Big, Beautiful Cuts: Medicaid, Mental Health, and Incarceration

Highlighted Stories

Editor's Note

This week’s first four highlighted stories—from California, Alabama, and Texas—illustrate the deepening crisis caused by the criminalization of mental illness.

The first California story comes from Los Angeles County, where jails are scaling back on buprenorphine treatment for opioid use disorder. Cost appears to be the main reason. Our subscribers, aware that California was the first state to receive a Medicaid 1115 waiver under the CalAIM Justice-Involved Initiative, might wonder why such treatments aren’t covered. The answer lies in the phased county-by-county rollout of Medi-Cal coverage for these services—beginning with Inyo, Santa Clara, and Yuba counties. Los Angeles County is not expected to implement the program until October 2026.

The second California story, along with those from Texas and Alabama, focuses on the growing mental health crisis within correctional facilities. In Sacramento, the sheriff has criticized the state’s mental health diversion program as too permissive, while advocates counter that the sheriff’s office has failed to provide adequate treatment for mentally ill detainees—a dispute that echoes reporting from The Sacramento Bee (October 31, 2023).

Meanwhile, both Texas and Alabama continue to report that people with serious mental illness languish in jail awaiting treatment. The closures of state psychiatric hospitals, the collapse of community mental health systems, and rising homelessness tied to economic inequality have blurred the line between criminal behavior and manifestations of untreated mental illness. When that line disappears, law enforcement becomes the default response, and without a continuum of care—or stable funding for that care—the cycle of criminalization repeats itself. This is a bipartisan failure, shared by deep red and deep blue states alike.

COCHS continues to argue that Medicaid offers both a payer and a mechanism for continuity of care, especially in states adopting 1115 waivers or extending services through federally qualified health centers operating behind the walls. Even though incarcerated individuals were protected from certain Medicaid cuts under the “One Big Beautiful Bill,” states continue to revise their Medicaid programs in ways that risk perpetuating this dysfunctional cycle of criminalizing mental illness.

Finally, this week’s last highlighted article from Politico reports that HUD, aligning with President Trump’s executive order Ending Crime and Disorder on America’s Streets, will shift funding from permanent housing to transitional programs. Internal HUD estimates suggest that this could put 170,000 people at risk of homelessness. COCHS will be closely following how this rise in homelessness may further strain correctional systems—already serving as the nation’s default mental health institutions.

California

People continue to die from drug overdoses in Los Angeles County jails, yet the Department of Health Services has scaled back access to opioid addiction treatment. In a Sept. 16 memo, Chief Medical Officer Sean Henderson announced a “pause on primary care in ordering buprenorphine,” the medication that reduces cravings and prevents overdoses. The directive prioritizes new arrivals to the jail system, placing others who seek treatment on a waitlist—now exceeding 800 people. The move follows the passage of Proposition 36, which increased penalties for some drug and theft crimes, swelling jail populations and straining resources. Meanwhile, the state is suing L.A. County over poor jail conditions and high in-custody death rates, with overdoses accounting for 28% of deaths this year. Two Correctional Health Services physicians told CalMatters the decision is “wildly dangerous,” warning that even short treatment delays could lead to more fatalities.

Standing before images of abused toddlers, Sacramento County Sheriff Jim Cooper and District Attorney Thien Ho condemned California’s mental health diversion law for allowing too many defendants to escape punishment. The 2018 statute lets defendants with a mental health diagnosis have charges dismissed after treatment. Cooper and Ho cited the wide range of qualifying disorders — including erectile dysfunction and caffeine withdrawal — and the limited list of crimes excluded from diversion. Judges must also presume a mental disorder contributed to the offense. Activist Keyan Bliss of Decarcerate Sacramento challenged the officials’ claims, noting that the Sacramento County Main Jail remains overcrowded and fails to treat mentally ill inmates adequately.

