Big Bill,Bigger Consequences: One Big Beautiful Bill Act (OBBBA) and Opioid Use Disorder Treatment—A Critical Review

Introduction

The opioid epidemic faced by the United States in the last 25 years has been one of the most substantial public health crises of modern history. The first wave began in the 1990s with increased marketing and prescribing of natural and semi-synthetic opioids. By the early 2000s, there was rising addiction and increasing overdose deaths from heroin during the second wave. During the third wave beginning in the 2010s, there was an increasing demand for synthetic opioids like fentanyl that flooded the illegal drug market as prescribing was more monitored (CDC, 2025). This caused a sharp increase in overdose deaths because fentanyl is 50 times stronger than heroin. At this time, the government began efforts to combat the crisis by tightening regulations on opioid prescribing. There were also efforts to increase access to medications for opioid use disorder (MOUD) such as methadone, buprenorphine, and long-acting naltrexone. Harm reduction strategies included widespread naloxone availability and needle exchange programs. In 2017, the United States Department of Health and Human Services (USDHHS) declared the opioid epidemic a public health crisis (USDHHS, 2022a).

The Coronavirus pandemic abruptly shifted the U.S.'s attention away from the opioid crisis, focusing instead on the deadly consequences of two interlinked public health emergencies (Baumgartner & Radley, 2021). With the disruption of medical services, isolation, and mental health struggles, this only exacerbated the problem. From 2019 to 2022, overdose deaths reached a historic high of over 107,000 (CDC, 2025). Both federal and state governments temporarily modified regulations during this time to prevent potential harm by increasing access to MOUD (Davis & Samuels, 2020). In 2023, there was a slight decrease in overdose deaths from over 107,000 to 105,000. Of those overdose deaths, 79,358 involved opioids, which were still above pre-pandemic levels (Saunders & Rudowitz, 2025). Kennedy-Hendricks et al. (2024) found that about 32% of the US adult population reported knowing someone who died of a drug overdose and believed addiction to be an important policy issue. As a result, they suggest addressing the concerns of these individuals to impact future drug policy change.

In April of 2025, the Trump Administration released its statement of drug policy concerns. This statement included six priorities for policies to help combat the opioid overdose crisis. These included (1) reducing the number of overdose fatalities, with a focus on fentanyl, (2) secure global supply chain against drug trafficking, (3) stop the flow of drugs across US borders and into communities, (4) prevent drug use before it starts, (5) provide treatment that leads to long-term recovery, and (6) innovate in research and collect data to support drug control strategies (The White House et al., 2025). However, the passing of the One Big Beautiful Bill Act (OBBBA) stands in direct contradiction to these priorities previously outlined, raising concerns about the government's approach and its long-term commitment to addressing the opioid crisis, exemplifying the rise of anti-liberal populism and subsequent transitions of political will in recent years (Leidig, 2020).

Multiple Streams Framework

The Multiple Streams Framework (MSF) was used in this policy analysis to outline the complexity of the current policy approaches to OUD treatment and drug policy. The specific concepts of the agenda, problems, political stream, and policy window were part of the structure of the analysis. According to Kingdon (2014), the transition of key participants in the government, such as a change of administration, coupled with perceived national mood, has a formidable effect on policy agendas. The separate streams of problems, policies, and politics come together downstream, determining the fates of public policy focus and outcomes. The policy opportunities that exist after an election create a window for change that can take a significant amount of time to undo (Hoefer, 2022).

Understanding Medicaid's Role in OUD

Medicaid is a collaborative health insurance program funded and managed by both the federal government and individual states. Its primary purpose is to provide health coverage to individuals and families who have limited income and resources (Rudowitz et al., 2025).

The federal government establishes the basic guidelines and requirements for Medicaid. However, each state has the responsibility of operating its own Medicaid program within those federal parameters. As a result, while there are overarching rules set at the national level, the specific details of Medicaid—including eligibility criteria and the range of benefits offered—can differ from one state to another (Rudowitz et al., 2025; USDHHS, 2022b).

As of March 2025, 71.2 million people were insured by Medicaid (Medicaid, 2025). Medicaid covers 47% of all nonelderly adults diagnosed with opioid use disorder (OUD). This makes Medicaid the most common insurer of those with OUD (Yarbrough et al., 2024). It also covers 56% of those receiving MOUD and 64% of adults receiving outpatient treatment and peer support services (Saunders & Rudowitz, 2025).

In 2014, when the ACA expanded Medicaid coverage and the number of insured, the use of MOUD increased; it added coverage for methadone, loosened prior authorization requirements for buprenorphine, and funded programs for care coordination and initiation of MOUD in Emergency Departments. In a study conducted by the Medicaid Outcomes Distributed Research Network, data was obtained from 11 states (DE, KY, MD, ME, MI, NC, OH, PA, VA, WV, WI). These data included 1,024,401 Medicaid enrollees. The prevalence of OUD among enrollees increased from 3.3% in 2014 to 5% in 2018. Although there was variation across states among those enrollees, those receiving MOUD increased from 47.8% to 57.1%. Those who were newly eligible under expansion accounted for the majority of that increase (Brown et al., 2021).

