Budget law stalls bipartisan pre-release Medicaid effort

Louisiana gets narrower approval under Trump administration

For decades, federal Medicaid dollars were prohibited from paying for most health care provided to people while incarcerated; that cost fell to counties and states. In 2018, Congress directed federal health officials to work with states on improving care for people leaving prison and jail, and the Biden administration granted 19 states permission to cover services 30 to 90 days before release. Eight additional states and Washington, D.C., also sought approval.

Four states — California, Washington, Montana, and New Hampshire — have begun providing Medicaid coverage to people inside, screening tens of thousands for substance use disorder and connecting them to care before release. Washington state officials said individuals who received Medicaid before release have been less likely to return to jail or prison.

H.R. 1, the sweeping budget law signed by President Trump last year and also known as the One Big Beautiful Bill, changed the landscape. The law requires state Medicaid agencies to implement work requirements, tighter eligibility checks, and budget cuts. Marc Stern, a Washington doctor who has spent 25 years working inside prisons and jails, described the challenge of building these programs. “What we really needed was a translator between the Medicaid agency and the jails,” Stern said. “Because Medicaid doesn’t speak jail, and jail doesn’t speak Medicaid.”

At least three states have paused their pre-release Medicaid work. Oregon Medicaid Director Emma Sandoe said bringing Medicaid behind bars aligned with her state’s long-standing push to expand coverage, but the law has forced Oregon to focus on other priorities. “What physically can be done with the amount of time, with the amount of resources available, is limited,” Sandoe said. Rhode Island and Michigan cited insufficient funding. In rescinding its application in December 2025, Michigan officials wrote, “This initiative will be archived and considered for future efforts to support reentry populations.”

In April, Louisiana became the first state to receive approval under President Trump. Pete Croughan, Louisiana’s deputy Medicaid director, said the proposal went through an “intensive delete process” as federal officials pushed the state to cover only the most essential services. Louisiana limited its pre-release benefits to mental health care, medications for addiction treatment, infectious disease screening, and medical equipment such as wheelchairs. The state scaled back plans to cover primary care inside jails and prisons, instead planning to connect individuals to a clinician they could see after release.

“There’s definitely evidence that folks with untreated mental health and addiction issues are more likely to die. So we have to solve for that,” Croughan said. “I don’t know that there’s evidence for that for someone with untreated knee pain.”

Louisiana also requested less federal startup funding, instead using money from the new Rural Health Transformation Fund and another existing federal funding source.

A spokesperson for the Centers for Medicare and Medicaid Services said in a statement, “The agency understands that states may face varying challenges during implementation, and CMS remains committed to supporting all states throughout this process.”

Lauren Brinkley-Rubinstein, a professor at Duke University who studies the health impacts of incarceration, said the services Louisiana plans to offer — especially medications for opioid use disorder — are the most impactful for keeping people alive. But she said many people leaving incarceration have multiple chronic illnesses that have often been inadequately treated inside. Under Louisiana’s plan, she said, newly released individuals will need to find care for those conditions on their own, on top of finding housing, food, and employment.

“Going to the doctor and refilling that prescription is just never going to rank higher than those other things,” Brinkley-Rubinstein said. “It makes it more likely that they are going to come back through the [jail or prison] door.”

Cody Coughenour of Port Angeles, Washington, described how the program worked for him. He had been jailed at least half a dozen times by age 47 — first for crimes related to alcohol, then, after his mother died of a meth-induced heart attack when he was 26, for crimes related to methamphetamines. “What people are running away from, that’s what they’re going to run into,” he said.

After each release, jailers gave him a phone number to call to enroll in Medicaid. The call would go to voicemail or he would be placed on a long hold, he said. That delay sent him to his dealer and eventually back to jail. December 2025 was different: He left the jail with medications for his anxiety, his Medicaid card in hand, and appointments already scheduled. “We went straight to the treatment facilities,” he said.