People leaving jail and prison die at sharply elevated rates in the first weeks after release, most often from overdose. Four states have now built programs to hand them a working Medicaid card before they walk out the door instead of a phone number to call afterward.
California, Washington, Montana and New Hampshire have started providing Medicaid coverage to people while still incarcerated, and tens of thousands are being screened for substance use disorder, started on medication and connected to community providers before release, according to reporting by Tradeoffs.
Here is the part that most coverage skips: it is too soon to know whether any of this is reducing deaths or emergency room visits. Officials in Washington say people who received Medicaid before release have been less likely to return to jail or prison, but that is a state observation, not a published evaluation.
What is documented is the other half of the story. A sweeping federal law is now forcing states to choose between building these programs and keeping up with new Medicaid paperwork requirements, and at least three have chosen the paperwork.
What These Programs Actually Do
For decades, federal Medicaid dollars could not pay for most health care delivered to incarcerated people, leaving that cost to counties and states. Care behind bars is frequently underfunded, and courts have ordered improvements in roughly half of state prison systems.
In 2018, Congress directed federal health officials to work with states on improving care for people leaving custody. States began requesting Section 1115 waivers to cover certain services 30 to 90 days before release. The Biden administration approved 19 state waivers, with eight more states and Washington, D.C. seeking approval.
Federal guidance set a floor: at minimum, states were expected to provide addiction treatment, medications before release, and someone to help people get care once out. Some states went further and offered full Medicaid benefits.
Building the systems took years. Marc Stern, a Washington physician who has spent 25 years working inside prisons and jails, described the core obstacle plainly, saying "Medicaid doesn't speak jail, and jail doesn't speak Medicaid."
The clinical logic is well established even if these specific programs have not been evaluated. Medications for opioid use disorder, including buprenorphine and naltrexone, are associated with lower overdose and mortality rates when continued through and after incarceration, and a gap of even a few days at release is the window in which people die.
Why Three States Stopped
H.R. 1, the federal law passed last year, requires state Medicaid agencies to implement work requirements, more frequent eligibility checks and budget reductions. Those obligations land on the same small teams that would otherwise be building reentry programs.
Oregon, Rhode Island and Michigan have paused their work. Oregon Medicaid Director Emma Sandoe said the state still wants to bring Medicaid into jails and prisons but has to prioritize the new federal requirements first, describing a hard limit on time and available resources.
Rhode Island and Michigan cited insufficient funding. Michigan officials wrote in December 2025 that the initiative would be archived and considered for future efforts.
This is the accountability question worth stating without spin: a program with bipartisan support in both red and blue states is being slowed less by disagreement about its merits than by the administrative load of unrelated Medicaid changes.
What the Louisiana Approval Signals
In April, Louisiana became the first state approved under the current administration.
Louisiana Deputy Medicaid Director Pete Croughan said the state's proposal went through what he called an intensive delete process, narrowing coverage to services the state determined were most essential. Tradeoffs later clarified that this narrowing was state-directed rather than a federal requirement.
The approved package covers mental health care, medications for addiction treatment, infectious disease screening and medical equipment such as wheelchairs. Louisiana scaled back plans for Medicaid to pay for primary care inside facilities, and instead will introduce people to a clinician they can see after release.
Croughan framed the tradeoff around evidence, noting strong evidence that untreated mental health and addiction problems raise the risk of death and less clear evidence for treating conditions like untreated knee pain pre-release.
Federal health officials declined to say whether other states must follow Louisiana's model. A CMS spokesperson said the agency understands states face varying challenges and remains committed to supporting them through implementation.
Who This Affects and What Is Still Unknown
The population is larger than most readers assume. Federal estimates indicate more than half of people in state prisons and about two-thirds of people sentenced in jails have substance use disorders.
Lauren Brinkley-Rubinstein, a Duke University professor who studies the health effects of incarceration, agreed that medications for opioid use disorder are the highest-impact service. But she noted that many people leaving incarceration have multiple chronic illnesses that were inadequately managed inside, and that under a narrower benefit they must arrange that care themselves while also finding housing, food and work. Her concern is that refilling a prescription never outranks those needs, which makes return to custody more likely.
What remains genuinely unknown is whether pre-release enrollment reduces overdose deaths, emergency department use, or reincarceration at population scale. No state has published an outcome evaluation. Readers should treat any claim that these programs are proven to save lives as ahead of the evidence, including claims made by supporters.
Autumn Boylan, who oversees California's program, has also noted that access to health care is only one piece, pointing to the parallel rollback of federal guidance encouraging states to use Medicaid for housing supports.
What Families Should Do and What Comes Next
If someone in your family is incarcerated in California, Washington, Montana or New Hampshire, the practical step is to ask the facility's medical or reentry staff whether Medicaid pre-release enrollment is available and whether the person has been screened for substance use disorder. Ask specifically whether medication for opioid use disorder will be started before release and who the community provider will be.
In states without a program, the equivalent step is to apply for Medicaid immediately upon release and to ask about naloxone before the person leaves. Tolerance drops sharply during incarceration, which is why the first days out carry the highest overdose risk.
Anyone who witnesses an overdose should call 911 and administer naloxone if available. Most states have Good Samaritan laws that provide some protection to people who call for help.
Watch for two things next. States with approved waivers that have not launched will decide whether to proceed under current funding, and CMS will signal through future approvals whether Louisiana's narrower benefit becomes the template. Evaluation data from California, which launched first, is the earliest realistic source of outcome evidence.
The confirmed situation is that four states are running these programs and three have paused theirs. The most affected group is people leaving custody with untreated addiction. The reasonable action for families is to ask about pre-release enrollment and naloxone. The central uncertainty is whether any of this reduces deaths, which nobody yet knows.
Frequently Asked Questions
Which states have working programs? California, Washington, Montana and New Hampshire have begun providing Medicaid coverage to people before release. Nineteen states have approved waivers overall.
Do these programs reduce overdose deaths? Unknown. No outcome evaluation has been published. Washington officials say participants have been less likely to return to custody, but that is a state observation rather than published data.
What services are covered before release? Federal guidance set a minimum of addiction treatment, medications before release, and help connecting to care afterward. Some states cover more, and Louisiana's approved package is narrower.
Why did some states pause? Oregon cited the administrative burden of new work requirements and eligibility checks under H.R. 1. Rhode Island and Michigan cited insufficient funding.
Why is the period right after release so dangerous? Drug tolerance falls during incarceration while access to care is often disrupted, which makes the first weeks after release the highest-risk window for fatal overdose.
What can a family do in a state without a program? Apply for Medicaid immediately on release, ask facility staff about naloxone before release, and identify a community provider in advance.
What happens next? States with approved but unlaunched waivers will decide whether to proceed, and California's earlier launch offers the first realistic chance at outcome data.