In another study across 20 states of people who inject drugs (PWID) and Medicaid, the odds of MOUD in states that covered methadone were 73–80%. However, there was no correlation between prior authorization of buprenorphine and PWID use of MOUD (Yarbrough et al., 2024). Abraham et al. (2020) found that the number of Opioid Treatment Programs (OTPs) accepting Medicaid was 5 times higher in expansion states. The number of OTPs and non-OTPs offering buprenorphine was 2.3 times higher (OTPs) and 1.4 times higher (non-OTPs) in expansion states. Also, the number of OTPs offering long-acting naltrexone was 3.5 times higher in expansion states compared to non- expansion states. Medicaid expansion translated to a 53% increase in OTPs offering buprenorphine and a 70% increase in injectable naltrexone.

Medicaid expansion led to an increase in the number of people who were eligible for coverage and therefore able to receive treatment (Brown et al., 2021). This could have been a significant contributing factor for the slight decrease in overdose deaths seen in 2023. However, if the estimated number of people to lose coverage under the new administration is accurate, then those numbers are likely to start increasing again.

Proposed Changes in OBBBA

Under the OBBBA, individuals eligible for State medical assistance (Medicaid) are required to have a work requirement. The enrolled person every month would have to work no less than 80 h, complete community service or a work program, be enrolled at least half-time in an educational program, or any combination of the above (One Big Beautiful Bill Act, 2025). Enrollees would have to verify this requirement every 6 months or more frequently if the State opted to conduct more frequent compliance verifications. There are some mandatory exceptions for those under the age of 19, anyone entitled to or enrolled in Part A of Title XVIII, enrolled in Part B of Title XVIII, or is an inmate of a public institution, those participating in an SUD program, or are “medically frail” (Hinton et al., 2025).

There is an exception for short-term hardship events. If an individual cannot fulfill the community engagement compliance requirements, they can be granted a short-term hardship. These hardship events would include inpatient hospitalization, nursing facility services, intermediate care for intellectual disability, inpatient psychiatric care, if you live in an area declared a National Emergency, or if the individual or dependent is required to travel outside of their community for an extended period to receive medical treatment that is not available in their own community for part or all of one month (OBBBA, 2025).

If an individual does not fulfill the community engagement compliance requirements and they do not meet criteria for exemption, they will be considered non-compliant. They will be issued a 30-day notice to provide proof of community engagement or exemption status. If not, they will be disenrolled from the program by the end of the month after the 30-day deadline has passed. Individuals will also be barred from purchasing subsidized marketplace coverage because the law makes them ineligible for premium tax credits to purchase coverage (Hinton et al., 2025). Each state will have the flexibility to not only implement sooner than January 2027, but also how an individual can re-apply if they are disenrolled from the program, and how many months the retrospective period would be to verify coverage (Hinton et al., 2025; OBBBA, 2025).

Projected Impact

In June of 2018, Arkansas was the first state to implement community engagement requirements for Medicaid (Sommers et al., 2020). It required adults aged 30–49 to engage in 20 h per week of community engagement. They were also required to complete a monthly online verification of their engagement to continue coverage. However, in April 2019, the requirements were blocked by a federal judge, stating that the program did not satisfy the primary objective of Medicaid.

Sommers et al. (2020) examined the impact of the Arkansas community engagement requirements. The participants included 8,661 adults in the targeted age range for the requirements. More than 95% of this target population was already meeting requirements or qualified for an exemption. In early 2019, 18,000 adults were disenrolled due to non-compliance. In fact, the percentage of adults with Medicaid coverage dropped from 70.5% in 2016 to 63.7% in 2018 after the requirements took effect.

Those who were disenrolled reported harmful effects such as serious problems paying off medical debt (49.8%) because of no longer having coverage; many delayed getting care due to the cost (55.9%), and even delaying their medication due to the costs (63.8%).

Many in this study reported public confusion due to inaccurate information regarding the requirements. When the program first began, the only way to verify engagement was through the computer, which made it harder to report the data. Many reported that they would have preferred another method for verification (Sommers et al., 2020). As previously noted, a significant percentage of this population was already meeting these requirements but were subsequently disenrolled due to the complexity of verification. There was no evidence that low-income adults increased employment either in the first year the policy was in effect or after the policy was blocked. There was also a substantial administrative cost to implement this policy ($26.1 million), much of which was funded by the federal government (Sommers et al., 2020).

The impact of the Arkansas policy was that it failed to boost employment, and thousands were disenrolled from the program (Sommers et al., 2020). The policy implementation in Arkansas offers a valuable case study from which to draw important lessons, particularly regarding the real-world consequences of Medicaid work requirements on access to care and health outcomes. By examining the challenges and unintended consequences observed in Arkansas, policymakers can better anticipate and address similar issues as the policy is considered on a broader scale.

