California’s Behavioral Health Staffing Crisis: A Stress Test for Medicaid Behind Bars

Highlighted Stories

Editor's Note

Our subscribers are well aware that the Weekly Update often features stories highlighting the persistent challenge of staffing shortages in correctional settings—an issue we revisit this week. The first highlighted story, from California, focuses on a bold effort to address this crisis: the state prison system is now offering $20,000 hiring bonuses to attract behavioral health workers.

We’re spotlighting this story to underscore the link between chronic staffing shortfalls and the adequacy—and quality—of care behind the walls. This challenge is only expected to grow as Medicaid’s role in correctional healthcare expands, assuming Congress maintains the provisions currently outlined in the House bill.

As COCHS has often underscored, many individuals in jail or prison are there at least in part due to an acute expression of an underlying behavioral health condition. The Prison Policy Initiative estimates that 44% of incarcerated people have been diagnosed with mental illness, while the National Institute on Drug Abuse reports that 65% meet criteria for a substance use disorder. Delivering care that meets Medicaid’s standards for access, quality, and timeliness requires a workforce both robust and supported.

California’s current strategy—offering steep bonuses under the pressure of court orders and federal fines—illustrates just how difficult it remains to recruit and retain qualified professionals. Whether these incentives will be enough remains uncertain.

To provide national context, our second highlighted story comes from Nebraska and details similar behavioral health workforce shortages in that state’s correctional system. We also revisit a resource from the December 10, 2024 Weekly Update: a guide from the Legislative Analysis and Public Policy Association (LAPPA) outlining strategies to address current and projected shortages in the substance use disorder workforce.

Behavioral Health Staffing Shortages

After decades of unsuccessful efforts to improve California prison conditions ruled unconstitutional and blamed for record-high suicides, advocates and a federal judge are betting that bonuses and better work accommodations will finally be enough to attract and keep the mental health providers needed to treat prisoners. The funds come from nearly $200 million in federal fines imposed because of California’s lack of progress in hiring sufficient mental health staff. They are being used for hiring and retention bonuses, including an extra $20,000 for psychologists and psychiatric social workers — roles with the highest vacancy rates — and $5,000 boosts for psychiatrists and recreational therapists. The cash is aimed at countering a scarcity of mental health workers in California and across the country. State officials blame this dearth of workers for their chronic inability to meet hiring levels required by the long-running suit — a failure that led a federal judge to hold top officials in contempt of court last year.

This documentary explores the mental health crisis unfolding inside Nebraska’s prisons: the severe shortage of mental health professionals. A large proportion of Nebraska’s prison population suffers from serious mental illnesses, yet there is a high vacancy rate for mental health professionals within the Nebraska Department of Correctional Services (NDCS). Two formerly incarcerated individuals provide first-hand accounts of their experiences while the prison director acknowledges the seriousness of the issue.

Drafted in collaboration with the O’Neill Institute for National and Global Health Law at the Georgetown University Law Center, the purpose of the Model Building the Substance Use Disorder Workforce of the Future Act is to address the current and projected shortage of professions for the substance use disorder workforce. This legislation guides states in adopting a strategy that supports and advances immediate, intermediate, and long-term measures to build and sustain an SUD workforce.

Follow Ups

Editor's Comment: This week’s Follow Ups return to a familiar setting: Oklahoma County, Oklahoma. The jail there is plagued by a mounting death toll and an ongoing standoff between its governing body—the Oklahoma County Criminal Justice Authority (OCCJA)—and the Oklahoma State Department of Health (OSDH). These stories have been the focus of multiple Editor’s Notes and an Editor’s Comment (see: September 17, December 10, December 23 of 2024; January 7 and January 14 of 2025).

At the heart of the crisis is the OCCJA’s persistent resistance to statutory oversight by OSDH. As COCHS has previously noted, this level of intransigence is rare and raises serious concerns that officials were fully aware of conditions at the jail yet refused to act—despite repeated inspection failures and a rising number of deaths. That resistance ultimately led to the resignation of OCCJA’s CEO, Brandi Garner, following a scathing report issued by OSDH after a district court permitted an inspection. Now, the Oklahoma Supreme Court has sided with the OSDH, reinforcing the department’s authority.

A contributing factor to the jail’s high mortality rate is addressed in the second article from Oklahoma County, which revisits the long-running debate over replacing the current facility. Many argue that the building itself plays a central role in the county’s unusually high in-custody death rate. The third article offers a different lens on the crisis, highlighting remarks from Oklahoma County District Attorney Vicki Behenna. She describes the facility as dangerously overcrowded and inadequate and calls for greater investment in diversion programs. Her focus: preventing individuals—particularly those with behavioral health challenges—from entering the jail system in the first place.

