On December 1, President Trump signed into law the SUPPORT for Patients and Communities Reauthorization Act of 2025, extending a number of substance use disorder (SUD) prevention, treatment, and recovery programs through fiscal year 2030. The bipartisan bill—which passed the House 366-57 in June and the Senate by unanimous consent in September—reauthorizes critical programs including SAMHSA’s Comprehensive Opioid Recovery Centers grant program, the SUD Treatment and Recovery Loan Repayment Program, and grant programs to deliver treatment for pregnant and postpartum women experiencing SUD challenges in residential or outpatient programs.
Building the Foundation: 2018-2024
As detailed in our May 2024 issue brief, originally passed in 2018, the SUPPORT Act made critical strides in advancing access to coverage and treatment for individuals with SUD. This was followed up by the 2024 Consolidated Appropriations Act (CAA), which built on the original law by making permanent and building off of many of the Medicaid and CHIP provisions. This includes permanently requiring state Medicaid plans to cover all FDA-approved medications for opioid use disorder along with related counseling and behavioral therapy, extending and expanding on requirements for HHS to issue public annual reports comprehensive data on the prevalence of SUDs and services provided for the treatment of SUDs in Medicaid, and adding certified community behavioral health clinics (CCBHCs) to the list of Medicaid-coverable services. (A full summary with implementation timeline can be found in our 2024 issue brief).
However, the remainder of the 2018 SUPPORT Act was not addressed. The 2025 reauthorization remedies this by extending key programs that were left unauthorized through 2030. (The National Council for Mental Wellbeing has a helpful rundown of the provisions). And while this is genuinely good news, a tough road lies ahead to make these promises a reality.
Four Major Implementation Challenges
First, funding. Here’s the thing about reauthorizations that often gets lost: authorization is not the same as appropriation. Congress can authorize a program, but that doesn’t guarantee the program will actually receive funding. That happens through the separate appropriations process—and right now, Congress hasn’t even been able to pass a full-year budget. We’re operating under a continuing resolution that expires January 31. Congress will need to act to fund these programs through appropriations if it intends for actual money to flow to them.
Second, agency capacity. SAMHSA—the agency responsible for administering many of the programs included in the reauthorization—was devastated by reductions in force during the government shutdown. Reports indicate nearly half of SAMHSA’s workforce has been laid off in the past year with the entire team that led the National Survey of Drug Use and Health impacted. While the continuing resolution that ended the shutdown reversed some layoffs, we still don’t know what SAMHSA’s actual staffing levels look like. As Dr. Stephen Taylor of the American Society of Addiction Medicine aptly noted on the SUPPORT Act reauthorization and SAMHSA capacity: “These programs risk being reauthorized in name only if SAMHSA is not fully equipped to administer them.”
Third, Medicaid cuts. Medicaid is the single largest payer of behavioral health services in the United States, covering nearly one-third of all adults with mental health disorders and one-fifth of all adults with SUDs. Yet, HR 1 cuts federal funding for Medicaid by nearly $1 trillion over 10 years.Based on CBO’s estimates issued after HR 1 became law, the law will increase the number of uninsured by 10 million people by 2034, with Medicaid and CHIP cuts accounting for 7.5 million of that total. Work requirements alone will increase the uninsured by 5.3 million. These cuts will force impossible choices about which services to maintain and which providers to reimburse adequately.
Fourth, work requirement implementation. While HR 1 on paper includes exemptions for individuals with SUDs and CMS just released new guidance on December 8 restating this point, many critical questions remain unanswered on how this will work in practice to ensure individuals with SUDs are actually exempted. How will states identify who has a SUD when stigma prevents disclosure? Will some people with a SUD lose coverage before they are able to meet with a health care provider and understand they have an exemption qualifying health condition? And how many hoops will individuals have to jump through to show they have an SUD? As has been highlighted on the Say Ahhh! Blog before, work requirements will have significant consequences on individuals with SUDs even with exemptions. Many people with SUDs have co-occurring conditions requiring treatment first. Without coverage, they can’t access that initial treatment. It’s an impossible catch-22.
The Work Ahead
We can collectively applaud the bipartisan achievement the SUPPORT Act reauthorization represents. These programs save lives. But we must be clear-eyed: reauthorization alone doesn’t make programs functional. Congress must follow through with actual appropriations. The Administration must ensure agencies have adequate staff and resources. And states must have sufficient federal Medicaid support to maintain coverage and access to treatment rather than being forced to cut coverage and services. The SUPPORT Act reauthorization is a step forward, but only if the programs it authorizes can actually function in practice.
As always, we’ll be watching closely at CCF, tracking implementation, and analyzing impacts on coverage and access as we navigate the road ahead. And for a full accounting of key SUD and mental health actions taken under the Trump Administration, check out KFF’s helpful new tracker.