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Cody Coughenour landed in jail at least half a dozen times by the time he was 47 years old. First, it was crimes related to his alcohol addiction. Then, when he was 26 years old, his mother died of a meth-induced heart attack.
The overwhelming grief led him to the same methamphetamines that killed his mother.
"What people are running away from, that's what they're going to run into," he said.
Each time Coughenour got out of jail in Washington state, the list of things he was supposed to do to get back on his feet felt overwhelming. He knew that addiction treatment and therapy should be near the top.
But to pay for that care, he needed health insurance.
When he would get released, his jailers would hand him a phone number to call to get onto Medicaid, the public health insurance program for low-income and disabled Americans. It would either go to voicemail, Coughenour said, or he'd be placed on a long hold. That delay was enough to send him straight to his dealer's house — and eventually back to jail.
December 2025 was different. Coughenour left jail with medications for his anxiety, his Medicaid card in hand and appointments already on the calendar.
"We went straight to the treatment facilities," he said.
A large experiment
Coughenour's experience is one example of a much larger experiment unfolding across the country. Some states are turning Medicaid on before some people leave jail or prison, with the goal of making sure they have a better chance of staying out of jail and staying alive.
But just as 19 states race to build these programs, Medicaid itself is changing.
H.R. 1, the sweeping federal budget law passed last year that's also known as the One Big Beautiful Bill law, is forcing state Medicaid agencies to implement work requirements, tighter eligibility checks and budget cuts. At the same time, the Trump administration is scrutinizing how much these "reentry programs" cost and what services they cover.
The result is a new test for a rare bipartisan Medicaid initiative: How much of a bridge from incarceration to care can states still build in a narrower Medicaid program?
Elevated risk of death after incarceration
For decades, federal Medicaid dollars were prohibited from paying for most health care provided to people while they were incarcerated. Instead, that cost was paid by the counties and states.
But health care behind bars is often underfunded and inadequate. Courts have ordered improvements in roughly half of state prison systems.
Many people leave incarceration with untreated mental illness, substance use disorders, chronic disease and few easy ways to connect to care once they return to the community. Research shows that they face sharply elevated risks of death in the first weeks after release, particularly from overdose.
In 2018, Congress directed federal health officials to work with states on ways to improve care for people leaving prison and jail. States started requesting waivers to allow them to cover certain services 30-90 days before release, and the Biden administration gave 19 states permission to move forward, with eight additional states and Washington D.C. also seeking approval.
In the four states — California, Washington, Montana and New Hampshire — that have started providing Medicaid coverage to people inside, tens of thousands of people are now being screened for substance use disorder, provided medications and connected to care before release, among other services.
It's too soon to know whether these efforts are reducing deaths or emergency room visits, though state officials in Washington say people who have received Medicaid before release have been less likely to return to jail or prison.
What is clear is that bringing Medicaid behind bars takes a lot of work. It took several years for officials in these states to build new systems, win buy-in from local jail operators and figure out how to integrate the worlds of Medicaid and incarceration.
"What we really needed was a translator between the Medicaid agency and the jails," said Marc Stern, a Washington doctor who has spent 25 years working inside prisons and jails. "Because Medicaid doesn't speak jail, and jail doesn't speak Medicaid."
Now, some Medicaid agencies say federal changes are making it impossible for them to replicate those efforts in their states.
Trump's cuts force some states to pull back
Advocates and policy experts who are assisting states with implementing this experiment say most are still moving forward with their plans for now. But at least three states — Oregon, Rhode Island and Michigan — have paused their work as a result of the OBBB.
Oregon Medicaid Director Emma Sandoe said bringing Medicaid behind bars fit squarely with her state's long-standing push to expand health coverage. But the OBBB has forced Oregon to focus on other urgent tasks, such as implementing new work requirements and more frequent eligibility checks. Sandoe said the state still wants to get Medicaid into jails and prisons, but it will have to wait.
"What physically can be done with the amount of time, with the amount of resources available, is limited," Sandoe said.
Rhode Island and Michigan cited insufficient funding in their decisions. In rescinding its application in December 2025, Michigan officials wrote, "This initiative will be archived and considered for future efforts to support reentry populations."
Louisiana offers clues to Trump vision for Medicaid behind bars
States pursuing this work are expected, under guidance from the Centers for Medicare and Medicaid Services, to provide people with at least addiction treatment, medications pre-release and someone to help them get care once they are out. Some states approved by the Biden administration went further — offering the full Medicaid benefits that someone in the community would receive.
Federal officials seem to be encouraging a more narrow approach now.
In April, officials from Louisiana and the Trump administration announced that Louisiana would be the next state approved to bring Medicaid into jails and prisons — and the first to be cleared under President Trump.
Louisiana Deputy Medicaid Director Pete Croughan said the state's proposal went through an "intensive delete process" as federal officials pushed Louisiana to cover only the services the state saw as most essential. To get a thumbs up from the Trump administration, Louisiana limited the services it would pay for to mental health care, medications for addiction treatment, infectious disease screening and medical equipment like wheelchairs.
Croughton said Louisiana scaled back its plans to have Medicaid pay for primary care services inside jails and prisons. Instead of having people see a primary care provider before release, the state now plans to introduce them to a clinician they can see once they are out.
"There's definitely evidence that folks with untreated mental health and addiction issues are more likely to die. So we have to solve for that," Croughan said. "I don't know that there's evidence for that for someone with untreated knee pain."
Louisiana also asked for less federal funding to help cover startup costs, including new staffing and technology. Instead, the state plans to use money it will receive from the new Rural Health Transformation Fund and another existing federal funding source.
Federal health officials declined to say whether other states must follow Louisiana's approach to receive approval going forward. A spokesperson for the Centers for Medicare and Medicaid Services said in a statement, "The agency understands that states may face varying challenges during implementation, and CMS remains committed to supporting all states throughout this process."
Experts worry that narrower programs could be less effective
Lauren Brinkley-Rubinstein, a professor at Duke University who studies the health impacts of incarceration, said the services Louisiana plans to offer — especially medications for opioid use disorder — are the most impactful for keeping people alive.
But she said many people leaving incarceration have multiple chronic illnesses that have often been inadequately cared for inside. Under Louisiana's plan, newly released individuals will have to find care for those conditions on their own — on top of needing to find housing, food and employment.
"Going to the doctor and refilling that prescription is just never going to rank higher than those other things," she said. "It makes it more likely that they are going to come back through the [jail or prison] door."
That was Cody Coughenour's experience every other time he left jail. But after Washington state got him on Medicaid before his most recent release, it's been a different story.
He's been sober and in therapy since he got out in December. He's working and going to school to become a phlebotomist.
Most importantly to Coughenour, the stability has opened the door to something he had missed out on for years: time with his teenage daughter.
"We baked cookies together," Coughenour said, recalling an afternoon a few months after he got out of jail. "She hugged me, and she cried."
Reporting for this story was supported, in part, by the philanthropy Arnold Ventures.
Julie Wernau is a reporter for Tradeoffs, a nonprofit news organization that covers healthcare's toughest choices. You can sign up for Tradeoffs' weekly newsletter to get the latest stories in your inbox each Thursday morning.
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