Texas

Thousands of people arrested each year in Texas are dealing with mental health issues. Some conditions can be treated with medicine, while others require hospitalization. But in many cases, the mentally ill end up in jail before ever getting access to the doctors who can help them. Inmates who need their competency restored are put on a waitlist for what's known as a forensic bed, a secure bed in a psychiatric hospital specifically for people involved in the legal system. As of May, there were about 1,700 people in Texas on the waitlist for forensic beds. The average wait for a minimum-security bed was six-and-a-half months. For a maximum security bed, the average wait was more than eight months.

Alabama

Fernando Clark spent ten months in an Alabama jail awaiting court-ordered psychiatric treatment after being arrested for stealing cigarettes and fruit. He died before receiving care. Clark was one of hundreds waiting for a spot in the state’s shrinking mental-health facilities, despite a federal consent decree meant to fix such delays. Seven years later, the backlog is nearly five times larger. Budget cuts and closures have gutted Alabama’s system: the Department of Mental Health lost $40 million in 2010, and at least ten state-run hospitals have closed over three decades. Only three inpatient facilities remain, totaling 504 beds—and just one treats men charged with crimes and deemed incompetent to stand trial.

Ending Crime and Disorder on America’s Streets

The Department of Housing and Urban Development announced major policy changes that will cut funding for permanent housing programs for people experiencing homelessness. More than half of HUD’s 2026 Continuum of Care funds will shift from permanent housing to transitional programs that include work or service requirements. Internal HUD documents estimate the cuts could put 170,000 people at risk of homelessness. The changes align with President Trump’s executive order, Ending Crime and Disorder on America’s Streets, which directs HUD to increase “accountability” in grants for housing and transitional programs.

Follow Ups

Telecommunications

Editor's Comment: Back in 2024, we carried articles reporting that the FCC, under the Biden administration, had reduced the cost of phone calls in correctional facilities. As we have seen under the Trump administration, there has been considerable reporting about the reversal of these cost reductions. The article below notes that this rollback of the previous regulation is now complete.

The Federal Communications Commission (FCC) has released the finalized version of its order regulating the costs of incarcerated people’s communication services (IPCS). The document released November 6 contains subtle but materially significant changes from the draft proposal shown to the public in October, and continues the commission’s trajectory of quietly defaulting on essentially every major provision of the original regulations it approved in 2024. In addition to bumping up the costs with the inflation factor, the FCC may also be preparing to backtrack on its prohibition of kickbacks. Securus, which along with ViaPath Technologies (better known as GTL) dominates most of the IPCS market.

New York

Editor's Comment: Another surge of stories out of New York’s prison system this week. The first two concern a newly released video showing an interaction between correctional staff and a prisoner at Sullivan Correctional Facility. An internal investigation concluded that the incident was “consistent with the type and amount of force justifiably used and reported by staff.” A state senator from Brooklyn, who chairs the Senate Committee on Crime Victims, Crime, and Correction, is now requesting further information from the Department of Corrections and Community Supervision (DOCCS).

Meanwhile, DOCCS appears to be taking a novel approach to the implementation of the HALT Act, which limits solitary confinement, arguing that the law does not apply to the general prison population.

On a somber note, a correctional officer has reportedly died by suicide at Marcy Correctional Facility—the same facility where Robert Brooks was murdered.

Finally, there is a proposal gaining attention that would require judges to spend more time visiting and observing correctional facilities firsthand. The plan calls for judges to tour “intake, housing, medical and mental health areas, solitary confinement units, food preparation and dining spaces, education and exercise quarters, and visiting rooms,” and to speak directly with incarcerated people.

COCHS often notes how isolated correctional healthcare remains from the broader community. Some of our subscribers may be equally surprised to realize how fragmented the criminal justice system itself can be.

After just 11 days at Sullivan Correctional Facility in upstate New York, Ernastiaze Moore was brutally assaulted by guards who pepper-sprayed and beat him, leaving injuries that required reconstructive surgery. Officials denied allegations of sexual assault, but the incident was captured on video. In the footage, an officer orders Moore to “drop your boxers,” while others exchange gestures and a sergeant shouts “stop resisting,” though Moore appears compliant. “I was just trying to survive,” Moore later said. He is now imprisoned at Mid-State Correctional Facility—the same prison where 22-year-old Messiah Nantwi was recently beaten to death by guards.

