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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.

Cody Coughenour, at home in his bedroom, holds his health insurance card. It’s made his most recent release from jail different than other times he was incarcerated and released.

Ramon Dompor for Tradeoffs

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Ramon Dompor for Tradeoffs

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.