State-by-State Variation in the Credentialing, Training, Supervision, and Medicaid Reimbursement of the High-School,...

Despite increased demand, few people receive the addiction services they need, and substance use disorders (SUD) workforce shortages persist. Addiction counselors are a workforce that can help address SUD needs. However, recent projections highlight national shortages of nearly 88 000 addiction counselors through 2036. Given state variations, it is difficult to discern how high school- and bachelor's-level (HS/BA) addiction counselors are defined based on education and training, state credentialing requirements, and Medicaid reimbursement allowances.

A state policy analysis across all 50 states and Washington, DC was conducted from November 2023 to June 2024. A systematic review of state Practice Acts, credentialing rules, and guidance documents from licensing bodies and state organizations was conducted to extract: (1) titles and degree classifications, (2) credentialing and examination requirements, (3) supervision, and (4) Medicaid state plans.

There are 160 credentials offered across all 50 states and DC across high-school (n = 56; 35%), associate's (n = 25; 16%), and bachelor's (n = 59; 37%) degrees. Only 3 states (AZ, NY, TX), offer addiction counselor credentials across all degree types. Thirteen states do not specify a degree but instead require training hours. However, the number of credentials offered per state ranges (1-16), and there is wide variability in how HS/BA addiction counselors are credentialed. Forty states allow some type of Medicaid reimbursement for HS/BS addiction counselors, while 11 states do not.

Addiction counselors are a critical workforce tasked with addressing SUD. To do so, they require clear training pathways, regulations, and payment mechanisms. Findings highlight wide variability within the addiction counselor workforce at the HS/BA level, including inconsistencies in minimum educational requirements and training hours, as well as an overall lack of uniformity across states. Clearly articulating addiction counselor career pathways is necessary to simplify and enhance states' SUD workforce. Identifying Medicaid and other reimbursement mechanisms is an important way to further expand how the SUD workforce is deployed to meet increased addiction-related needs.