A New York state senator requested that the State Department of Corrections and Community Supervision turn over information about a violent incident that led an inmate to accuse prison guards of sexual assault.The request was made by Senator Julia Salazar, a Brooklyn Democrat. Ms. Salazar, the chairwoman of the State Senate’s committee on Crime Victims, Crime and Correction, asked the department for a detailed summary of the internal investigation into the incident. The request centered on the correction department’s treatment of Ernastiaze Moore, 25, who was being held at the Sullivan prison.

In an ongoing court battle, New York’s Department of Corrections and Community Supervision argues that key provisions of the 2021 HALT Solitary Confinement Act don’t apply to most of its prisons. The agency claims 35 of its 42 facilities already comply with the law, which limits isolation and requires out-of-cell time. Its reasoning rests on a narrow interpretation that exempts general population units—where most incarcerated people live—from HALT’s protections. The dispute comes as the prison system continues to recover from a major corrections officer strike that ended in March, resulting in about 20% of guards losing their jobs.

Friday morning, a civilian staff member at Marcy Correctional Facility was found dead of an apparent suicide. The New York State Police reports that Abdalla Hadian, 55, was found deceased around 8 am. According to the New York State Department of Corrections and Community Supervision, Hadian used a firearm he had brought into the prison with him. Life saving measures were attempted, though they were unsuccessful. Marcy Correctional Facility has been in the public spotlight for nearly a year, following the deadly beating of inmate Robert Brooks by corrections officers, including one who was convicted of murder.

A new proposal would require every New York judge involved in sentencing or detention to visit a correctional facility annually. The idea, introduced by Judge Daniel Conviser, aims to give judges a clearer view of the conditions they impose. While a 1978 rule already mandates visits every four years, these are often brief or ignored. The new rule would require judges to tour key areas—intake, housing, medical and mental health units, solitary confinement, kitchens, education spaces, and visiting rooms—and speak directly with incarcerated people. It would also ensure visits are distributed across facilities statewide, including women’s prisons.

ICE

People held at the CoreCivic-run ICE jail in Kern County, California, are being denied medical care, legal access, and basic accommodations for disabilities, according to an ACLU class-action lawsuit. The facility—the largest immigration jail in California—can hold up to 2,560 people and is projected to generate $130 million annually once fully operational. The Trump administration has been a major financial boost to private prison companies: ahead of its November earnings call, CoreCivic reported $580.4 million in third-quarter revenue, up 18% from the previous year.

Solitary confinement at immigration detention centers has surged since President Donald Trump returned to office, even as the Department of Homeland Security’s internal oversight network has been gutted. Immigration and Customs Enforcement facilities in Arizona account for much of the increase. ICE data show that detainees in protective custody at some point during the second quarter of 2022 spent an average of 19.5 days in segregation. For the period July to September this year, the average was 120 days – in other words, they spent the entire three-month period in isolation.

At a GEO Group immigrant detention center in Colorado, detainees say they were threatened with solitary confinement if they refused to work as unpaid janitors, allowing the company to save money by avoiding paid staff. GEO is asking the Supreme Court to grant it immunity from such lawsuits, claiming that as a government contractor it deserves the same protections as the government. Opposing the company is an unusual coalition—the public-sector union AFSCME, the conservative Cato Institute, Citizens for Responsibility and Ethics in Washington, and even the Trump administration, which argues that while private prison contractors may merit immunity, this case isn’t the right one to decide it..

The U.S. Supreme Court heard arguments Monday in a class action lawsuit by immigrants against the Aurora U.S. Immigration and Customs Enforcement (ICE) Detention Center owned by The GEO Group Inc. Monday, the Supreme Court Justices also seemed skeptical of GEO Group’s defense. “You're just asking for a blanket no liability for contractors who are following the government's instructions,” Justice Ketanji Brown Jackson said. The Supreme Court's decision will largely hinge on its interpretation of the 1940 case Yearsley v. W.A. Ross Construction Co.

