Trump’s Paradigm Shift: Medicaid, ICE Detention & Homelessness

Highlighted Stories

Editor's Note

In this Weekly Update, we highlight several long-running themes and how recent actions by the Trump administration are affecting them. Specifically, we look at these stories through the lens of the executive order Ending Crime and Disorder on America’s Streets (ECDAS) and the One Big Beautiful Bill Act (OBBBA). The changes anticipated from ECDAS and the OBBBA are potentially paradigm-shifting. But, as the articles below make clear, those changes are not automatic. They can be slowed by legal challenges, complicated by local resistance, and, at least for a time, forced to coexist with older policies in this new environment. Let’s dive in.

In the first article, we see that HUD Secretary Scott Turner’s effort to align with ECDAS by cutting permanent supportive housing funding and redirecting money to transitional housing may have been a bit too hasty. As the article notes, the changes were announced at the last minute, and a federal judge—appointed by President Trump during his first term—has now blocked them through an injunction. Secretary Turner is appealing that ruling. The rush to align with the executive order does not come without its pitfalls.

In the Matter article, we move from policy change to local consequence. The piece reports that the CDC has told recipients of overdose-prevention funding that they may no longer use the slogan “Never Use Alone.” That message arose from a grim reality: many overdose deaths occur when people are using drugs by themselves, with no one present to intervene. CDC spokesperson Andrew Nixon is quoted as saying, “Federal funds may not be used to support harm reduction efforts that primarily serve to facilitate illegal drug use and its attendant harm.”

In the final ECDAS-related article, The New York Times reports that the Justice Department would give officials at the Department of Veterans Affairs authority they currently lack to initiate guardianship proceedings for homeless veterans. This is particularly noteworthy because guardianship is ordinarily governed by state law, making the Justice Department’s role here highly unusual. Even supporters of the idea acknowledge the difficulty of implementation, which would require coordination among police officers, social workers, clinicians, and lawyers—often employed by different levels of government. From a COCHS perspective, where we have often pointed to the difficulty of coordinating correctional staff and healthcare staff even in tightly controlled environments, the scope of this new authority is truly ambitious.

Turning to the ICE articles, the OBBBA allocated $45 billion for detention facilities. COCHS has previously noted that private prison companies CoreCivic and GEO Group donated to the 20024 campaign. We have also followed inspections and scrutiny of these facilities by elected officials. But the first ICE article, from CalMatters, is especially notable because it is not just about inspections, but about how private detention centers may violate state law. In San Diego, county health officials were blocked from inspecting the Otay Mesa Detention Center, which is operated by CoreCivic. Under a 2024 California law, county health officers are authorized to inspect private detention facilities. CalMatters also notes that this inspection authority has not been widely used by other counties. The following articles, from Vermont and Marana, Arizona, show continuing problems with ICE facilities. In Vermont, immigration lawyers say prison officials are making it harder to meet with detainees. In Arizona, the federal government is already seeking a major capacity increase at the proposed Marana ICE detention center. As we have mentioned before, local residents have voiced opposition to there even being a detention center in their community.

The final article, from The New York Times, may at first glance seem unrelated to the OBBBA. But the OBBBA casts a very long shadow. The article describes California’s CalAIM Justice-Involved initiative, which is beginning to enroll incarcerated people in Medi-Cal—California’s Medicaid program—up to 90 days before release. As our subscribers know, COCHS has long argued that Medicaid is likely to be a more effective mechanism for improving care in correctional settings than oversight bodies that may fail to produce meaningful change. The shadow here is that the OBBBA introduces major Medicaid cuts, estimated at between $800 billion and $1.2 trillion, along with work requirements. As The New York Times notes, states may be able to exempt newly released individuals from those requirements for a period after release. The law allows that exemption to last for up to 90 days. That is not much time for someone to regain stability, and we will see how many fall off the rolls when these provisions take effect in 2027. It is worth noting that COCHS was ahead of this issue: back in 2010, we held a convening titled Health Reform and Criminal Justice: Rethinking the Connection between Jails and Community Health, recognizing early the impact Medicaid expansion under the Affordable Care Act would have on people cycling through correctional systems.

