May 15, 2025
Dear Colleague:
The House Energy & Commerce Committee recently released proposed legislation aimed at cutting $800 billion from Medicaid over the next decade. The cuts include new eligibility restrictions, shorter redetermination windows, and work requirements for many enrollees, which are not scheduled to go into effect until 2029. In a policy environment defined by cuts, what didn’t get cut is striking.
Buried in the legislation is a powerful signal that access to Medicaid services in jails and prisons still matters. People who are incarcerated, or within 90 days of release, were explicitly carved out from the new work requirements. Core carceral Medicaid reforms that we have all fought for—like 1115 waivers for pre-release services, the ability for FQHCs to operate in jails, or the requirement under Section 5121 of the Consolidated Appropriations Act that youth be covered 30 days pre-release—remain untouched.
These aren’t just policy choices. They are acknowledgments that Republicans in Congress recognizes what we’ve long known: the justice system has become the front line for people with complex behavioral health needs.
At the same time these protections remain in place, other changes could push more people into carceral settings as a pathway to coverage. The proposed six-month redetermination requirement means that someone who churns in and out of jail may have a better shot at staying insured than someone who simply struggles to keep up with paperwork in the community. For people with serious behavioral health conditions, who often lack stable housing or regular care, this is not a theoretical concern, it is a daily reality.
While Medicaid’s role in jails was always meant to improve care and create pathways back to community-based services, we now face the risk that it becomes something else: a justification for neglecting the community system altogether.
We see the signs already. In California, recent efforts to clear homeless encampments without offering housing or treatment alternatives suggest a shift away from care-first models. When states abandon “housing first” and “treatment first,” and then shore up jail-based Medicaid instead, we’re no longer talking about jail as the last resort—we’re turning it into the first resort.
This is not what sheriffs signed up for either. Many have welcomed Medicaid reforms not out of a desire to expand their role, but to reduce the burden they never wanted in the first place. They’ve made it clear: they are not hospitals, and they are not mental health systems. Medicaid was supposed to help them offload, not absorb, this responsibility.
We’ve made real progress. Medicaid is in the jail, not only as a payer, but as a tool for reentry, coordination, and accountability. That remains worth protecting. But we have to stay clear-eyed. Success in policy design does not guarantee success in implementation, especially when the broader system is failing.
So we’ll say it plainly:
- Jails are not therapeutic settings.
- The behavioral health system is not working for the people who need it most.
- And the risk of building a Medicaid structure that works better inside jail than outside it is very real.
We can’t let the success of our reforms be used to excuse the collapse of community care. Medicaid should follow people into jails—not trap them there.
Sincerely,
Daniel Mistak
Director of Health Care Initiatives for Justice-Involved Populations,
Community Oriented Correctional Health Services (COCHS)