We also return—yet again—to the New York State prison system. A new Marshall Project article explores the difficulty of proving correctional officer abuse without video evidence. Infirmaries, which often lack surveillance, have long been cited as abuse hotspots. That wasn’t the case for Robert Brooks: the correctional officers who killed him at Marcy Correctional Facility appear to have been unaware that the infirmary was under video surveillance.

Oklahoma County

The Oklahoma Supreme Court ruled the Oklahoma State Department of Health (OSDH) has lawful authority to conduct surprise inspections of the Oklahoma County Detention Center (OCDC). The Wednesday morning decision ends a year-long legal battle between the Oklahoma County Criminal Justice Authority (OCCJA) and the health department over the embattled jail. The OCCJA sued the OSDH on July 29, 2024, asking an Oklahoma County district judge to stop the agency from conducting unannounced inspections at the detention center. In response, the OSDH filed a motion to dismiss on Aug. 19, 2024. The agency argued it has always conducted unannounced inspections at the county jail, adding that the surprise factor encourages real-time compliance of required standards. The judge sided with the OSDH, ruling on Nov. 19, 2024, that the agency’s surprise visits do fall under the language in the state statute authorizing the inspections. Following this, the OCCJA filed an appeal on Jan. 7, 2025, moving the case to the Oklahoma Supreme Court. In a statement, OSDH said Thursday, "We continue to take our statutory responsibility to conduct inspections seriously, ensuring the health and safety of individuals in jail facilities across the state."

Nearly halfway through 2025, the Oklahoma County Jail is on pace to break its grim r ecord for detainee deaths while still struggling with staffing shortages, failed inspection reports and doubts among those tasked with overseeing the facility’s day-to-day operations. Seven detainees have died at the jail this year. Sixteen detainees died at the jail in 2022, its worst year on record. The jail saw seven deaths per year in 2023 and 2024. Since the Oklahoma County Criminal Justice Authority — known as the “jail trust” — took over operation and governance of the detention center in 2020, there have been 58 detainee deaths, according to the People’s Council for Justice Reform. While questions about the funding and future of the new county jail have delayed the 34-year-old facility’s eventual decommission, what appears clear to officials and the community at large is that Oklahoma County detainees are dying at an alarming rate.

Vicki Behenna, District Attorney for Oklahoma County, writes: I have worked in the criminal justice system my entire career. As a federal prosecutor and now as Oklahoma County district attorney, I’ve seen firsthand how untreated mental illness fuels the revolving door of arrest, incarceration, release, rearrest, incarceration and release. I’ve spent decades navigating the complexities of our justice system, and I can confidently say that there is a direct correlation between the investment in intervention and treatment programs and crime in our community. In Oklahoma County, we’re witnessing the consequences of this misalignment. The Oklahoma County jail has long grappled with overcrowding and inadequate conditions.

New York

A recent investigation by The Marshall Project found at least 46 cases in which prisoners in New York alleged guards abused them in an infirmary. Advocates say that officers have intentionally taken prisoners to infirmaries to beat them because the medical wings lacked cameras. The corrections department has begun putting more cameras in prisons following the December beating death of Robert Brooks, during which several body cameras were, unbeknownst to the officers, recording. The video shocked the public and led to criminal charges against 10 officers. But most abuse cases don’t have video.

Opioid Epidemic

As a group, we are concerned that Secretary Kennedy will use his position to promote punishment, abstinence only, and 12-step programs as a way to address the current drug crisis. There is no evidence that those strategies will lead to sustained recovery for most people with substance use disorders and addiction, and there IS evidence that they are insufficient or will cause harm. In its policy statement, APHA calls for policy actions that address barriers and foster equitable access to the full continuum of prevention, intervention services, and evidence-based care.

Racial Disparities

Black men in the United States face high incarceration rates and formerly incarcerated Black men (FIBM) have worse mental health outcomes than Black men who have never been incarcerated. Incarceration is a driver of population health inequities and as such, its role in contributing to negative mental health outcomes must be examined within FIBM's broader social, environmental, and historical context. The purpose of this study was to examine FIBM's perceptions of mental health broadly, and in relation to their lived experiences with incarceration.

Incarcerated individuals were 39 percent more likely to die from any cause than those who were not incarcerated. They were also three times more likely to die from a drug overdose. People living in counties with higher incarceration rates faced higher overall death rates, even if they themselves weren’t incarcerated. For every 10 percent increase in a county’s jail population, there were approximately 5 additional deaths per 100,000 people. Incarcerated individuals were more likely to be younger, male, Black, or Hispanic, and to have lower levels of education and income. They also tended to live in communities with higher poverty rates and higher percentages of Black residents, which are linked to worse health outcomes.

