There was a program working. A genuinely, measurably, bipartisan-supported program that was keeping people out of prison and keeping them alive. It involved getting Medicaid coverage to people before they walked out of jail so they didn't go straight back to their dealer. And now the Trump administration is strangling it.
The Part That Actually Works
Cody Coughenour had been in and out of jail at least six times by the time he was 47. First alcohol. Then meth, after his mother died of a meth-induced heart attack when he was 26 years old. Every time he got out, he was handed a phone number to call about Medicaid coverage. NPR reports it would go to voicemail, or he'd sit on hold until the wait was long enough to send him straight to his dealer's house.
December 2025 was different. He left jail with his anxiety medications, his Medicaid card already in his pocket, and appointments already on the calendar. He went straight to a treatment facility instead. That is the entire program right there, in one human being's story. Give people coverage before the door swings open, not after.
This isn't some radical left-wing social experiment cooked up at a Berkeley think tank. Congress directed federal health officials to work on this back in 2018, under the first Trump administration, according to NPR. The Biden administration gave 19 states permission to move forward. Eight more states and Washington D.C. were in line waiting for approval. Four states had already launched: California, Washington, Montana and New Hampshire.
Why People Die After Getting Out
Here is the thing about leaving incarceration that most people who have never experienced it don't fully understand. The first few weeks out are, statistically, some of the most dangerous weeks of a person's life. NPR cites research showing sharply elevated risks of death immediately following release, particularly from overdose. Your tolerance drops inside. Your body forgets. You get out and use what you used to use and you don't wake up.
For decades, federal Medicaid dollars were legally barred from paying for most health care provided while someone was incarcerated. The states and counties picked up the tab, and they mostly didn't, which is why courts have had to order improvements in roughly half of state prison systems, according to NPR. People were leaving with untreated mental illness, active substance use disorders, unmanaged chronic disease, and a phone number on a piece of paper.
The bridge program these states were building was designed to close that gap. Get Medicaid activated 30 to 90 days before release. Screen for substance use disorder. Get medications started. Book the appointments. When someone walks out, they walk out with a plan and the insurance to pay for it. Washington state officials told NPR that people who received Medicaid before release have been less likely to return to jail or prison. That is the whole ballgame.
Enter the One Big Beautiful Wrecking Ball
H.R. 1, which the Trump administration branded the One Big Beautiful Bill, passed last year and is now tearing through Medicaid like a lawnmower through a garden. Work requirements. Tighter eligibility checks. Budget cuts. Every state Medicaid agency in the country is now scrambling to implement a pile of new federal mandates that require significant administrative time and resources to execute.
The result, NPR reports, is that at least three states have already paused their prison reentry Medicaid work entirely: Oregon, Rhode Island and Michigan. Oregon Medicaid Director Emma Sandoe told NPR that her state still wants to build the program, but the OBBB has eaten up the time and resources needed to do it. The state now has to focus on implementing work requirements and more frequent eligibility checks before it can get back to, you know, keeping people from dying after they get out of prison.
On top of the administrative crunch, the Trump administration is reportedly scrutinizing the reentry programs directly, examining how much they cost and what services they cover. That kind of federal attention is not a sign of enthusiastic support. It is a flashing warning light for every state that was hoping to get a waiver approved.
The Translator Problem
Even before the OBBB made everything harder, building these programs was not easy. NPR spoke to Marc Stern, a Washington doctor who has spent 25 years working inside prisons and jails, who put it plainly: "What we really needed was a translator between the Medicaid agency and the jails. Because Medicaid doesn't speak jail, and jail doesn't speak Medicaid."
It took years for the leading states to build the systems, get buy-in from local jail operators, and figure out how to integrate two bureaucracies that weren't designed to talk to each other. That institutional knowledge took time to develop. The states that were just getting started were going to be learning from what California and Washington built. Now those states are being told to put the whole project on hold while they implement a fresh load of federal paperwork requirements.
So the four states that got there first get to keep their programs running, for now. The fifteen states with waivers already approved but not yet launched are in limbo. The eight more waiting for approval are watching their chances shrink by the month. And the people who would have been Cody Coughenour in those states are still getting handed a phone number that goes to voicemail.
The Dingo Take
Let's be honest about what is happening here. The federal government spent years encouraging states to build a program that kept people alive and out of prison. It cost money, sure. So does incarcerating someone, which runs anywhere from $35,000 to over $60,000 per person per year depending on the state. The math on early Medicaid coverage is not complicated. It was not controversial enough that even the first Trump administration helped set it in motion.
But the OBBB does not care about the math. The OBBB is not a carefully reasoned piece of legislation designed to trim waste and improve outcomes. It is a blunt instrument for cutting the federal budget in ways that hurt poor people while delivering tax cuts to people who will never see the inside of a county jail. The work requirements and eligibility checks now consuming every Medicaid agency's bandwidth are not going to make anyone healthier. They are going to knock people off the rolls, generate paperwork, and make it impossible for states to do the creative, life-saving work they were in the middle of building.
Cody Coughenour got lucky. He got out in December 2025, just before the walls started closing in. He got his card, he got his appointments, he went to treatment. Somewhere in Oregon or Michigan or Rhode Island, someone is getting out of jail this week, getting handed a phone number, and sitting on hold until the wait is just long enough. The federal government knew how to fix that. It chose not to.
