When Jon Desantis was released after a six months stint in jail last September, he had lost many of the moorings of a stable life.
He could not go back to his apartment, because the girlfriend he had shared it with before his conviction on assault charges had cut ties with him. The construction company where he’d worked for years told him his position had been filled. And though it was nearly paid off, creditors repossessed his F-250 pickup truck, with storage for tools that he had built himself.
Born and raised in San Jose, Mr. Desantis, 37, might have called acquaintances for help, but that carried its own risks. “It’s very easy for me to fall into situations or run into people that I have known for a very long time that aren’t necessarily doing the things that they should be doing,” he said.
Instead, he got a vital assist from an unexpected place: California’s Medicaid program.
A month before completing his sentence, Mr. Desantis met with a county health care worker in the jail, who assessed his needs. He walked out with a 30-day supply of his prescription medications for depression and anxiety, emotions he had begun to identify as the root of his alcoholism and drug use. A case manager with a local nonprofit was waiting to line up appointments with a psychiatrist and a therapist. Within months, he was picking up contracting work and filing documents to start his own carpentry business.
All these services were covered by Medicaid. Without that care, Mr. Desantis said, “I couldn’t tell you what would have happened.”
“It’s a scary thing to be in a facility and get released to nothing,” he added.
Until recently, jail and prison inmates were excluded from Medicaid coverage, despite their elevated rates of mental and physical illness. Now, as a result of changes in federal law made with overwhelming bipartisan support, Medicaid has begun paying for a narrow set of services beginning up to 90 days before an inmate is released and continuing afterward. Law enforcement and correctional leaders say it represents a seismic shift in how incarcerated people navigate the perilous transition back to freedom, with significant benefits for their health and safety and for the communities they rejoin.
Twenty-seven states have sought or received federal approval to expand Medicaid to prisoners on the eve of their release. California’s state Medicaid program, Medi-Cal, has already enrolled tens of thousands of incarcerated people.
Dr. Noha Aboelata, who founded the Bay Area nonprofit Roots Community Health, which helped Mr. Desantis after his release, said the policy change was among the most significant since the passage of the Affordable Care Act.
People released from jail or prison were fragile, she said, and there was a lack of coordinated services for them. “We’re asking systems: Work together more. Talk to each other more,” she said. “A lot of these bureaucratic silos we have are actually killing people.”
Freedom can be deadly
Extending health coverage into jails and prisons might seem like a simple shift, but it has taken years, and required a cascade of changes by federal, state and county lawmakers.
Medicaid’s policy of excluding people in prisons and jails from coverage goes back to the program’s inception in the 1960s. A person with Medicaid coverage would typically lose it upon incarceration, and then, need to re-enroll upon their release — a process that could take months — before health care providers would schedule appointments or refill prescriptions.
That opened a hazardous gap in services for incarcerated people, many of whom have chronic conditions. About 60 percent of people in jails have substance use disorders, and the prevalence of serious mental illness is several times higher than in the general population.
Perversely, being freed from jail or prison — and disconnected from the minimal clinical services the facilities provide — can pose a danger for former inmates. One study found a person’s risk of death during the first two weeks after release was nearly 13 times that of the general population.
More than a decade ago, the nonprofit Legal Action Center, along with county officials and sheriffs, began pushing for changes in federal law that would allow Medicaid to cover services during this period of transition.
Vikki Wachino, who was at the time a deputy administrator of the Centers for Medicare and Medicaid Services, said law enforcement’s interest caught her attention. “People return to the community without support, and frequently cycle back into jail later,” she said. “Sheriffs and wardens have seen that over and over again.”
In 2018, Congress passed legislation inviting state Medicaid programs to experiment with approaches to bridge the services gap. Having left government, Ms. Wachino set up the nonprofit Health and Reentry Project to help states submit and carry out their plans, called waivers.
California’s waiver was the first to be approved, in January 2023. It built on the state’s efforts to make drug and alcohol treatment easily available in state prisons, Autumn Boylan, deputy director at the California Department of Health Care Services, said. But it also went further, enrolling eligible detainees in Medi-Cal, and providing case management for up to a year after release.
In Santa Clara County, the new process has been underway for 18 months. At the Elmwood jail one afternoon in January, Johnny Granados, an inmate, met with Angel Coronado, a community health worker, to plan for his release.
Born in the nearby farming community of Gilroy, Mr. Granados said he had become addicted to methamphetamines after his mother died, when he was about 18. He’d been living in a tent before his latest arrest, for a parole violation stemming from a petty theft, and he felt trapped in cycles of behavior that seemed impossible to break. In jail, he said, he had sobered up, and he was desperate not to relapse. “I’m tired of the tired,” he told the case worker.
Mr. Coronado fired up a laptop for them to meet virtually with the case manager from a local nonprofit clinic who would help Mr. Granados after his release.
Together, they double-checked Mr. Granados’ release date, confirmed that his applications for benefits like food stamps were underway and went over his health needs.
Asked for a home address, Mr. Granados paused, and then gave his sister’s. Many detainees lack stable housing, but upon release they may be eligible for assistance with up to six months’ rent and a security deposit.
Ideally, the plan would see Mr. Granados through re-entry to the services he needed on the outside, and keep him from falling through the cracks.
Santa Clara’s Sheriff, Bob Jonsen, called the Medicaid expansion “fantastic and long overdue.” He said he expected the changes would improve safety in the community and also in the jails. “If you can stabilize people, you are going to have a more safe and peaceful environment all the way around,” he said.
Santa Clara had a leg up. One of the wealthiest and most populous counties in the state, the local government already provided health care in its jails, rather than contracting out the work.
The county also operates clinics, pharmacies and hospitals in the area, all with a shared electronic medical record system, which made it easier to begin billing Medi-Cal for eligible services in the jails.
The changes have required more coordination among courts, jails and medical services. Now, when the court ordered the jail to release someone, the medical team was notified to ensure the person had their medications. A public defender might be consulted to see if release to a different county with more family support was preferable.
“For years, it’s always been kind of three independent structures,” Michelle de la Calle, who oversaw the changes for Santa Clara County’s health system, said. “The way we’ve approached it in Santa Clara County is saying: There’s a human at the center of this.”
A lot of unknowns
California’s rollout is changing re-entry across the state. All 31 state prisons and 34 county jails and youth facilities are participating, with the remainder expected to begin later this year. As of January, more than 50,000 inmates have received prerelease services paid for by Medi-Cal, according to the state health department.
Other states are not far behind: Medicaid programs in Washington, Montana, New Hampshire, New Mexico and Vermont have begun paying for some re-entry services.
Twelve other states have had their waivers approved. Another eight and the District of Columbia have filed plans with the federal government, but the Trump administration has yet to approve them. Chris Krepich, a spokesman for C.M.S., said the agency “carefully assesses demonstration proposals in accordance with current law and applicable statutory authority.”
The expansion has been complicated by the sweeping changes to Medicaid enacted in the tax and domestic policy bill that President Trump signed last July. Oregon’s Medicaid program, which had received approval to put in effect a waiver for re-entry services, withdrew in October, citing a lack of bandwidth to address competing priorities compelled by the federal legislation.
Beginning next year, Medicaid enrollees must show they are working, in school or doing community service to maintain their coverage. That could affect people during re-entry, according to Robin Rudowitz, director of the Medicaid program at the health research group KFF.
But states must exempt people who were recently released from incarceration and who have certain medical conditions, including substance use disorders. How that works in practice will depend on yet-to-be-published federal guidance. “There are a lot of unknowns,” she said.
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