critical access to care to individuals who need SUD treatment. The House-passed budget bill would cause significant Medicaid coverage losses, and in doing so, could erect new barriers to care for the more than 1.6 million Medicaid expansion enrollees receiving treatment for SUD.

Methodology

To calculate state-level impacts of how coverage losses would be felt by Medicaid enrollees with SUD due to the House-passed budget bill, CAP started with the Urban Institute’s April 2025 projection that work requirements for expansion enrollees ages 19 to 64 would cause between 5.5 to 6.3 million people to lose coverage by 2026. Urban’s estimate of 5.5 million people losing coverage assumed a 72 percent coverage-loss impact (applied equally to each state) among expansion enrollees ages 19 to 64 subject to work reporting requirements based on Arkansas’ experience implementing this policy. Urban’s 6.3 million estimate assumed an 82 percent coverage loss impact based on New Hampshire’s experience attempting work reporting requirements. CAP applied those percentages to federal data from 2021 (the most recent year available) on the number of Medicaid expansion enrollees who received SUD treatment that year (roughly 2 million people) by state. CAP then calculated the midpoint of those coverage losses in each state to estimate that more than 1.6 million Medicaid expansion enrollees receiving SUD treatment could become uninsured under the bill, leading to disruption or discontinuation of care.