To sum up—well, that is not entirely easy. The articles that crossed our desk this week all, in one way or another, bear the imprint of these federal changes. This felt like a moment to take stock of where things stand and to consider what these developments may mean for the issues COCHS continues to follow. The OBBBA was signed into law on July 4, 2025, and ECDAS followed on July 24. So what we are talking about is a relatively short time, about eight months—this paradigm shift is clearly not over.

Ending Crime and Disorder on America’s Streets

In November 2025, HUD Secretary Scott Turner announced plans to cut permanent supportive housing funding and redirect money to transitional housing. The move was in accordance with President Donald Trump’s July 2025 executive order, “Ending Crime and Disorder on America’s Streets,” according to HUD’s release. In December 2025, U.S. District Judge Mary McElroy of Rhode Island — a Trump appointee — granted a preliminary injunction, ruling that the last-minute changes to homelessness program requirements were unlawful. The changes were announced with little notice, just weeks before local homeless service providers had to apply for about $4 billion in new funding. Judge McElroy ordered the agency to maintain its previous funding formula.HUD is appealing the decision to the Federal Appeals Court.

Officials from the Centers for Disease Control and Prevention reportedly told recipients of overdose prevention funding that they may no longer be allowed to promote the message, Never Use Alone, that has become one of the pillars of harm reduction. The administration wants sure make sure that recipients were in compliance with President Trump’s executive orders, an in particular July’s “Ending Crime and Disorder on America’s Streets.” But date reports suggest that about 70 percent of overdose deaths in Ohio, there is no bystander present. On the White House website, the administration ignores the root causes of homelessness (lack of housing) and calls for the directing of federal funds away from programs that support “so-called ‘harm reduction’ or ‘safe consumption.’”

The Trump administration has announced a new effort to initiate legal guardianships for hundreds of veterans, including some who are homeless or “at risk of homelessness,” that could be used to force more of them into involuntary or institutional care. Under the new arrangement, the Justice Department would give officials at the Veterans Affairs Department authority they currently lack to initiate guardianship proceedings in state courts for veterans who have no family and are “unable to make their own health care decisions.” The initiative comes amid a push by the Trump administration to compel more homeless people into institutional treatment for mental illness and drug addiction.

ICE & Local Jurisdictions

San Diego County filed a lawsuit in federal court alleging the Trump administration illegally blocked a public health inspection of the Otay Mesa Detention Center, escalating a dispute over oversight of the privately-run immigration detention facility near the U.S.-Mexico border. The complaint seeks a court order requiring the Department of Homeland Security, U.S. Immigration and Customs Enforcement and private prison contractor CoreCivic to allow county health officials inside to conduct a full inspection. San Diego officials say the inspection is authorized under a 2024 California law that grants local public health officers power to inspect private detention facilities to ensure they meet health and safety standards. CalMatters reported in October that local officials across the state were not utilizing the new authority. San Diego County Public Health Officer Dr. Sayone Thihalolipavan arrived at the Otay facility on Feb. 20 to conduct an inspection under California’s health code after what county officials described as “alarming reports from inside the facility.”

Attorneys and volunteers with the Vermont Asylum Assistance Project used to go into Vermont’s prisons and meet with every immigration detainee, using their phones and computers for language interpretation, according to Jill Martin Diaz, executive director of the organization. But they say that access changed this fall after Jon Murad took over as interim commissioner of the Vermont Department of Corrections. Since then, attorneys with the organization said the department has made it harder to meet and work with their clients, citing language barriers and lack of meeting space.

A former prison in Marana slated to become an immigration detention center has a capacity of 513 people, according to state documents. But a procurement order released by the federal government aims to push that capacity to 775. That’s a change that local advocates say would be devastating for detained people. “There is no way to raise the population by that amount in an ethical way,” said immigration attorney Daniela Ugaz, who heads the legal research team for Pima Resists I.C.E., a group created specifically to resist the detention center. The building, formerly a state prison, is owned by private prison operator Management and Training Corporation, or MTC, which bought it from the state in 2025. MTC had previously operated a minimum security prison in the building until 2023.

