In February, Hawai‘i’s parole board granted the now-52-year-old compassionate release, which allows prisoners to receive early probation to seek .

But without a long-term care facility willing to accept him, Alameda has not been able to leave.

As of June, at least three other prisoners granted release to tend to their medical needs were living indefinitely in the infirmary after long-term care facilities were unwilling to accept them, primarily because of their criminal backgrounds, the state parole authority said.

“This is a challenge across the country,” said Molly Crane, an attorney for FAMM, which advocates for .

Every state allows for prisoners, though HawaiÊ»i is the only one without a specific law, relying instead on an internal policy. The prisoners who typically qualify for compassionate release can’t care for themselves or have terminal illnesses and may need an assisted living center, a nursing home, or hospice.

But many long-term care facilities nationwide decline to take such prisoners, leaving them incarcerated for months — or years — after they were granted release.

In , a study found that rejections from nursing homes soared after they were told that a patient was coming from prison. , prisoners with extensive medical needs stayed an average of 200 days after being granted parole, because of denials from long-term care centers. And in , prisoners granted parole sued the state when they couldn’t get placed in nursing homes.

President Donald Trump’s signature One Big Beautiful Bill Act further strains long-term care providers’ ability to take people from incarceration. Prisoners don’t qualify for Medicaid, so parolees after they’re granted the release. The law, enacted last summer, reduces the window in which facilities can get reimbursed from three months to before they apply. That means facilities risk not getting paid for new Medicaid patients whose applications are not submitted within the reduced timeframe.

The Centers for Medicare & Medicaid Services “encourages providers and beneficiaries to prioritize timely application submission to maximize coverage,” CMS spokesperson Timothy Foster said.

‘Risk Is Just Too High’

Most nursing homes nationwide already have a waiting list for new residents, according to a by the American Health Care Association and the National Center for Assisted Living. Those waitlists are another hurdle to getting prisoners placed, said Bob Merce, a former attorney who advocates for prisoners’ compassionate release.

“We tell the nursing homes that most of the people who we are talking about cannot hurt somebody,” Merce said.

Some of the prisoners staying at the Halawa infirmary in June couldn’t walk or dress themselves. One man couldn’t recall what his illness was. Another with brain cancer couldn’t coherently respond to questions.

Sean Sanada, the OÊ»ahu Region CEO with the HawaiÊ»i Health Systems Corp., oversees the region’s two state-funded long-term care facilities, Leahi Hospital and Maluhia. Sanada said that the health system has reviewed dozens of compassionate release referrals but has never accepted any of them.

Sanada said the facilities don’t discriminate based on where the resident comes from. His main concerns, he said, were his staff’s safety and the lack of resources to adequately care for the patient.

“The risk is just too high in most of those instances,” Sanada said.

Violent incidents in long-term care facilities have been well documented. A observing 14 assisted living facilities found that in just one month, 15% of residents experienced resident-to-resident aggression.

When long-term care facilities refuse to accept prisoners who have been granted compassionate release, it leaves state taxpayers footing a larger bill. The annual cost to incarcerate an individual in Hawai‘i with complex needs is up to eight times the $112,505 average of housing one person in prison, according to FAMM. In comparison, the average Medicaid reimbursement for a long-term care patient at a Hawaiʻi Health Systems Corp. facility is about .

Four states — Connecticut, Georgia, Massachusetts, and Vermont — contract with nursing facilities to take prisoners who are granted compassionate release, according to FAMM.

The iCare Health Network’s MissionCare Health, which operates nursing homes for people coming out of prison, secured contracts in three of those states. David Skoczulek, iCare’s vice president of business development and communication, estimated that its rates are $100 to $350 a day more per patient than the average nursing home rates in the states where they operate.

In Hawaiʻi, the correctional department determines recommendations to send to the parole board, which decides whether to grant the release. Prisoners who are granted the early probation can be released to family members who commit to caring for them or to a long-term care facility.

Corey Reincke, head of the HawaiÊ»i Paroling Authority, said that in his 24-year career he couldn’t recall getting anyone placed into a long-term care facility without family intervening, for instance by contacting facilities themselves.