Incarceration significantly increases the risk of death for individuals and community populations, underscoring the need for reforms in criminal justice and public health policies to address the severe health risks associated with incarceration. This cohort study used data from the Mortality Disparities in American Communities (MDAC) study, linking over 3 million 2008 American Community Survey (ACS) respondents to National Death Index data from the respondents’ 2008 interview date through December 31, 2019.

Pregnancy

This statistical brief presents findings on maternal healthcare and pregnancy prevalence and outcomes for persons in the custody of state or federal correctional authorities in the United States. It reports statistics on (1) pregnancy testing and positive tests among female admissions; (2) pregnancy prevalence and outcomes by type; (3) pregnancy-related training for staff, emergency transportation protocols, and medical services provided to pregnant and postpartum women; (4) accommodations and support services for pregnant and postpartum women; and (5) provision of and participation in nursery or residential programs in which mothers reside with their children.

When the Bureau of Justice Statistics released the first-ever national look at reproductive issues in state and federal prisons in April, it answered some long-standing questions, while raising a few more, about pregnancy and maternal care behind bars. Even though women are the fastest-growing segment of the prison population, no agency tracks vital statistics on pregnancy and reproductive care in state and federal prisons. The BJS release covered a few key data points: the number of pregnant people in state and federal prisons in 2023, the outcomes of their pregnancies over the course of the year, and the kind of maternal health services that prisons say they provide. It does not include private facilities and local jails, where pregnancies are much more common.

Aging & Incarceration

The incarcerated elderly (defined as persons over 50 or 55 years of age) is the fastest growing segment of the incarcerated US population. The Bureau of Prisons’ statistics from May 2025 indicate that 20.1% of the federal incarcerated population is 51 years or older. Due to a tendency toward poor dietary and exercise habits, and high levels of substance use pre-incarceration, the incarcerated population has a physiologic age, on average, that is ten to fifteen years older than their chronological age. This is exacerbated by previous general lack of access to healthcare services and a poor socio-economic background. Thus, geriatric care models must be integrated into correctional healthcare, including consideration of screenings to be conducted earlier than they would be in the general population.

BOP

The Bureau of Prisons (BOP) has issued new guidance on expanding the use of home confinement for people eligible under the First Step Act and Second Chance Act. Responding to the announcement, AV’s Vice President of Criminal Justice Advocacy Kevin Ring said: “Using incarceration in a more targeted way can enhance public safety. This expansion of home confinement would allow the BOP to focus scarce resources on those people who are genuine threats to the public."

A federal judge has ordered the Trump administration to continue providing gender-affirming care to hundreds of transgender prison inmates, ruling that an abrupt decision to curtail their medical care was not based on any “reasoned” analysis, as the law requires. U.S. District Court Judge Royce Lamberth previously ordered the Bureau of Prisons to continue to provide medical care to several individual prisoners who are transgender, but his ruling is the first that broadly blocks federal prison officials from carrying out an executive order from President Donald Trump targeting “gender ideology.”

ICE

Immigrants held at a federal detention center in Kansas say they’re facing harsh conditions and continued confinement even after winning their legal cases, according to a letter sent to immigration officials by the American Civil Liberties Union. The May 29 letter focuses on the Federal Correctional Institution in Leavenworth, where U.S. Immigration and Customs Enforcement are holding at least 80 detainees. ICE and the Federal Bureau of Prisons (BOP) have a formal agreement to use the Leavenworth facility as a detention site for immigrants in federal custody. At the same time, other individuals not held by ICE are also detained at the facility, resulting in immigrants undergoing more restrictive conditions.

The Supreme Court agreed Monday to hear an appeal from a private prison company facing a lawsuit claiming immigration detainees were forced to work and paid a $1 a day in Colorado. The GEO Group appealed to the high court after a judge refused to toss out the 2014 lawsuit saying the detainees had to perform both unpaid janitorial work and other jobs for little pay to supplement meager meals.The company says the lawsuits are really a back door way to push back against federal immigration policy, and its pay rates are in line with Immigration and Customs Enforcement regulations.

