We fixed opioid coverage but not the system behind it

About 1 in 6 Americans met the criteria for a substance use disorder in 2024, according to the Substance Abuse and Mental Health Services Administration. National spending on substance use disorder (SUD) and mental health treatment has grown from roughly $41 billion in 2000 to nearly $140 billion by 2021. And yet only about 1 in 5 of those who needed treatment actually received it. The reasons are real and well-documented: too few providers, too much stigma, too little infrastructure in rural communities. I spend a lot of time with the leaders running behavioral health and SUD organizations across the country, and these challenges come up in almost every conversation. But there’s another problem that the field knows intimately and that rarely breaks through into the broader policy conversation—one that makes all of those challenges harder to solve. The red tape around getting paid for SUD treatment is so fractured, so volatile, and so demanding to navigate that it functions as a structural tax on the entire field. Real progress has been made on workforce, access, and stigma, yet the reimbursement environment isn’t moving with the same urgency. A SYSTEM THAT TOOK DECADES TO SHOW UP For most of its history, opioid treatment was largely a cash business. Methadone was the primary option, coverage was minimal, and the field operated on the margins of mainstream healthcare financing. Progress came slowly and unevenly. In-network opioid treatment program (OTP) contracts with major commercial insurers were still a rarity well into the mid-2010s. In 2017, a Health Affairs review found that commercial insurance plans frequently excluded methadone—the gold standard for opioid treatment—from their coverage entirely. Medicare didn’t cover opioid treatment at all until January 2020, driven in part by a demographic reality that had become impossible to ignore: The population living with addiction had grown older, and millions of people who needed treatment were aging i