Building a Resilient Substance Use Disorder Treatment Safety Net in An Era of Austerity: Challenges for US State Governments

Policy Points State governments play a central role in reducing the health harms of substance use. This role has grown over the past two decades because of the evolving opioid crisis, expanded Medicaid eligibility, and new federal grants. Recent declines in drug overdose and improvements in services have been spurred by supportive federal policies and Medicaid funding, but progress could be undercut by ongoing federal policy changes. States seeking to maintain their progress in reducing overdose mortality and addressing substance use disorders will need to sustain investments in strategies that have expanded the continuum of specialty services and promoted integration with primary care, with vigilance to not backslide toward siloed, short‐term services. Context State governments play a central role in the delivery of substance use care in the United States, which has a profound impact on public health. Their role has grown substantially over time, as they have assumed more functions and confronted an unprecedented drug overdose crisis. While states have a wide array of regulatory and financing tools, they are confronting both longstanding challenges coordinating services and new headwinds from federal policy. Methods We examine historical and recent case studies in state substance use policy and synthesize key lessons. Findings States have undergone a massive transformation since the Affordable Care Act in their financing, but treatment services mostly remain segregated from general health care and partnerships across agencies remains a challenge. We highlight promising examples where states have pioneered new approaches to oversight, quality of care, or standards. Conclusions Anticipated budgetary pressures, including the impact of the “One Big Beautiful Bill” on Medicaid funding, will put further pressure on states to innovate, but also place major gains—such as the recent decline in overdose deaths—at risk.