Issues In Corrections

For decades, our correctional system has operated under a fundamental misconception: That maximizing immediate security and control must come at the expense of the conditions that promote long-term success. This false dichotomy has shaped everything from facility architecture to operational policies, creating a self-defeating cycle where the pursuit of short-term safety actively undermines true long-term public safety. The evidence is clear: Our current approach has failed on both fronts. There is a fundamental contradiction in our current approach: We place people in environments known to increase trauma, aggression and mental deterioration, then expect those same environments to prepare them for a law-abiding life in the community. We subject our staff to chronically stressful, dehumanizing workplaces, then express surprise at high turnover rates and diminished performance.

While the California Department of Corrections and Rehabilitation (CDCR) spends nearly one-third of its budget on health care, it allocates less than $4 per day per incarcerated person for all three meals. The Impact Justice report tells a story that is obvious to those who survive on the food behind prison walls. “Most prisons rely on refined carbohydrates (e.g., white bread, biscuits, cake) to reach the mandated calorie count,” the report states, “and many have turned to fortified powdered beverage mixes as the primary source of essential nutrients—a cheap but woefully inadequate alternative to nutrient-dense whole foods.”

State & District of Columbia Roundup

California

The California Department of Corrections and Rehabilitation is reviewing hundreds of state parole hearings to see if any inmates who were denied parole were rejected because of faulty drug tests. Nearly 6,000 drug tests in California prisons are believed to have yielded false positives between April and July last year, and attorneys for the Board of Parole are now conducting a review of inmate files to determine if any of them need to appear before the parole board again to be reconsidered, according to officials with CDCR.

Anyone entering a California prison — including visitors, staff and attorneys — will be subject to a canine search under a new policy rolling out today across the state. CalMatters obtained a California Department of Corrections and Rehabilitation memo from March 10, announcing the statewide implementation of the policy. t said the canine searches are meant “to combat the introduction of illegal drugs and contraband into (prisons) and reduce the overall level of narcotics, contraband, and criminal activity within the incarcerated population, thereby enhancing the safety and security of all institutions,” the memo stated.

The Los Angeles County jail system faces a staggering challenge: nearly 6,000 inmates struggle with mental health issues, making it America’s largest mental health facility. Four years ago, the system launched an unusual solution that has since become a national model for correctional mental health care: Training inmates as mental health assistants who work directly with peers experiencing severe psychological distress. The program is called Forensic Inpatient (FIP) Stepdown.

Colorado

As of May 28, 2025, 139 sentenced inmates (post-trial) are currently housed at the El Paso County Jail. These individuals await available bed space within the Colorado Department of Corrections (CDOC). This number has steadily increased over the past few months and now exceeds the capacity of a large ward, which typically accommodates 80 people. Our billing to CDOC utilizes a legislatively mandated rate of $77.16 per inmate per day. In contrast, the daily cost to house each inmate is $143.18, resulting in a daily shortfall of $66.02 per person.

Connecticut

An effort to compel Connecticut’s Department of Correction to release an independent report on some of the worst medical malpractice and neglect cases that happened in its custody was halted after Gov. Ned Lamont’s office requested a provision calling for the release be removed from legislation as the General Assembly’s 2025 session drew to a close. The report was commissioned by the Department of Correction in 2017 for $63,000 and completed within the year by the Criminal Justice Institute Inc.. The report covered the period when the University of Connecticut Health Center, under UConn’s Correctional Managed Health Care, was responsible for the medical care of incarcerated people in the state. Ken Krayeske, a civil rights attorney says it is “another example of Governor Lamont’s repeated failure on prison management and oversight.”

District of Columbia

People died in D.C. Department of Corrections custody at a rate more than three times the national average at jails between the summers of 2023 and 2024, with overdoses being the most common cause of death, according to a report from the D.C. Auditor released this week that also noted D.C. had an “urgent” need for a new jail. The report, whose findings D.C. Department of Corrections officials dispute, also described other alleged problems at the D.C. jail, including a failure to control vermin and mold; an overreliance on restrictive housing; significant understaffing and overtime use; and a lack of transparency about deaths in custody.

Commenting on the story above, the Washington Post Editorial Board writes: District officials should look beyond the jail’s physical structure and focus on the serious problems that the audit uncovered regarding how the jail is managed. This includes persistent staff vacancies, streams of contraband entering the jail and a lack of access to health services. They can ameliorate some of these problems with new hiring, better training and higher correctional officer pay. But the Department of Corrections leadership needs more accountability, too — not just more investment.

Florida

A federal judge has rejected a request by Florida corrections officials to dismiss a potential class-action lawsuit alleging the state has violated inmates’ rights because of hot conditions at a prison in Miami-Dade County. U.S. District Judge Kathleen Williams on Wednesday issued a 30-page ruling that said inmates at Dade Correctional Institution can pursue claims under the U.S. Constitution’s 8th Amendment, the Americans with Disabilities Act and a disabilities-related law known as the Rehabilitation Act. The 8th Amendment bars cruel and unusual punishment.

