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Guest Editorial — Medicaid Unwinding May Have Substantially Disrupted Buprenorphine Treatment

By Rachel Landis, PhD, MPP, and Bradley D. Stein, MD, PhD

The opioid crisis remains one of the most pressing public health emergencies facing the United States. A 2023 KFF poll found that nearly one-third of adults reported that they or a family member had experienced an opioid addiction.1 In the same year, about 5.7 million Americans were diagnosed with an opioid use disorder (OUD),2 a chronic medical condition characterized by persistent use of opioids despite harmful consequences, including overdose and death. Nearly 80,000 people died from opioid overdose in 2023—almost 10 times the number of deaths in 1999.3

Unsurprisingly, OUD prevalence varies substantially across population subgroups, and low-income individuals with Medicaid insurance are among the hardest hit. Indeed, Medicaid provided coverage to 47% of nonelderly adults with OUD in 2023 and paid for medication for opioid use disorder (MOUD) treatment for 56% of those receiving it.4 MOUD, including buprenorphine and methadone, is the gold standard of OUD care, dramatically increasing treatment retention5 and reducing the risk of overdose and death.6,7

Because it is available in outpatient settings, buprenorphine is often a more accessible treatment option compared to methadone. A myriad of federal policies have been enacted over the past two decades to further increase access to buprenorphine for OUD treatment. But despite the availability of safe and effective buprenorphine treatment for OUD, only 1 in 5 adults with OUD receive this life-saving care.8

Studies have consistently demonstrated higher rates of MOUD use among Medicaid enrollees compared to those with private insurance,9 underscoring the critical role that Medicaid plays in combatting the opioid crisis. The Families First Coronavirus Response Act, a federal law enacted in March 2020 in response to the COVID-19 pandemic, included a continuous enrollment provision requiring Medicaid programs to maintain continuous enrollment for beneficiaries through the end of the COVID-19 public health emergency, in exchange for enhanced federal funding.10

The continuous enrollment provision expired on March 31, 2023, and states began reviewing Medicaid eligibility and disenrolling individuals who no longer qualified for or failed to complete renewal paperwork (hereafter, unwinding). Though unwinding was meant to bring state Medicaid rolls back to their pre-pandemic levels by resuming pre-pandemic enrollment and renewal processes, the reality is that millions of individuals—many of whom may still have been eligible—lost Medicaid coverage as a result of unwinding.11 In fact, nearly 70 percent of individuals who lost Medicaid coverage were disenrolled for procedural reasons (ie, failure to complete the required renewal process), whereas ~30 percent were determined to be ineligible.12

Given the importance of Medicaid in facilitating access to OUD care, it is critical to understand how unwinding may have affected the treatment of individuals receiving buprenorphine. To provide a more nuanced understanding of unwinding’s effects on individuals starting or ending buprenorphine treatment, we used IQVIA Real World Data longitudinal prescriptions data—which capture 93% of prescriptions dispensed at retail pharmacies across all 50 states and the District of Columbia—to examine the association between Medicaid unwinding and the average monthly change in new and ending buprenorphine treatment episodes by payer (Medicaid, commercial, Medicare, discount cards/vouchers, and cash pay). We examined the effects of Medicaid unwinding overall as well as the magnitude of unwinding—the extent of unwinding relative to each state’s population—in the 6 months after unwinding began, categorizing states with the greatest, moderate, or smallest decline in Medicaid enrollment.

We found that unwinding was associated with a substantial increase in the number of Medicaid buprenorphine treatment episodes ending and a sharp decrease in the number of treatment episodes starting. The greatest changes were in the states with the largest reductions in Medicaid enrollees as a percentage of their population.

Changes in Medicaid-paid episodes appeared not to be offset by other payers. When examining all payers combined, we found a slight increase in episodes ending and virtually no change in new episodes, thus undercutting the assumption that individuals losing Medicaid coverage would easily switch to another insurer or pay out of pocket to continue buprenorphine treatment. Unwinding simply resulted in fewer people receiving this evidence-based care for OUD.

Our finding that states with the greatest disenrollment experienced the greatest changes in buprenorphine treatment initiation and discontinuation likely reflects broader variation in how states have approached Medicaid renewal decisions. A majority of states (36) have adopted automatic renewal policies for Medicaid beneficiaries with previously documented zero income, while just over a third of states (19) extend automatic renewals to those with incomes below the federal poverty threshold.13 Receipt of in-person assistance dramatically improves continuity of coverage; 30 states currently offer community-based Medicaid navigation programs, and 20 states and DC allow managed care organizations to support enrollment.14 These differences in state approaches to renewal decisions highlight significant and impactful variation in efforts to improve continuity of coverage; enrollees’ likelihood of Medicaid renewal is heavily dependent on renewal processes in the state in which they live.

