Congress: Close Medicare’s dangerous gaps in coverage for addiction treatment

While many people immediately picture young adults when thinking about the current addiction and overdose epidemic, this crisis is affecting all generations. In fact, more than 7 million older Americans struggle with substance use disorders. Opioid use disorder, in particular, has skyrocketed among Medicare beneficiaries, with opioid overdose death rates rising higher among people 65 and older than in any other age group.

Yet Medicare does not cover non-hospital-based residential treatment for substance use disorders or outpatient treatment in many community-based treatment facilities. Nor does it provide adequate coverage for services delivered by the full range of providers who make up a significant part of the substance use disorder and mental health care workforces. That leaves many Medicare beneficiaries without access to lifesaving addiction treatment services.

These coverage gaps stand in stark contrast to what is generally covered under Medicaid. All state Medicaid programs cover community-based substance use disorder treatment facilities, and at least 38 states and the District of Columbia cover at least one level of residential substance use disorder treatment.

These gaps persist despite the goals set by the Mental Health Parity and Addiction Equity Act, passed in 2008. Under this law, the standards of health insurance plans for substance use and mental health benefits must be comparable to — and no more restrictive than — the standards for other medical or surgical benefits. But nearly two decades after this historic legislation was passed, millions of Americans covered by Medicare continue to face unnecessary and discriminatory barriers to addiction care. Why? Because Medicare is not subject to this landmark civil rights law.

Medicare’s failure to fully cover addiction care costs lives, is discriminatory, and needs to change.

Substance use disorders are treated along a continuum of care, just like many other chronic health conditions. People with the most acute needs often receive inpatient care at a hospital, while those with the least acute needs receive outpatient counseling in office-based settings or community-based treatment programs. In between there are intermediate levels of care, including intensive outpatient treatment, partial hospitalization programs, and residential treatment services that provide a structured mix of medical care, psychoeducation, and psychotherapy. There are also effective medications approved by the Food and Drug Administration to treat opioid, tobacco, and alcohol use disorders. The course and length of treatment vary based on the specific needs of the individual.

A 2022 report from the Legal Action Center, which one of us (P.N.S.) leads, shows that a modest federal investment in Medicare (approximately 0.04% of the total Medicare budget) would help tens of thousands of beneficiaries with substance use disorders access residential treatment each year. This funding would reduce unnecessary hospitalizations and support more opportunities for recovery, ultimately reducing overall costs to the Medicare program.

Congress is increasingly focused on developing solutions to this pressing problem.

Rep. Paul Tonko (D-N.Y.), who co-chairs the U.S. House of Representatives Addiction, Treatment and Recovery Caucus, spoke at a congressional briefing earlier this year to highlight the severity of this issue and underscore the urgency for lawmakers to act now.

And there are plans underway to introduce legislation to create a new Medicare Part A benefit for residential addiction treatment programs that meet nationally recognized standards set by the American Society of Addiction Medicine. With many Medicare beneficiaries living on fixed incomes, this legislation would ensure they do not have to forego medically necessary treatment because they can’t pay the costs entirely out of pocket.

These efforts build on substantial progress that Congress and the Centers for Medicare and Medicaid Services have made over the past few years to expand Medicare coverage for addiction treatment, but more work is necessary to close the remaining gaps that prevent people from getting the treatment they need and deserve.

There is no reason that Medicare should be using inadequate standards that lag behind other health care plans. Older adults and individuals with chronic disabilities deserve robust health insurance coverage that includes treatment for addiction and mental health conditions.

This is a bipartisan issue that Congress can and should move quickly to address. Closing Medicare’s alarming gaps in addiction and mental health care coverage will ensure that the millions of beneficiaries living with a substance use or mental disorder can access and afford lifesaving treatment. Anything less would be an abdication of our responsibility to care for older Americans and those living with chronic disabilities.

Brian Hurley, M.D., is the president of the American Society of Addiction Medicine, which represents more than 7,000 physicians, clinicians, and associated professionals in the field of addiction medicine. Paul N. Samuels is the director and president of the Legal Action Center, a legal and policy organization that works to promote health and justice, including access to quality substance use disorder and HIV/AIDS health responses for all.