Five States Can Now Pay People to Stay Sober. Here’s Why That Number Is Still Too Small.

The clinical argument for contingency management is settled. Give people a tangible reward — a gift card, a cash payment, a voucher — for a drug-negative urine screen or for showing up to treatment, and they use drugs less. The evidence base has been building for three decades. Meta-analyses consistently show contingency management (CM) produces better outcomes for stimulant use disorder than any other currently available treatment. There are no FDA-approved medications for methamphetamine or cocaine use disorder — none — which makes CM the closest thing the field has to a first-line treatment.

The political argument against it has always been: we shouldn’t pay people to do what they should do anyway.

As of 2026, five states have navigated past that argument and secured CMS approval to cover CM under Medicaid via Section 1115 demonstration waivers: California, Delaware, Hawaii, Montana, and Washington. Michigan and Rhode Island have submitted applications and are awaiting CMS action. Together, these programs are the most significant expansion of evidence-based stimulant use disorder treatment in the United States in years.

The mechanics vary by state. California’s Recovery Incentives Program — the largest in operation — provides Medicaid-enrolled members with financial incentives for negative drug screens across a 24-week program. Montana’s program runs 12 weeks. Delaware extends coverage to 64 weeks for pregnant and postpartum members with certain substance use disorders — a recognition that the treatment window for this population requires sustained support. Across the approved programs, enrollees can earn between $596 and $1,092 in financial incentives over the course of participation.

The incentives are calibrated to be meaningful without being so large as to create perverse effects. They are not enough to constitute income that would affect other benefits. They are enough to matter.

For the 45 states that have not secured CMS approval — including Arizona, where stimulant use disorder overlaps heavily with the state’s fentanyl and polysubstance crisis — people with methamphetamine or cocaine use disorder are largely on their own to find and pay for a treatment that works. Medicaid does not cover it. Private insurance often does not cover it. The out-of-pocket cost for structured CM programs is prohibitive for the population most likely to need them.

This is not an abstract access question. The ADAPT-2 trial’s secondary analysis shows that craving and impulsivity are the primary mediators of whether someone returns to methamphetamine use. Contingency management works by interrupting those mechanisms behaviorally — providing an external reward signal that the dopamine-depleted brain can act on. It is, in the absence of a pharmacological option, the treatment. Restricting it to five states is the equivalent of approving buprenorphine for opioid use disorder and making it available only in California, Delaware, Hawaii, Montana, and Washington.

The question isn’t whether paying people to stay sober feels morally acceptable. The question is whether the alternative — not covering the most effective treatment while 57,500 people die annually from stimulant-involved overdoses — is morally acceptable instead.

Michigan and Rhode Island are waiting. The other 43 states haven’t started.