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 into a coverage system that didn’t recognize their condition.
Since 2020, the number of OTPs nationally has grown to over 2,000, and Medicare acceptance among OTPs has expanded dramatically. But coverage expansion is not the same thing as the system becoming simpler. And that distinction matters enormously for the providers doing this work every day.
WHAT COMPLEXITY LOOKS LIKE
Every commercial payer operates differently: different codes, different prior authorization requirements, and different documentation standards for the same clinical services. Providers operating across state lines navigate multiple parallel systems simultaneously, each capable of changing mid-year. Research published in the Journal of Substance Use & Addiction Treatment found that these administrative burdens carry a direct financial cost: providers are only reimbursed for care delivered, not for the billing and tracking work required to collect that payment.
The instability compounds everything. In New York, providers could once choose between bundled and fee-for-service billing week by week, until the state changed course, introduced new add-on codes, and rewrote the rules. Each shift requires staff retraining, documentation updates, and logic changes inside billing systems. I’ve heard it described as a bottomless ocean. You never find the floor. And as soon as you think you’ve built something solid, the water moves.
WHERE THE COST ACTUALLY LANDS
The direct cost of this complexity is clinical capacity. A 2023 survey from the National Council for Mental Wellbeing found that 93% of behavioral health workers have experienced burnout, and 68% of clinical staff say administrative burden directly takes away from time with patients. Much of that burden is a product of reimbursement complexity. It dictates what must be documented, in what format, for reasons that often have little to do with clinical value and everything to do with what a given payer requires to cut a check.
The access gap has the same root. Providers can’t expand into underserved rural communities when managing reimbursement is already consuming capacity in their existing locations. Telehealth and mobile dispensing units are extending reach in encouraging ways, but those tools operate inside the same reimbursement infrastructure. The reach expands; the complexity travels with it.
WHAT HAS TO CHANGE
The goal doesn’t have to be full federal uniformity. What the field needs is a meaningful reduction in the volatility and fragmentation that make stable operations so difficult to build. On the policy side, the Centers for Medicare and Medicaid Services’s (CMS) growing role in the OTP space is a lever worth pushing on. When CMS moves, states and commercial payers tend to follow.
On the technology side, the opportunity is to build systems that absorb billing complexity without passing the cognitive load to clinical staff, so clinicians can stay present with patients rather than managing payer requirements in the background. And on the payer side, there needs to be a clearer acknowledgment that billing rule changes have downstream effects on provider capacity and patient access. Costs that don’t disappear when a rule changes, they just transfer.
THE GAP THAT SHOULDN’T STILL EXIST
The field has made genuine progress on stigma, coverage, and reach. These are real wins. But 4 in 5 people who need substance use treatment still don’t receive it.
To be clear, the providers doing this work aren’t failing. They’re carrying a disproportionate share of a structural problem the system has never fully owned. Both naming that and demanding that payers, policymakers, and technology partners share the burden of solving it is what the field needs from its leaders right now.
Josh Schoeller is CEO of Qualifacts.