Georgia

Protestors took to the streets for jail reform at the Bibb County jail. During the protest, the sheriff came to speak to the crowd, which is when many people shared their firsthand experiences of the reported unsafe living conditions and unfair treatment. The conditions at the jail are such that the Bibb Counyt Coroner Leon Jones has vouched for people in order to get them released. He says his reason for helping is that he is an elected official. "I tell people, being the coroner, everyone elects me. Everyone in Macon-Bibb is my boss: the taxpayers. So it is my duty to help somebody if they call me and say I have a problem with the jail," said Jones.

Louisiana

A federal judge has again ordered prison officials to protect incarcerated men from heat on a work detail at Louisiana's largest prison, finding the men are at "substantial risk of suffering serious harm" under current practices. The decision marks the second time inside of a year that Louisiana Middle District Judge Brian A. Jackson has said corrections officials must boost heat precautions on the "farm line" at Louisiana State Penitentiary, the prison best-known as Angola. It comes as part of a sweeping lawsuit posing a challenge to the work assignment.

Missouri

The city sheriff is threatening to stop transporting city jail detainees to and from hospitals for medical care unless the city approves increases to his office’s budget. In a letter to Mayor Cara Spencer earlier this week, Sheriff Alfred Montgomery said his office, struggling with a budget crisis, had neither the money nor the responsibility. And he said the task takes deputies away from “core law enforcement duties.” Starting June 9 , the city corrections department will have to do it instead. The broadside marked an escalation of Montgomery’s ongoing efforts to secure more funding for his office, which is currently projected to overspend its budget by more than $600,000 in the current fiscal year. If the threat is carried out, it could cause problems for a jail trying to improve health care for inmates after years of problems.

North Carolina

About 5% of 31,767 inmates — or about 1,650 people — were in solitary on May 20, the state said. Yet, since 2020, about half of all suicides the prison system reported occurred in solitary confinement cells. This at a time when deaths by suicide in North Carolina prisons have increased in recent years, reaching record levels for the second time in 2024 when 13 men and women took their lives while locked inside. Life in solitary confinement, inmates spend nearly every minute of the day alone in a cell about the size of a parking space. The cells are bare concrete spaces. People with mental health problems are 30% to 60% more likely to be sent to isolation compared to inmates without those illnesses. No matter the reasons prisoners are in solitary confinement, prison leaders have a legal responsibility to protect inmates from harm, according to the 1994 U.S. Supreme Court case Farmer v. Brennan.

Pennsylvania

Now, more than 100 days into his tenure, Warden Trevor Wingard is drawing praise from even the facility’s most ardent critics. In a dozen interviews, observers including activists, lawyers, subordinates and a union leader said Wingard is making a positive difference. He’s putting his decades of experience into practice, using a personal touch to make connections and shake things up. Under the prior warden, Orlando Harper, tensions were high. Harper’s tenure was plagued by a high suicide rate on the pods, complaints about poor communication with family members of incarcerated people, friction with an oversight board, allegations of discord between unionized employees and administrators, and lawsuits for a range of alleged abuses.

South Carolina

A man told a Charleston County jail guard that he had tried to hang himself, showing her the rope he had cobbled from bedding, according to a recently released report and other documents. That landed Jordan Nicholas Bell on suicide watch. For one day. Three days later, he was dead. On June 23, 2024, deputies found the 33-year-old man hanging from a light fixture in his cell at the Sheriff Al Cannon Detention Center. He used another homemade rope fashioned from a mattress cover, much like in his earlier attempt to end his life. Bell told his screening nurse that he was not having suicidal thoughts, though he had attempted suicide at age 26. The nurse ultimately determined that Bell was not at risk of suicide, according to his suicidal assessment

Correctional Healthcare Vendors

Turn Key Health Clinics/TK Health

A federal court has denied the request by former Smith County Jail medical provider Turn Key Health to dismiss claims against them involving the death of an inmate. The family of deceased inmate D’Vonte Valentine have requested a jury trial for damages in a Federal court. The defendants are Turn Key Health and Smith County, who at the time, in 2022, used Turn Key Health for inmate medical care. According to the suit, Valentine had a condition called congenital adrenal hyperplasia, and the medical staff failed to administer his steroid medication, instead placing it in his locker with personal belongings taken from him when he was incarcerated. Without follow-up care, the suit alleges, Valentine became sicker and stopped eating, collapsed several times, and finally died after two weeks without his steroid medication.

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