Medicaid

Medicaid's exclusion of incarcerated people dates to the program's inception in the 1960s. Upon incarceration, a person with Medicaid coverage would typically lose it, then face a re-enrollment process upon release taking months. That began to change with bipartisan federal legislation allowing Medicaid to cover a narrow set of services beginning up to 90 days before release. Twenty-seven states have sought or received federal approval to expand Medicaid to prisoners on the eve of their release, and California's Medi-Cal program has already enrolled tens of thousands. The expansion drewsupport from law enforcement. Vikki Wachino, then a deputy administrator of the Centers for Medicare and Medicaid Services, noted that law enforcement's interest caught her attention, observing that people returning to the community without support frequently cycle back into jail. Wachino later founded Health and Reentry Project to help states develop reentry waivers. That progress is complicated by sweeping Medicaid changes President Trump signed. Beginning next year, enrollees must demonstrate they are working — though states may exempt recently released individuals.

Follow Ups

San Diego County

Editor's Comment: The article below from the San Diego Union-Tribune points out that NaphCare, the healthcare provider at the jail, is unable to perform the billing functions necessary to comply with Medi-Cal rules. It is worth taking a moment to interpret what this most likely means: the electronic health record (EHR) system used at the jail cannot meet Medi-Cal billing requirements because jails historically have not billed insurance or Medicaid. As a result, the vast majority of EHRs built for correctional environments were never designed to generate a superbill. These systems generally track diagnoses using ICD-9 or ICD-10 codes and are sometimes little more than electronic problem lists. Critically, they do not track procedures, services, devices, or drugs through Current Procedural Terminology (CPT) codes — which are essential for billing.

It therefore makes sense that San Diego is turning to AmeriHealth, a subsidiary of UnitedHealthcare — a company that unquestionably knows how to bill. It should also be noted that when the sheriff references an October deadline, this refers to the CalAIM Justice-Involved Initiative's mandate that all California jails offer prerelease services by that date. To be precise, the actual deadline is September 30, 2026. For more information about CalAim, refer to the New York Times article above: A New Lifeline Helps Inmates Transition to Life Outside the Bars.

When the Sheriff’s Office signed a contract with national correctional health care provider NaphCare in 2022, officials said the deal would reduce costs and streamline services for people locked up in San Diego County jails. But instead of saving money, the costs for off-site hospital care for people detained in county jails has soared — and now Sheriff Kelly Martinez is turning to a new provider to control expenses. Later this month, Martinez will ask county supervisors for nearly $14 million to issue a no-bid contract to AmeriChoice, a service of health care giant UnitedHealthCare Services. “Currently, NaphCare is unable to perform billing functions that are imperative for the Sheriff’s Office to comply with the state mandated CalAIM program,” which must begin by October (see New York Times article above)

Mississippi

Editor's Comment: House Corrections Chairwoman Becky Currie, after the setbacks covered last week, has successfully introduced an amendment to the corrections budget bill that would allow the Department of Corrections to conduct a "request for proposals," opening the contract to competition with VitalCore from other entities.

Lawmakers are considering spending over $480 million on the Mississippi Department of Corrections over the next fiscal year, said House Corrections Chairwoman Becky Currie, who presented the agency’s budget bill. The largest single chunk of the budget goes to a prison medical contract currently held by Kansas-based VitalCore Health Strategies. “This bill is higher because we are paying VitalCore more money this year,” Currie said. “By contract, it goes up from $124 million to $128 million, and next year it will be $133 million.” Currie has been a sharp critic of VitalCore, which was awarded over $315 million in emergency, no-bid state contracts by the Department of Corrections from 2020 to 2024. The company has since faced legal challenges and allegations that it routinely denies or provides inadequate care inside Mississippi’s prisons.

New York

A coalition of more than 50 advocacy organizations is urging New York lawmakers to scrutinize the state’s prison system, pressing for answers about alleged brutality, deaths behind bars and violations of solitary confinement reforms as the legislature weighs more than $4 billion in funding. The push for reforms comes amid renewed scrutiny of the correctional system following the deaths of Robert Brooks and Messiah Nantwi, two incarcerated men killed by officers inside state prisons four months apart.