As this policy expands nationally, each state will have the authority to establish its own specific rules and procedures for implementation (OBBA, 2025). This decentralization underscores the need for states to adopt clear, accessible, and minimally burdensome reporting systems, if not eliminate reporting altogether. Programs such as Montana's Health and Economic Livelihood Partnership (HELP) initiative can serve as a model demonstrating that reducing or removing reporting requirements can help maintain coverage continuity and reduce administrative barriers (Coughlin et al., 2019).

The HELP program offers Montana Medicaid participants with career coaching, employment and skills assessments, goal setting, financial literacy, training, and job placement. It assists those who are aged 19–64 and earn less than 138% of the federal poverty level. Since the start of the program, 32,000 have received services, and 72% are employed in the year after training; the most common occupation pursued is Nursing (Montana Healthcare Programs, n.d.). This program has increased the labor force and removed administrative barriers such as engagement verification.

Both the Arkansas and Montana programs were developed with the intention of promoting enrollee accountability and engagement in personal healthcare management. Arkansas pursued this objective through the implementation of work requirements and extensive reporting mandates. In contrast, Montana incorporated income-based premiums and copayments alongside job training opportunities while minimizing administrative barriers (Coughlin et al., 2019). Montana's program was initially projected to enroll more than 70,000 individuals within its first four years; however, that benchmark was reached within the program's first year of implementation.

The current trend of decreasing overdose mortality is likely the result of Medicaid expansion, increased access to MOUD treatment, and harm reduction policies such as the liberal provision of naloxone. From 2023 to 2024, there was a 20,000 decline in opioid overdose deaths. This reduction in deaths has been a substantial public health accomplishment, combining the streams of federal policies, windows of opportunity, and political and community will. Reducing Medicaid enrollees and access to MOUD treatment, combined with the added strain on state budgets from incremental federal cuts to Medicaid, shunts resources away from individuals and communities who have made these important gains (Wilson & Rights, 2025).

Implications for Nursing

Nurses working with individuals diagnosed with OUD can expect added difficulties from Medicaid coverage losses due to more stringent eligibility criteria and subsequent lack of care continuity. Insurance instability will add complexity to managing patients across the care continuum. The loss of Medicaid coverage and access to MOUD stands to reverse the current trend of opioid overdose deaths and lead to more catastrophic medical care. Rural health systems will be hardest hit because they rely disproportionately on Medicaid reimbursement. The OBBBA will contribute to the rural healthcare worker shortage and drain resources from local economies, leading to rural hospital closures (Howren & Hansen, 2025).

Conclusion

The Congressional Budget Office estimates that approximately 11.8 million Americans will lose health insurance under the proposed requirements. Evidence from prior state-level implementation, most notably in Arkansas, suggests the potential for significant adverse outcomes; however, similar policies are now being advanced at the national level, thereby amplifying their potential impact. Alternatively, Montana's HELP program illustrates how employment-oriented Medicaid policies can be designed around supportive services rather than punitive verification mechanisms, enabling individuals to strengthen workforce participation while maintaining health coverage and continuity of care.

OBBBA presents significant risks for vulnerable populations, particularly individuals with substance use disorders, who frequently encounter structural barriers to meeting work-reporting requirements, including housing instability, limited access to technology, and ongoing medical or psychiatric conditions. As a result, many are at heightened risk of losing Medicaid coverage, thereby jeopardizing access to treatment services, harm-reduction programs, and continuity of care. Loss of coverage is expected to worsen health outcomes, increase emergency department utilization, and contribute to elevated rates of relapse, overdose, and preventable mortality. While certain exemptions are included in the statute, there is currently no clear federal guidance regarding verification processes or the required frequency of such verification of exemptions, leaving significant implementation questions unresolved.

Enactment of the legislation will necessitate extensive operational costs across federal and state systems, including major IT system upgrades, comprehensive outreach and education efforts, workforce training, and coordination with external organizations and stakeholders, with projected administrative costs of $200 million in 2026. Resources required for eligibility verification, compliance monitoring, and enforcement will divert funding away from direct clinical services. Furthermore, proposed restructuring of federal agencies and the elimination of funding streams that support evidence-based treatment will create additional barriers to care and reallocate resources away from the very populations the administration claims to support.

Nurses should actively engage with state legislators, Medicaid offices, and regulatory agencies to advocate streamlined and flexible employment verification processes. This includes urging policymakers to adopt alternatives to monthly or digital-only reporting, such as automatic data matching, expanded exemptions for individuals with chronic health or behavioral health conditions, and simplified pathways for reinstatement after lapses in coverage. By providing testimony, participating in stakeholder meetings, and collaborating with professional nursing organizations, nurses can clearly demonstrate how stringent verification requirements lead to unnecessary disenrollment, disrupt access to MOUD, and increase preventable morbidity and mortality. Through sustained advocacy, nurses can promote state-level policies that reduce administrative burden while safeguarding continuity of care for vulnerable populations.