Ann Breeding remembers the moment she was told her 29-year-old son, Daniel Bailey, had died of a drug overdose.
Breeding recalled dropping to her knees in the living room — now decked with pictures and shrines paying homage to her late son — of her Bondurant home, screaming “no” over and over again.
When Bailey died, he had been drug-free for six months after nearly 12 years of addiction thanks to finally receiving treatment for his long-term substance use at Bridges of Iowa, an addiction care center in Des Moines, Breeding said.
Though getting him treatment was no easy feat. Breeding said Bailey had to jump through insurance loopholes, even though he was on Medicaid, just to get into the treatment center.
Millions like him, who access care through Medicaid, might not be able to get treatment through the public insurance program as Republican federal lawmakers enact changes to the program in their “One Big Beautiful Bill Act.”
The bill makes nearly $1 trillion in cuts to Medicaid spending over a decade through a series of changes restricting access to Medicaid, to pay for a trillion dollars in tax cuts.
One of the wide-ranging changes to Medicaid enacts work requirements for able-bodied adults, though a litany of exemptions were included in the bill — including an exception for those with substance use disorder. Experts worry the added paperwork and eligibility requirements will be difficult for those suffering from addiction to access care.
These changes come as Iowa sees a shortage of mental health providers and inpatient care for addiction, providers say.
At first, Breeding tried getting her son legally committed for treatment, which she said she later regretted. After a 72-hour hold, he was released. Then, when Bailey was finally ready to try treatment on his own, he struggled to navigate the system.
“It’s either they don’t have a bed, there’s a wait list, you don’t have the right insurance — we had state insurance when he did finally get into treatment — I’ll never forget that experience,” Breeding said.
She said any delay in getting long-term drug users into treatment can cause them to never seek treatment. She said barriers to care and paperwork are what can make it so some never get treatment, even if they want it.
“You can’t wait another week, you can’t say, come back in two weeks,” Breeding said. “Instant, immediate access to treatment — that’s what he needs.
Breeding said the consequences of a delay can be life or death.
“When he’s ready, he’s ready, and if you don’t help, the alternative is that he’s going to die, and people don’t understand that urgency,” she said.
Work requirements could jeopardize coverage
According to an analysis by the Center for American Progress, it is estimated that more than 1.6 million Americans who are receiving substance abuse care will lose access to their Medicaid coverage because of work requirements.
The law is expected to go into effect on Jan. 1, 2027, and require able-bodied, or those without a disability that prevents them from working, adult beneficiaries between the ages of 19 and 64 to work for at least 80 hours per month. The law also requires certain adults, including parents with children under 18, disabled adults, and those who are medically frail, to be exempt from
work requirements.
The law spells out an exemption for those suffering from substance use disorder, though health policy experts say the paperwork involved with proving exemptions is often difficult and burdensome for those suffering from addiction.
“There are concerns that individuals with substance use disorder who are currently in treatment don’t need additional stress and barriers to their coverage,” said Natasha Murphy, the health policy director at the Center for American Progress and the author of the study.
Murphy said Arkansas’ work requirements, implemented under a waiver of Medicaid rules during President Donald Trump’s first administration, give clarity on how work requirements will play out on a much larger scale, given their similarity to those implemented in the law. A case study from the Brookings Institution shows work requirements did not increase employment but rather resulted in a loss of benefits.
Murphy said the same thing played out for those with exemptions in Arkansas, and the multistep process resulted in those with disabilities and other exemptions losing coverage.
The study by the Center for American Progress estimates roughly 22,300 Iowans will lose access to Medicaid due to work requirements, out of 603,000 children and adults who are covered by Medicaid in the state. This is coupled with the more than 28,000 Iowans receiving addiction care through Medicaid.
U.S. Rep. Mariannette Miller-Meeks, R-Iowa, who sits on the committee
authoring Medicaid portions of the bill, pointed to the exemptions in the law for those with disabilities and substance use disorder.
“As a physician, I’ve seen firsthand how critical it is to protect care for those who need it most, including individuals in treatment for substance use disorders,” Miller-Meeks said in a statement to The Daily Iowan. “Nothing in this bill cuts or restricts that care. The work requirements apply only to able-bodied adults without dependents and explicitly exempt those with disabilities or those receiving substance abuse treatment.”
