Medicaid’s regulatory failures must be addressed.
Despite thousands of lawsuits against OxyContin maker Purdue Pharma now being settled, the opioid crisis continues to devastate families and communities. This is why there are massive national efforts to expand addiction treatment, develop non-opioid pain alternatives, promote natural remedies, and confront the Mexican drug cartels flooding America with fentanyl. In recent years, opioid-related deaths have finally begun to decline, suggesting those initiatives are starting to make a real impact. But that progress may already be slowing.
The introduction of work requirements for Medicaid eligibility under the One Big Beautiful Bill is producing unintended consequences for people in addiction recovery. Early studies show that declines in Medicaid enrollment correlate with drops in the number of patients receiving treatment for opioid use disorder (OUD). Because Medicaid is the primary source for buprenorphine and addiction services, these enrollment changes threaten fragile but meaningful recovery gains.
Work requirements aren’t the problem—they’re sound policy to preserve the financial stability and original intention of the program. The real issue is Medicaid’s regulatory structure, which is too rigid and dysfunctional to absorb yet another layer of complexity.
This problem has been building for years. Long before work requirements arrived, Medicaid’s regulatory design and state-level policies were already limiting access to effective OUD treatment. Patients have also been facing prior authorization mandates that delay care, restrictive prescriber rules that gatekeep life-changing medications, and certificate-of-need (CON) laws that prevent treatment facilities from opening or expanding. These rules are often created with good intentions—to manage costs, prevent overprescribing, or ensure medical oversight. But in practice, they’ve made it harder for people in recovery to get consistent help.
In states where prescriber limits and facility restrictions already make treatment scarce, adjusting Medicaid eligibility has a serious impact on the availability of buprenorphine providers. The problem lies in creating a policy that requires personal responsibility within an already bureaucratic structure that actively slows treatment access. When enrollment pressures combine with supply constraints caused by CON laws and prescription rules, the result is fewer people getting the care that keeps them alive.
This is especially true in Appalachia, which is ground zero of the opioid crisis. Pennsylvania explicitly prohibits off-site methadone “medication units,” while legislation has been floated in West Virginia that aims to ban methadone clinics. Local governments across the region routinely block zoning permits for treatment facilities, often caving to community pushback rather than addressing a staggering public health emergency. Many states still impose CON laws, restricting the ability of hospitals and clinics to add new treatment beds or open new OUD programs.
On the provider side, well-intentioned prescribing rules have created even more barriers. Despite a dire shortage of addiction specialists, many states limit the prescription of OUD medications only to certain providers, leaving primary care doctors—who could dramatically expand treatment access—underutilized or prevented from issuing prescriptions. Lawmakers have inadvertently created a bottleneck: too few qualified providers and too many hoops to jump through for those who want to treat addiction.
As the Trump Administration continues building a populist coalition that includes voters from Western Pennsylvania, Ohio, and other communities deeply scarred by opioid addiction, it must confront this reality head-on. Doing so does not require abandoning conservative principles, nor does it mean reversing work requirements. Those reforms remain both necessary and widely popular. But a serious conservative healthcare agenda must recognize that Medicaid’s regulatory architecture is undermining progress against opioid addiction—and America cannot afford to lose ground now.
The nation has made hard-won gains against opioid misuse in the last few years. Letting regulatory burdens erode that momentum would betray both the moral and political commitments conservatives have made to the working-class communities most harmed by fentanyl.
Conservatives champion individual responsibility—but responsibility also requires ensuring that systems designed to help people reclaim their lives aren’t working against them. Addressing Medicaid’s regulatory failures is not just good policy: it is essential to sustaining progress in one of the most consequential public health fights of our time.
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