From April 2023 through September 2024, more than 25 million individuals lost Medicaid coverage as a result of Medicaid unwinding.12 Our study suggests that unwinding was associated with a substantial increase in the number of Medicaid enrollees stopping buprenorphine treatment and a substantial decrease in enrollees beginning it, with the greatest effects in states with the greatest disenrollment. This finding is particularly salient at a time when policy changes are increasing uncertainty about Medicaid coverage for many individuals. It is critical that states pay attention to the potential effects of large-scale coverage cuts. If we hope to sustain recent progress made in addressing the opioid crisis,15 ensuring treatment continuity for those relying on this life-saving medication should be a policy and practice imperative.

Rachel K. Landis is a policy researcher at the nonprofit, nonpartisan RAND Corporation. Her primary research interests focus on health policies related to substance use, mental health, and maternal and child health. She is a principal investigator of two studies funded by the National Institutes of Health. She received her PhD from the George Washington University Trachtenberg School of Public Policy and Public Administration and her MPP from the Johns Hopkins University Bloomberg School of Public Health.

Bradley Stein is a practicing physician and senior physician policy researcher at RAND. His research career has focused on improving access to, the quality of, and outcomes from care of individuals with mental health and substance use disorders being treated in community settings. For two decades, Dr. Stein has studied the opioid crisis, serving as principal investigator for numerous federally and privately funded studies. Dr. Stein has published multiple peer-reviewed articles related to studies of opioid use disorder treatment, harm reduction, and the effects of state and federal policies, and he has provided Congressional testimony related to his research on multiple occasions. Dr. Stein’s work has been covered by a range of media outlets including the Economist, Washington Post, and New York Times.

References

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  2. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2023 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/reports/rpt47095/National%20Report/National%20Report/2023-nsduh-annual-national.pdf. HHS Publication No. PEP24-07-021. NSDUH Series H-59. Published 2024. Accessed November 3, 2025.

  3. Garnett MF, Miniño AM. Drug overdose deaths in the United States, 2003–2023. National Center for Health Statistics. https://stacks.cdc.gov/view/cdc/170565. Data Brief No. 522. Published December 2024. Accessed November 3, 2025.

  4. Saunders H, Rudowitz R. Implications of potential federal Medicaid reductions for addressing the opioid epidemic. KFF. https://www.kff.org/medicaid/implications-of-potential-federal-medicaid-reductions-for-addressing-the-opioid-epidemic/. Published May 14, 2025. Accessed November 3, 2025.

  5. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews. 2014;(2):CD002207. doi:10.1002/14651858.CD002207.pub4.

  6. Kelty E, Hulse G. Fatal and non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine or implant naltrexone. Int J Drug Policy. 2017;46:54–60. doi:10.1016/j.drugpo.2017.05.039.

  7. Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study. Ann Intern Med. 2018;169(3):137–145. doi:10.7326/M17-3107.

  8. Jones CM, Han B, Baldwin GT, Einstein EB, Compton WM. Use of medication for opioid use disorder among adults with past-year opioid use disorder in the US, 2021. JAMA Netw Open. 2023;6(8):e2327488. doi:10.1001/jamanetworkopen.2023.27488.

  9. Shen K, Thornburg B, Kennedy-Hendricks A, Meiselbach MK. Medicaid enrollees with opioid use disorder were more likely to receive medication treatment than commercial enrollees. Health Aff. 2025;44(9):1092–1101. doi:10.1377/hlthaff.2025.00253.

  10. Tolbert J, Ammula M. 10 things to know about the unwinding of the Medicaid Continuous Enrollment Provision. KFF. https://www.kff.org/medicaid/10-things-to-know-about-the-unwinding-of-the-medicaid-continuous-enrollment-provision/. Published June 9, 2023. Accessed November 3, 2025.

  11. Center on Budget and Policy Priorities. Unwinding watch: tracking Medicaid coverage as pandemic protections end. https://www.cbpp.org/research/health/unwinding-watch-tracking-medicaid-coverage-as-pandemic-protections-end?item=29306. Published September 2024. Updated January 7, 2025. Accessed November 3, 2025.

  12. KFF. Medicaid enrollment and unwinding tracker. https://www.kff.org/medicaid/medicaid-enrollment-and-unwinding-tracker/#8815e057-6ee9-4945-8ca1-705913d143b8. Updated November 18, 2025. Accessed November 3, 2025.

  13. Centers for Medicare & Medicaid Services. COVID-19 PHE unwinding Section 1902(e)(14)(A) waiver approvals. Medicaid.gov. https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/covid-19-phe-unwinding-section-1902e14a-waiver-approvals. Updated December 2024. Accessed November 3, 2025.

  14. Brooks T, Lawson N, Green H. State Medicaid and CHIP outreach resources and enrollment assistance snapshot. Center for Children and Families, Georgetown University McCourt School of Public Policy. https://ccf.georgetown.edu/2024/05/09/state-medicaid-and-chip-outreach-strategies-and-enrollment-assistance-snapshot/. Published May 9, 2024. Accessed November 3, 2025.

  15. Ahmad FB, Cisewski JA, Rossen LM, Sutton P. Provisional drug overdose death counts. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Updated September 17, 2025. Accessed November 3, 2025.