Discretion’s Impact on Substance Use Disorder Treatment

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The United States is grappling with a drug epidemic of unprecedented proportions. With over 100,000 drug-related deaths in 2022 alone, finding effective ways to address substance use disorder (SUD) is more critical than ever. Medicaid, as the largest provider of SUD treatment services and medications, plays a pivotal role in this battle. But did you know that access to these lifesaving treatments can significantly vary depending on the state you live in and the Medicaid managed care plan you’re enrolled in?

A recent study by Lauren A. Peterson and her colleagues shed light on the discretionary power given to Medicaid-managed care plans by most states, which can greatly influence the accessibility and quality of SUD treatments.

The Crucial Role of Medicaid in SUD Treatment

Medicaid covers a substantial portion of Americans with SUD, including nearly 40% of those diagnosed with opioid use disorder (OUD). Given the high prevalence of SUD among Medicaid enrollees and their disproportionate share of SUD-related deaths, state Medicaid programs’ decisions regarding treatment coverage and management are immensely consequential.

Medicaid managed care plans (MCPs) administer benefits for approximately 68 million enrollees, including those with SUD. These plans often have significant discretion in determining which treatments are covered and under what conditions. This discretion can lead to substantial variability in access to care, which can ultimately affect patient outcomes.

Variability in Coverage and Restrictions

Peterson’s study, conducted through an extensive survey of 33 states and Washington, D.C., found that while most states mandate coverage for common SUD treatments, fewer than one-third prevent MCPs from imposing prior authorization for each treatment service. Additionally, only a minority of states prohibit MCPs from implementing drug testing, “fail first,” or psychosocial therapy requirements for most treatment medications.

These findings are concerning because such utilization management strategies can delay or deter individuals from receiving necessary care. For instance, prior authorization can create barriers to timely access to medication-assisted treatment (MAT), which is crucial for managing OUD.

The Impact of Prior Authorization and Other Restrictions

Imagine needing immediate help for a severe condition but being told you must wait for approval before receiving treatment. This is the reality for many individuals with SUD under Medicaid MCPs. Prior authorization requires healthcare providers to obtain approval from the insurance plan before prescribing certain medications or treatments. While intended to control costs and ensure appropriate use of services, it often leads to delays that can be detrimental to patients’ health.

Moreover, requirements like drug testing or proving the failure of other treatments first (“fail first” policies) can add further hurdles. While designed to ensure the appropriateness of prescribed treatments, these strategies can discourage patients from seeking care due to the additional steps involved.

State Policies: A Mixed Bag

The study reveals that states differ widely in how they regulate MCPs. While some states have robust requirements ensuring comprehensive coverage and minimal restrictions, others grant MCPs broad discretion. This inconsistency means that access to SUD treatment can depend heavily on where an individual lives.

For example, while most states mandate coverage for FDA-approved medications for OUD (like buprenorphine and methadone), only about half require coverage for all ten SUD treatments recommended by the American Society of Addiction Medicine (ASAM). This can lead to gaps in care, leaving many individuals without access to the full spectrum of necessary treatments.

Why This Matters

The opioid epidemic and rising rates of other substance use disorders pose significant public health challenges. Ensuring consistent and comprehensive access to SUD treatments across all states is vital for combating this crisis. The discretionary power of Medicaid MCPs to impose various restrictions can undermine efforts to provide effective and timely care to those who need it most.

Public health practitioners, policymakers, and advocates must push for more uniform and stringent regulations to ensure that all Medicaid enrollees have equitable access to SUD treatments. This includes minimizing the use of prior authorization and other utilization management strategies that can delay care.


Peterson’s study highlights a critical issue in the fight against the drug epidemic: the variability in state Medicaid policies regarding SUD treatment coverage and restrictions. By understanding and addressing these disparities, we can work towards a more equitable and effective healthcare system for all individuals battling substance use disorders.

What do you think?

  1. What challenges have you or someone you know faced when seeking treatment for substance use disorders under Medicaid?
  2. How do you think state policies should change to improve access to SUD treatments?

We invite you to share your experiences and thoughts in the comments or on social media. Your insights are valuable in helping us better understand this critical issue.

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