Aging

The Tennessee House Judiciary Committee will consider legislation that takes a pragmatic step toward improving oversight of the state’s correctional system. Sponsored by Republican Rep. Elaine Davis, the substitute amendment to House Bill 36 focuses on a straightforward goal: to collect better data on how Tennessee’s medical and geriatric parole and furlough processes actually work. Rather than expanding eligibility or changing release rules, the amendment requires the Tennessee Department of Correction to publish annual reports detailing how these processes, which address situations in which incarcerated individuals are seriously ill or medically incapacitated, function in practice.

Little is known about how older adults navigate aging and access healthcare in the jail setting. Two major themes emerged. First, participants reported difficulty navigating the jail environment related to aging and unaddressed disabilities. Examples included climbing to use the top bunk of a bunk bed, difficulty grasping objects due to a Parkinsonian tremor, and significant visual impairments. Others reported facing numerous challenges when attempting to access healthcare, including lack of clarity around procedures for accessing care and mutual distrust sometimes marking their relationship with medical staff.

Capital Punishment

The New York Times editorial board writes: The use of the death penalty has risen sharply, with more executions in 2025 than any year since 2009. In theory, the death penalty is reserved for "the worst of the worst." In practice, it is very different. People who are executed are disproportionately poor or intellectually disabled, often lacked good lawyers, and are more likely to be sentenced to death for killing a white person. The chances that an innocent person will be executed remain far too high. Executions often go awry and become a grisly spectacle — as Alabama administered nitrogen gas to kill Mr. Boyd, he violently thrashed and drew agonized breaths for 30 minutes. States have passed secrecy laws to obscure the cruelty of executions; Indiana now blocks reporters from witnessing them entirely. The United States has become an outlier among democracies as states that still conduct executions have accelerated the pace.

Studies

This study aimed to assess the adherence and willingness to participate in colorectal cancer screening programs in people living in prison (PLP). This survey was conducted from October 2023 and July 2024. Of the 995 participating, 314 were eligible for colorectal cancer screening. Those who reported consumption of at least 5 daily portions of fruit and vegetables, that were minimally active and had at least one chronic disease were significantly more likely to have undergone fecal occult blood test, whereas those who had a length of detention of 2–10 years, those who reported correct protein consumption, and those who do not drink alcohol were significantly less likely to have undergone a fecal occult blood test for colorectal cancer screening purposes.

State Roundup

Alabama

Families, former inmates and former corrections staff packed a State House committee room to describe what they called ongoing violence, extortion and unsafe, overcrowded conditions inside Alabama’s prisons. Lawmakers advancing Senate Bill 316 say the measure is designed to increase oversight of Alabama’s corrections system. The bill would create an independent prison oversight coordinator tasked with inspecting prisons and investigating complaints. It would also establish a Corrections Oversight Board, requiring regular inspections and public reports on prison conditions.

Colorado

The 13th Amendment of the U.S. Constitution abolished slavery at the end of the Civil War, it included a carveout that sanctions it as punishment for people convicted of crimes. In 2018, Colorado voters overwhelmingly passed Amendment A, which made the state the first to erase that language from its state constitution.But District Court Judge Sarah Wallace found that the CDOC’s policies “compel and coerce work” from incarcerated people, “constituting servitude." The judge found that the Colorado Department of Corrections ,(CDOC) hadn’t so much as reviewed their policies after Amendment A’s passage to make sure prison officials were complying, let alone made any changes to policies or practices.

Florida

Legislation to guarantee air conditioning and basic rights for Florida inmates is once again dying quietly without a single Committee hearing — even as a related lawsuit moves forward. The bills would establish a statutory “Inmate Bill of Rights,” requiring air conditioning in newly constructed prisons and mandating cooling or ventilation systems in existing facilities. .

Michigan

Michigan’s prison population has seen a slight increase after years of decline, driven in part by inmates serving longer minimum sentences, putting the state’s correctional facilities closer to operating at full capacity. A new report from the Crime and Justice Institute, a Boston-based nonprofit, shows that as of 2023, more people were staying behind bars longer in Michigan, even as the number of available prison beds has declined following recent facility closures. “The thing that is particularly dire in Michigan is the increases we saw in how long people are staying (in prison),” said Maura McNamara, deputy director of the Crime and Justice Institute. More than 65% of inmates are serving sentences of 10 years or more, the study found.