Weeks after a Chinese immigrant had a seizure at the Imperial Regional Detention Facility and died in late September, the ICE contractor who runs the detention center posted a job online. They were looking for a doctor. Among other duties, the Utah-based private prison company Management and Training Corporation (MTC) said they were seeking a part-time physician to document detainees’ medical histories, give emergency medical aid and “monitor all potential catastrophic illnesses.”

Aging and Dying

California Medical Facility in Vacaville, California is a medium-security penitentiary within the state’s sprawling prison system. Most of the 2,144 men who live here require specialized medical care. Some are dying in the facility’s hospice unit. Most of the 2,144 men who live here require specialized medical care. Some are dying in the facility’s hospice unit. Just as the general population in the United States is aging, so too is the population of people who are in prison — only faster. In 1991, incarcerated people over 50 years old made up just 3 percent of the U.S. prison population, according to a 2025 report. Researchers predict that by 2030, that number could reach as much as 30 percent.

Capital Punishment

Justice Sonia Sotomayor broke the fourth wall in her Oct. 23 opinion dissenting from the U.S. Supreme Court's refusal to stop Alabama's nitrogen gas execution of Anthony Boyd, speaking directly to the reader. She asks the reader to imagine what it is like to suffocate to death with a mask on your face pumping your lungs with nitrogen gas. Later that evening, after her dissent Boyd was put to death. News media witnesses saw Boyd thrashing against his restraints, rolling his eyes back and lifting his legs from the gurney in an execution that took nearly 40 minutes. Justice Sotomayor's scathing dissent, in which she was joined by Justices Elena Kagan and Kentanji Brown Jackson, was a pointed volley in the legal battles over the methods states use to put people to death.

Studies

Funded by the Foundation for Opioid Response Efforts (FORE) Foundation, this project, named Pharmacy Bridge, focused on a demonstration of the real-world application and outcomes of two innovative models of pharmacy-based, low-barrier buprenorphine induction and maintenance services: collaborative care through a collaborative practice agreement (CPA); and independent pharmacist prescribing of buprenorphine. The report contains state-by-state descriptions and analyses of relevant statutes and regulations as well as a detailed summary of overall findings.

To better understand mental health trends in jail populations, researchers analyzed data from the Registry of Electronic Archives in Correctional Healthcare (REACH), a large multisite database of individuals discharged from 34 jails between 2013 and 2023. REACH was created to track historical trends in correctional healthcare and support predictive models for growing service demands. The database includes information on prescribed medications, demographics, discharge histories, and clinical indicators such as urine drug tests and emergency department use.

A new study conducted in a U.S. prison suggests that incarcerated men have complex perceptions of staff that stem from previous communications and interactions. Published in the Journal of Criminal Justice, the study's findings suggest that incarcerated people want accessibility, support, and humane treatment from staff, and when they perceive that these are lacking, the adversarial distance between the two groups can widen.

Medical parole, or compassionate release is a mechanism for people with advanced illness in prison to be released because they are no longer considered public safety threats. The implementation of medical parole policies is varied, with individual states and the federal prison system all having unique eligibility criteria and application processes. The researchers conducted a retrospective review of 31 people incarcerated in Massachusetts Department of Corrections facilities who submitted a medical parole claim through Prisoner Legal Services between 2022 and 2023.

People with opioid use disorder (POUD) who are incarcerated are disproportionately impacted by the overdose crisis. This study identifies overdose policies that allocate resources with maximal efficiency to reduce mortality among POUD in the New Jersey (NJ) Department of Corrections. It employs a probabilistic state-transition model of a simulated cohort of POUD incarcerated in NJ to simulate maximizing medication for opioid use disorder (MOUD) during incarceration and/or post-release in the community and naloxone in the community.

