The Trump administration continues to wage war on programs that keep people who use drugs healthy and alive. Experts fear that the recent decline in overdose deaths, after years of unprecedented crisis—the last year of the Biden administration saw a 26 -percent drop—will stall or reverse, as people lose access to health care and harm reduction.
Close to $1 trillion will be cut from Medicaid over 10 years, under the One Big Beautiful Bill Act that President Trump signed in July 2025. Medicaid is the biggest payer for substance use disorder treatment in the United States, and around 40 percent of people with opioid use disorder rely on the program for health coverage.
Specific cuts and further threats apply to naloxone provision, medications for opioid use disorder, harm reduction research and much more.
Then in January, the administration abruptly slashed $2 billion from Substance Abuse and Mental Health Services Administration (SAMHSA) grants to public health and social programs, including harm reduction—before reversing the decision the very next day. The impacts on scrambling providers were still real.
“As far as scaling up to meet the community’s need, that’s not the conversations providers are having. It’s really about survival mode.”
The Legal Action Center (LAC) works for health justice, advocating for the rights of people impacted by criminalization, substance use disorders and HIV. To help get a sense of the current damage and future prospects, Filter spoke with Gabrielle de la Guéronnière, LAC’s vice president of health and justice policy. Our interview has been edited for length and clarity.
Tana Ganeva: What’s your overview of the situation with the cuts, and how they threaten access to care and harm reduction for people who use drugs?
Gabrielle de la Guéronnière: We’ve been very concerned. It’s been a very challenging time for people who are running programs on the ground. People are trying to help people stay healthy and stay alive, and there has been a lot of confusion from the administration in a number of different ways, and a lot of really concerning, harmful rhetoric that’s very stigmatizing toward the people who are being served by those programs and toward people working in those programs.
Suggesting that these are dangerous services, that they are not evidence-based, that they are ineffective, and that they shouldn’t receive support—when we know that they are evidence-based. They are extremely effective in preventing infectious disease, and also in connecting people who would like substance use disorder treatment and recovery services to those services.
So it’s been a very difficult, challenging time.
TG: What was it like for programs that were told, if only for one day, that their grants were going to be cut under the January SAMHSA defunding decision?
GdlG: Programs received notification that grant funds would be terminated immediately—and we know that people lost their jobs because of that, because programs were told that this was happening, that funding would not be coming. And so in very real terms, we know that there were programs that were impacted.
When you think about how difficult this work is, when we know how many people are at risk for overdose and are at risk for all kinds of other health problems, the focus should be what [harm reduction programs] need and doing what they do best, which is providing those critical health services, because they are health services.
Instead, providers are worrying about how they’re going to keep the doors open. As far as potential expansion or scaling up to meet the community’s need, that’s not the conversations people are having.
It’s really about survival mode. It’s hard to forecast. And nonprofits need to forecast. It’s very difficult.
“We are very worried with what we’ve seen with the work requirements for Medicaid … They are forecasting that millions of people will lose health coverage.”
TG: Without being in the administration’s heads—a scary place—can you guess why, having yanked the SAMHSA funding, they then reinstated it?
GdlG: I think one positive thing has been that there are a lot of people in both parties who understand the value and the need for funding for these services around the country.
We immediately saw that policy change, literally overnight, because there were all kinds of stakeholders who weighed in with their members of Congress, and talked about how critical these dollars were, both substance use funding, and mental health dollars that help people in their community to get healthy, to maintain their health, to prevent all of the different harms that could occur if someone’s disconnected from care and services and supports and medications.
TG: Then there are the massive cuts to Medicaid over 10 years. What do you make of that, and what is LAC doing to try to mitigate the impacts?
GdlG: We’re extremely concerned about the Medicaid cuts. We do a lot of work with people who have substance use disorders, have mental health conditions, have histories of incarceration, and face a lot of stigma and discrimination in the job market.
We are very worried, too, with what we’ve seen with the work requirements—as different states have tried work requirements, and attaching that to Medicaid—that people who are working often lose coverage, because the administrative burden is really difficult.
So they are forecasting that millions of people will lose health coverage. We’re extremely concerned about that, and doing a lot of work to try to engage with decision-makers, and states and localities and stakeholders, to try to help people to maintain coverage. It’s so critical to helping people stay safe and alive.
TG: In the wake of all this, do you envision a spike in overdose deaths?
GdlG: I worry about that. There are many people who worry about that, that people are vulnerable, and if you make it harder for them to be able to access health care, it’s going to make it more difficult for them to stay healthy. Our whole health care system is very unaffordable and it’s a very challenging time with the economy and getting jobs. So we’re worried about it. We’re very worried about it.
“There are a number of things that states can do to try to minimize the burden on individuals … There are ways that you can create systems to protect people.”
TG: Looking ahead, in terms of these and potential further cuts, what are your worst fears? And do you see any more encouraging signs?
GdlG: We were pleased that the conferenced fiscal-year 2026 Labor, Health and Human Services, and Education bill, which President Trump signed into law, increases SAMHSA funding by $65 million over last year’s levels. We appreciate the continued strong bipartisan support in Congress for treatment, prevention and recovery services.
We continue to be extremely concerned about the administration’s repeated attempts to claw back Congressionally appropriated funds which have created huge uncertainty and upset for community-based programs providing life-saving services in our communities.
We are also extremely concerned about the administration’s continued negative, inaccurate rhetoric and damaging actions related to harm reduction services. Harm reduction strategies and interventions are evidence-based health services that are effective in meeting the health-care needs of people who use drugs, and connecting people who need and want it to substance use disorder services, medications and support in treatment and recovery.
Precluding the use of federal dollars for critical harm reduction services will make it more difficult for community programs to keep their doors open, will make communities less healthy, and will put more people at risk for overdose.
TG: What’s the best realistic outcome in the next couple of years? What can be done to adapt?
GdlG: There are a number of things that states can do to try to minimize the burden on individuals. There are different systems they can set up, so if they have data about a person’s health history or work history, they can use that data to demonstrate that that person qualifies for an exemption to the work requirements [for certain Medicaid enrollees].
There are a number of provisions that create exemptions—for people who are in certain kinds of substance use to start treatment, or people who have recently reentered from incarceration, or a person who has a chronic, serious health condition. There are certain protections there, so there are ways that you can create systems to protect people.
There are also wonderful people in our field, who will be working to really protect people and ensure that people are able to demonstrate what they need to, to maintain coverage. It’s really going to take all of us working together to make sure people can continue to access coverage and care.
Photograph by Nikolaos Dimou via Pexels