Missouri

A federal jury awarded $667,000 in damages to a group of Muslim men incarcerated in Missouri who were pepper-sprayed by state correctional officers while praying. The lawsuit in eastern Missouri's U.S. District Court alleged that the men had been allowed to pray together many times in their prison housing unit after the chapel was locked down during the COVID-19 pandemic. The money will be distributed among eight men who were handcuffed, pepper-sprayed and placed in solitary confinement after praying in the housing area at the Eastern Reception, Diagnostic and Correctional Center in Bonne Terre on Feb. 28, 2021.

New Jersey

New Jersey corrections officials are trying a new approach to reducing prison suicides: a buddy system. Department of Corrections officials launched a “peer companion” program last August that pairs incarcerated people with prisoners who are on suicide watch and tasks them with “supportive observation and interaction,” department spokesman Christopher Greeder said. The program is modeled after a federal Bureau of Prisons program now in place in California and Colorado, Greeder said. Peers sit outside the monitored person’s cell to observe and talk with them, record their observations in unit logbooks, and debrief with clinical staff after other peers come to relieve them, he added.

Pennsylvania

An inmate at a Pennsylvania prison was successful in convincing a jury that two correctional officers subjected him to cruel and unusual punishment in a case that involved candy, a lamp stand and a stint in solitary confinement. The civil suit, filed in the U.S. District Court for the Western District of Pennsylvania, claimed prison staff at State Correctional Institution – Greene (SCI Greene) in Greene County denied the inmate, Maurice D. Able, 43, things like sleep, reading materials, time outside, toothbrushes and toothpaste, and held him in solitary confinement long after he had been cleared of possessing drug contraband in 2018.

Rikers Island

For detainees on Rikers Island spiraling into a psychiatric crisis, a trip from the troubled jail complex to one of the city’s public hospitals can serve as a medical lifeline. But that relief is often short-lived. In around half the cases, detainees are returned to Rikers within hours after what critics describe as cursory hospital checks, landing them back in the same environment that jail clinicians initially deemed unsafe for their mental health. The hospital back-and-forth is particularly notable because medical care at both Rikers and the hospitals is overseen by the same public system, NYC Health + Hospitals.

The Mamdani administration is looking to hire a “borough-based jails czar,” according to a job listing posted by the mayor’s office. “The City Council passed a law last year requiring this role, and the Mamdani administration is implementing it," City Hall spokesperson Sam Raskin said in an email. "The mayor is committed to closing Rikers Island and replacing it with smaller, borough-based facilities now under construction."

In late February, at the end of the 45-day deadline Mayor Mamdani had given the Law Department to work with the federal monitor, the city presented a proposed plan. Mamdani called it "a decisive step to improve conditions and move our jail system toward long-term stability and safety for those in custody and correction staff." Under the proposal, the city would move toward complying with Local Law 42, which effectively bans solitary confinement in New York City jails. The plan would limit the DOC to brief "de-escalation" confinement following an incident, generally capped at two hours during the day or four hours within a 24-hour period. Staff would be required to check in regularly with the person rather than leaving them in prolonged isolation.

Telecommunications

For the people in Virginia's correctional facilities who spend hours each day locked in cells the size of a parking space, the prospect of tablets supplied by ViaPath — with easy access to games, music, and movies — is an exciting one. As part of the agreement with ViaPath, the state has agreed to pay the company $1 million a year for software, security equipment, infrastructure improvements, and lower phone rates. The deal also provides the Department of Corrections with a 5% kickback on gross revenue. For those incarcerated, each message costs twenty cents — and new limits on the number of characters per message may require sending three emails where the previous system required only one. Incarcerated people also report having lost access to all of the emails, games, and music they had already paid for when the state previously did business with a competing company, Securus.

Correctional Health Care Providers

Mediko

Shasta County supervisors, after a grand jury repport, approved a $25 million contract with Virginia-based Mediko to provide health care services to inmates at the county jail. The three-year with Mediko contract costs around 40% more than the county’s agreement with its current provider, Wellpath, but would add much-needed medical staff to the jail. A grand jury investigation after five in-custody deaths occurred at the Shasta County Jail over a 13-month period beginning in 2023 The company has faced over a dozen lawsuits in Virginia for medical malpractice and wrongful death.

Finally we want to wish all our subscribers
A Happy St. Patrick’s Day!