State Roundup

California

Two correctional officers at California State Prison, Sacramento are hospitalized and an attempted murder investigation has been launched following an alleged attack on the officers. According to the California Department of Corrections and Rehabilitation, the correctional officers were escorting an inmate from a cell when they were attacked by an improvised weapon. The guards were taken to the prison's triage and treatment area before taken to an outside medical facility. CDCR officials said both officers are in "fair" condition.

Life in prison often becomes a constant effort to avoid confrontation, with little help from officers as fear and anxiety build and mental health declines. “You don’t know what the capacity of this person is, or what their crime is,” said Steven Warren, currently incarcerated at San Quentin Rehabilitation Center. Some California lawmakers and prison officials argue it’s time to reconsider such housing practices. They propose expanding single-occupancy cells to improve safety and well-being. A bill to establish more single-cell units advanced in the legislature this year but didn’t reach Governor Newsom; it’s expected to return in 2026.

A jury awarded a $16.8 million judgment to a California prison doctor who alleged her employer did not respond appropriately to a threat she received from an incarcerated person, fired her when she raised concerns about her safety and then defamed her by allowing rumors to spread among staff. The verdict, reached last week, caps Dr. Beth Fischgrund’s six-year effort to contest her dismissal from Salinas Valley State Prison, where she worked as a contract psychologist beginning in September 2017.

Illinois

On September 3, Illinois prison officials moved — by emergency rule — to replace most physical mail with scanned copies, though a key legislative panel has already pushed back. At the same time, New York is installing mail scanners in prisons, raising alarms about privacy and attorney-client privilege. Texas has already shifted to “digital mail,” where letters are scanned and delivered on tablets or as photocopies. Though billed as a way to reduce contraband, these “paperless” policies constrict how people read, write, and organize behind prison walls.

Maryland

The Maryland Board of Public Works last week approved a $185,000 settlement for a man who was held in solitary confinement for nearly a year with little legal basis and without access to out-of-cell exercise. The spending board approved the settlement for Samuel Smalls without discussion, despite the state winning at the pretrial motions stage in Maryland U.S. District Court, where Smalls represented himself. The state did not challenge his appeal to the U.S. Court of Appeals; the two sides repeatedly extended the state’s deadline to respond.

Massachusetts

A local nonprofit serving current and formerly incarcerated prisoners says the state Department of Correction’s moves to improve transparency in the wake of several suicides is not enough. The Department of Correction is hiring an independent expert to review the six suspected and confirmed suicides of men in its custody this year, and boosting its training and clinical support for prisoners who may have behavioral health illnesses. DOC will boost staff training to deepen suicide prevention skills and recognize mental health symptoms. The Department will work with its health care partner VitalCore Health Strategies to enhance clinical support.

North Carolina

On Nov. 3, North Carolina officials announced a $9.5 million pilot program to provide intensive support to people with serious mental illnesses — such as schizophrenia, bipolar disorder and chronic post-traumatic stress disorder — as they reenter the community after incarceration. The goal: to reduce repeat encounters with the justice system and guide people to the help they need. These Forensic Assertive Community Treatment, or FACT, teams will deliver personalized clinical and social support to justice-involved individuals with serious mental health needs who also present a medium to high risk of repeated criminal behavior.

Tennessee

An overcrowded jail system is being blamed for a recent rise in inmate deaths in Shelby County. In less than two weeks, the jail has seen three deaths involving those in custody. This marks at least the 79th death at the jail since 2016. Shelby County Commissioner Charlie Caswell believed the newly opened Alliance Health Center on Broad Avenue could be a part of the solution, providing mental and clinical care instead of jailing and releasing people back into the community.

Texas

Bexar County has turned jail crowding into a standing expense. The county is routinely sending “paper-ready” inmates to nearby facilities and paying other counties to hold them — leaving thousands inside the Bexar County jail while hundreds are housed elsewhere, and the tab is already in the millions. In the most recent period, Bexar held about 4,673 inmates in its own jail while paying other counties to house roughly 266 more. Sheriff Javier Salazar says the transfers keep the jail compliant with Texas Commission on Jail Standards requirements on staffing and capacity.