In a June 24 speech on the Senate floor, U.S. Sen. Chuck Grassley, R-Iowa, reiterated the exemptions available under the law, and that work requirements are “common sense.”
“Establishing work requirements in Medicaid for able-bodied adults, with reasonable exemptions – then from the previous precedent of welfare reform – that all makes common sense, yet today,” Grassley said during his speech. “States like Iowa are already leading the way in establishing work requirements for able-bodied adults in Medicaid.”
Murphy said losing coverage can be devastating to someone’s sobriety.
“It will put folks’ sobriety at risk if they do lose their Medicaid coverage, particularly in the manner in which it would be lost through work requirements,” Murphy said. “A lot of folks wouldn’t have an affordable, viable option for alternative coverage sources.”
Losing coverage creates barriers to access
With work requirements adding burdens to those seeking care, providers worry it could prevent some from seeking treatment, even though they want it.
“It’s just going to throw in more obstacles for our clients,” Dan Keller, the executive director of Alcohol and Drug Dependency Services of Iowa said. “It’s going to be challenging for those clients and for our staff, who, quite frankly, are already really challenged, as the current system already exists.”
Alison Lynch, the director of the Addiction Medicine Clinic at the University of Iowa Health Care, said access to addiction care is paramount because addiction is quite treatable.
“Because treatment is often quite helpful for people, they need to be able to access it,” Lynch said. “When people can’t access it, then they continue to be in a state of having untreated health issues or things that are interfering with them from focusing on what’s really important to them in their life.”
Keller said accessing care can often be difficult on its own, so his staff will be working to educate clients on how to maintain coverage.
“Any loss in coverage for individuals is going to be really significant; it adds more barriers put in place for folks obtaining services,” Keller said.
Medicaid overwhelmingly pays for addiction care; without it, providers suffer
According to data from the Institute for Health Metrics and Evaluation, Medicaid pays for 60 percent of addiction care in the U.S. and for 56 percent of all addiction care in Iowa.
With roughly $1 trillion in cuts to Medicaid set to take effect in 2027, providers are looking to diversify their revenue to brave the shift.
Keller said 35 percent of Alcohol and Drug Dependency Services’ revenue comes from Medicaid for the Burlington-based nonprofit.
“We spend a huge amount of time every single day just simply trying to figure out how we’re going to get paid for the services that we provide, navigating that tangled web,” Keller said. “It’s really a mess with Medicaid — private insurance, self-pay, state block grant, any number of other sources — take up a huge chunk of our time.”
Murphy said rural providers are more likely to feel the effects of these cuts, and it could further decrease access in Iowa, though experts say there already isn’t enough access in Iowa.
Murphy said an increase in uncompensated care costs, or costs for providing care to someone without coverage and the inability to pay, could push a lot of these providers over the edge and cause many to close.
“Substance use disorder treatment centers really rely on Medicaid to reimburse them for the critical treatment support they are providing to individuals in their respective communities,” Murphy said. “Particularly in rural areas, there’s a lot of concern that these facilities end up closing.”
This comes as Iowa already faces a shortage of access to addiction care, specifically for inpatient services.
Iowa also faces a shortage of psychiatric providers, with 73 out of 99 counties in Iowa not having any psychiatrists, according to UI Health Care.
Substance use disorders affect roughly 17 percent of all Americans, according to the 2024 survey on National Drug Use and Health by the National Institutes of Health.
Lynch said although there are many facilities throughout the state, many still struggle with accessing treatment for several reasons, namely the shortage
of providers.
“Even if everybody did feel comfortable asking, and had lived nearby, had insurance and stuff — we don’t have enough treatment providers in Iowa,” Lynch said.
Though efforts at the state level are working to effect change on that front, cuts to Medicaid could devastate rural providers and make access even more scarce for addiction care.
Breeding said getting access to care was the hardest part of treatment once Bailey was ready for it. She said she continues to fight for change and to increase access to addiction care in Bailey’s memory.
“I tried so hard, and that’s the part that sucks, is that I tried so freaking hard,” Breeding said through tears. “I went to Texas to bring him home when he was ready for help. As soon as I got the ‘I’m ready.’ When they’re ready to get help, they need it now, and they need it long-term so that they can heal.”