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Over the past 15 years, formerly incarcerated people have greatly benefited from expansions to Medicaid healthcare coverage. Those gains are now at risk in the face of an estimated $1 trillion in federal spending cuts outlined in President Donald Trump’s One Big Beautiful Bill Act. Experts who spoke to The Marshall Project warn that the lost coverage will lead to unnecessary deaths.
Medicaid coverage is especially important for people post-release, because incarceration can wreck their health. One long-term study published in 2021 that investigated the mortality consequences of incarceration using national data found that imprisonment decreased the life expectancy of a 45-year-old person by 13%.
Dr. Shira Shavit, the co-founder of the Transitions Clinic Network, which provides care to people post-incarceration, has seen the toll of imprisonment on her patients.
“Carceral systems are not really set up to be healthcare systems,” she said, before pointing to the conditions often found in jails and prisons, such as overcrowding and inadequate treatment for chronic diseases, mental health, and opiate use disorder. The poor health that people develop on the inside follows them when they get out, and can worsen as they struggle to access consistent health care.
As an example, Shavit pointed to a patient she’d recently treated after prison. He was enrolled in Medicaid in the wrong county, and fixing the error caused him to miss three months of lifesaving cancer treatments.
Since Shavit co-founded Transitions in San Francisco in 2006, she has seen successive federal efforts to try to expand health care coverage and close the gaps for her post-incarceration patients.
The expansion of Medicaid under President Barack Obama’s 2010 Affordable Care Act, was the first major advance in access to care. According to the U.S. Government Accountability Office, the act made health insurance available to 80% to 90% of formerly incarcerated people who had previously been ineligible. Shavit noted that President Joe Biden’s administration gave states permission to enroll incarcerated people in Medicaid prior to their release. “This allows people to get care that might not have been historically provided as they were leaving incarceration, like medications for opiate use disorder,” Shavit said.
Interruptions to care can be deadly. One widely cited study on people released from the Washington State Department of Corrections between 1999 and 2003 found that they faced a risk of death almost 13 times higher than other state residents, largely due to the risk of drug overdose. Grim realities like these have Shavit fearing the fallout from the Big Beautiful Bill, which the Congressional Budget Office estimates will increase the number of uninsured people nationwide by more than 10 million over the next decade.
“This pulling back on access to Medicaid post-release is really a step backwards,” Shavit said.
The most consequential change to Medicaid in the new bill are work requirements, which go into effect on Dec. 31, 2026 and drive the largest share of expected cuts to the program. Under the new requirements, Medicaid enrollees older than 19 will have to demonstrate that they’ve been employed, or are participating in forms of “community engagement,” such as community service, for at least 80 hours in the month prior to health coverage. To maintain coverage, they’ll need to re-certify their work status at least every six months.
Wanda Bertram, a communications strategist for the Prison Policy Initiative, an advocacy non-profit focused on mass criminalization, believes these stipulations are especially burdensome for the formerly incarcerated, who face stigma when trying to get hired. “Our data says that 27% of people who have been to prisons are unemployed, meaning they want to work, but they cannot find work,” Bertram said. By comparison, the nation’s unemployment rate is 4.2%.
Michigan University law professor Mira Edmonds says many formerly incarcerated people are working, just not in jobs that would fulfill the requirements in the new legislation. Because their criminal record worsens employment impediments like racial discrimination and incomplete schooling, “the jobs that they can get are on the black or gray market, under the table,” Edmonds said. Those jobs are inconsistent and can’t reliably provide references.
The new law does have some carve outs that could blunt the impact on incarcerated people, most notably a pause on work requirements for three months after a person has been released from prison. There are also exemptions from work requirements for people with proof of a qualifying condition, such as substance use disorder or a developmental disability.
But Shavit says that the three-month pause is not enough time to find your footing after prison. “It is so difficult to manage the needs and requirements from probation and parole in those first few months. People have to pick and choose where their priorities lie and are often very confused about how to navigate the systems,” she said.
Lily Roberts, the managing director of inclusive growth for the progressive nonprofit Center for American Progress, believes these exclusions are almost as onerous as the work requirements. The exclusions call for paperwork and doctor's visits — all while people are dealing with their health issues. Roberts added that the red tape is likely self-defeating, if the point is to promote employment. “People who are healthy get a better job, and they stick with it for longer,” she said.
Trump officials like Dr. Mehmet Oz, administrator for the Centers for Medicare and Medicaid Services, tout work requirements as an opportunity for beneficiaries to “show they have agency over their future” and as a way for the federal government to fight “waste, fraud, and abuse.”
But Andy Schneider, a research professor for the Center for Children and Families at Georgetown University with more than 50 years of experience working with Medicaid, believes the requirements are just a tactic to “make states walk away from adults covered under the ACA Medicaid expansion.”
Something similar is already happening in Georgia, which implemented Medicaid work requirements in 2023 through a program called Pathways. The program was pitched as a way to get people coverage and get them back to work. But according to a recent investigation by ProPublica and The Current, Pathway’s enrollment has been 75% lower than initially estimated, in part because of the onerous process and the state not having enough people to help with sign-ups. At the start of this year, there were thousands of applications still being processed. And more than 40% of the people who started applications gave up.
“It’s diabolical to make cuts that you know are going to make it harder for people who were otherwise eligible to access these programs,” Roberts said. “This doesn’t incentivize people to get a job. It incentivizes people to quit trying.”
Schneider, the Georgetown researcher, believes that formerly incarcerated people across the country will be especially vulnerable to losing coverage due to the work requirements’ paperwork. But he said states will also suffer — even if some of those states want to continue covering the scores of formerly incarcerated people who were eligible for Medicaid under the ACA. “On a day-to-day basis, it’s the states that are gonna have to administer all this paperwork and ultimately, they’re going to have to outsource that work to private companies,” Schneider predicts.
In Georgia, Deloitte Consulting has been paid more than $50 million for software the state uses to help verify work requirements. According to reporting by ProPublica and the Current, users of Deloitte’s application have had issues with their info disappearing and their progress being erased.
“The point is the red tape,” Schneider said of work requirements. “It’s designed to make it more painful.”
Bertram, from the Prison Policy Initiative, agrees that work requirements are not being instituted to fight fraud. “When you think about it, you realize that you can't cash in and sell your Medicaid on the black market,” she said. “The idea that people would be personally profiting off their Medicaid coverage is just totally out of whack.”
Instead of fighting crime, Bertram believes that rolling back access will create more crime. That’s because, according to research by the Prison Policy Initiative, states that expanded Medicaid have seen lower recidivism — the number of formerly incarcerated people who commit new offenses. One study found that in those states, the recidivism rate of “multi-time offenders with violent offenses” was as much as 16% lower during the first two years after they left prison, compared to states that did not expand health coverage between 2010 and 2016.
“The consequence of these requirements is going to be that more people end up arrested and in jails and in prisons, which has its own cost,” Bertram said of the Big Beautiful Bill mandates. “This bill is a transfer of public spending away from healthcare and towards incarceration, which I think is in line with the Trump administration's explicit priorities.”