The Harris County Sheriff's Office on Thursday told the Texas Commission on Jail Standards that it would cancel one of its million-dollar, out-of-state outsourcing contracts, months after a commissioner pressured the sheriff's office to bring all out-of-state inmates back to Texas. There have been 71 inmate deaths since 2022 in Harris County. Chief Deputy Thomas Diaz told commissioners that the sheriff's office's contract with private prison company CoreCivic for a facility in northwest Mississippi will be terminated at the end of the month.

Virginia

On Monday, Nov. 3, 2025, the Arlington County Sheriff’s Office (ACSO) will assume operational control of the Arlington County Detention Facility’s (ACDF) medical care and healthcare mission. This significant transition marks the first time medical care within the facility will be directly managed by county-employed staff rather than a private contractor. The transition has been supported by Falcon Correctional and Community Services, Inc., a respected team of correctional healthcare consultants. With their guidance, the ACSO has already implemented improvements to floorplans, workflows, and policies, strengthening efficiency and patient outcomes.

Washington State

While incarcerated at Washington State Penitentiary, Alex Kuhnhausen suffered a medical emergency and died under prison care. His wife, Katie Kuhnhausen, accuses officials of deliberate neglect. Last year, 39 people died in Washington prisons—a number that spiked during the pandemic and remains high. An independent watchdog found at least three deaths from infections in fiscal year 2024, including one of a 45-year-old prisoner. Despite a 2021 law requiring the Department of Corrections to publish reports on unexpected deaths, key details are often missing, leaving lawmakers and families in the dark.

Rikers Island

New York City’s mayor-elect, Zohran Mamdani, says jailing people for homelessness and mental illness is unsustainable — and closing Rikers is key to building a safer city. His public safety platform proposes changes to how the city coordinates prevention and enforcement. It also outlines a continued commitment to closing Rikers Island and addressing longstanding challenges within the city’s correctional system.

The 625-foot blue-and-white barge, known officially as the Vernon C. Bain Center, and more unofficially as The Boat, has been sold by New York City to a Louisiana scrap company. On Monday the buyer came to pick it up from this industrial edge of the South Bronx and begin towing it south for recycling. The Bain Center opened in 1992. It had an 800-inmate capacity and was the last of a handful of floating jails used by New York City in the late 1980s and early 1990s, a temporary remedy to address a soaring prison population fueled by the crack cocaine epidemic.

A Rikers Island detainee who died in February had 121 pills and multiple synthetic drugs in his cell, according to a new city oversight report that highlights ongoing failures by jail officials to secure housing areas and respond to medical emergencies. Ramel Powell’s death is among 11 fatalities in Department of Correction custody reported so far this year. A 24-page report details the deaths of the first five detainees who passed away on Rikers between the start of the year and March 31. The board report also noted that Correction staff in two of the five deaths did not immediately notify medical personnel after witnessing detainees in distress.

CoreCivic

Tennessee’s Department of Correction is seeking a $13 million funding increase for CoreCivic, the state’s private prison contractor, despite ongoing scrutiny over violence and federal investigation. The increase is part of an $86 million budget request for fiscal 2026–27, which would raise the department’s annual budget to $1.57 billion. CoreCivic has faced repeated criticism for high staff turnover and death rates at the four prisons it operates, including Trousdale Turner, now under Department of Justice investigation for civil rights violations tied to violence and murders.

Correctional Health Care Providers

NaphCare

Restrictive insurance rules and Washington’s legal system have created an almost monopolistic jail healthcare market. Most public agencies lack the resources to provide medical care, while major contractors have pulled out over fears of large civil penalties. Kitsap County illustrates the problem: Everhealth LLC, a NaphCare subsidiary, was the only bidder to staff its Port Orchard jail. With no alternatives, the county agreed to pay $6.8 million in 2026—over $1 million more than last year and more than twice what it paid five years ago.