Two recent analyses highlight how the Medicaid changes proposed in the reconciliation bill would harm people with addiction.

Overall coverage loss: A Center for American Progress analysis estimates that the House-passed reconciliation bill would lead more than 1.6 million individuals with Medicaid receiving substance use disorder (SUD) treatment to become uninsured, cutting off their access to lifesaving care.

• The Senate’s deeper Medicaid cuts could cause even greater coverage losses and disruptions to care.
• The bulk of those coverage losses would come from the proposed work requirements.

Why work requirements are a particular challenge: A KFF brief highlighted the challenges that Medicaid work requirements may pose for adults with mental health or substance use disorders (MH/SUD).

• Medicaid expansion coverage: The work reporting requirements would apply to beneficiaries covered under the Affordable Care Act’s Medicaid expansion. Most people with MH/SUD enrolled in Medicaid are covered under expansion — 59% of Medicaid-covered adults with SUD, 61% of those with opioid use disorder, 51% of those with any mental health disorder, and 45% of those with serious mental illness. The shares are even higher in expansion states.
• Inadequate exemptions: The bill includes exemptions from proposed work requirements for individuals with SUD or “disabling” mental disorders, as well as those participating in a SUD treatment program. But the bill does not explicitly define which diagnoses constitute “disabling” mental disorders, and few people receive needed SUD treatment due to a wide range of barriers.
• Unclear implementation: The extent of the impact of work requirements may depend on how the requirements are defined and operationalized at the federal and state levels, and many details remain unclear. The bill does not specify how states would be expected to identify individuals who are exempt or whether/when individuals may be required to self-report or provide documentation to confirm they meet exemption criteria. It also does not specify if states will be required to use available data to automatically verify exemptions.
• Data limitations: Even states using data to automatically identify people who meet exemption criteria may miss some individuals due to data limitations. While states could cross-reference Medicaid enrollment records with other data sources (e.g., Medicaid claims) to identify exemption conditions like MH/SUD, there is often a delay in claims data. States with outdated or less integrated data systems may face additional challenges, potentially increasing reliance on manual reporting.
• Self-report challenges: Common behavioral health symptoms would make it more challenging for individuals with MH/SUD to self-report work or exemption status. For example, challenges with concentration, planning, energy levels, anxiety, feelings of overwhelm, and difficulties managing stress may make it harder to understand requirements, navigate complex submission processes, and address issues that arise. Individuals experiencing severe/acute symptoms may find it particularly difficult, especially if compounded by unstable employment or housing instability/homelessness.
• Provider burden: Provider burden may increase if provider documentation is required to obtain an exemption.
• Employment gaps: Mild and moderate mental health disorders may not qualify for exemptions, but symptoms could lead to employment gaps. The House bill allows states to provide short-term hardship exceptions, such as during inpatient psychiatric stays, but these exceptions are not federally required and must be requested by the enrollee. Individuals with new or undiagnosed behavioral health disorders may struggle to qualify or maintain Medicaid coverage without sufficient work history or formal diagnoses. Disruptions or losses in coverage can interrupt treatment.