“Parole has to find a facility that can meet their medical needs and is also willing to take them,” Reincke said. “That’s where we’re hitting the roadblocks.”

For one parolee, Reincke called more than 100 care homes, he said, but they all declined to accept the patient, over safety concerns. According to a 2024 state report, while HawaiÊ»i’s long-term care facilities use about workforce strains make it difficult to maintain even those levels.

HawaiÊ»i Prisoners’ Refuge: Family

Last year, 69-year-old Paul Kupihea died at a hospital five days after the state granted him compassionate release to his family. He died before he could get on a flight to his home island.

In July 2025, Lahela Kruse, the mother of Kupihea’s child, received a call from a Honolulu hospital informing her that his condition had become severe. By then he had been diagnosed with an incurable form of cancer and had been in and out of the hospital while still in custody.

Kruse and their daughter flew to Oʻahu to see him and were shocked when they saw how sick he was. Their daughter agreed to take him into her home in Hilo, on Hawaiʻi Island, despite not having a relationship with him for most of her life.

“She knew he was sick,” Kruse said. “I told her that, but she didn’t know the severity of it. I didn’t truly know.”

Her daughter’s willingness to take him prompted his compassionate release. But Kruse said the notification about Kupihea’s illness came too late.

FAMM’s Crane has been working on expanding compassionate release laws in states to allow for more prisoners to qualify and strengthen transparency in the process. HawaiÊ»i lawmakers have tried for years to pass bills on compassionate release, but none has succeeded.

Crane said without a law that outlines a formal process and who qualifies, even family support isn’t enough. Prisoners can still face life-threatening delays, she said.

“The absence of a compassionate release statute means that people who need compassionate release languish and even die in prison,” Crane said.

In Alameda’s cell, two beds stood about 3 feet apart, with a seatless metal toilet in the corner and a window looking out on a concrete wall. The smell of bleach permeated the room. Alameda said he hoped to see his daughter soon. She recently turned 5.

“I made some mistakes in my life,” said Alameda, who has been incarcerated since 2024 for drug possession, driving a stolen vehicle, and jumping bail. “I tried when my daughter was born, but I know I’ll change, because she needs me out of here.”

Merce, the former attorney, is still trying to find a place for Alameda, who committed no violent crimes. Merce became aware of prisoners’ struggles through his work as a trial lawyer. He said he has helped about 15 prisoners leave HawaiÊ»i correctional facilities for medical treatment.

He said he’s seen cases in which people have waited years to get out.

“The ones that stick with me, though,” Merce said, “are the ones that I never found placements for.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

A podcast producer and director emeritus of WOUB Public Media zeroed in on our article about restless doctors, sharing his thoughts on X:

This must be Trump and Kennedy’s idiotic plan to make American Healthy Again…

— Tom Hodson (@thodson)

— Tom Hodson, Athens, Ohio

Oh, Canada Welcomes American Doctors!

The article “American Doctors Are Moving to Canada To Escape the Trump Administration” (May 30) presents us Canadians with welcome news. In every part of Canada, in every province, there are not enough doctors. In our city of Victoria, for instance, many people do not have a family doctor because so many doctors have retired; those who are left are unable to take new patients because their lists are full. Walk-in clinics are overbooked, the emergency rooms at the hospitals all have overfull waiting rooms and doctors and nurses are doing 12-hour or longer shifts. We need doctors and will welcome American doctors here with wide-open arms.

There are many aspects of Canada’s health system that could help lure American doctors to join us. The mortality rate for infants and mothers in the USA is worse than in Cuba. Ours is much better. We do not have a director of national health preaching against the use of vaccination. Our national record for health care during the covid pandemic emergency was second to none. Our women’s clinics are not plagued by political ideology. Our society has always been more open than that of the USA to immigrants and others of all races.

Doctors who agree to work for the armed forces receive special benefits. The experience is known to be valuable and rewarding.

I would also recommend Quebec as a great place to live and work. This would present a valuable opportunity for doctors and their families to learn French. France has a wonderful health service and would be a great place for family members to study and work. Germany is also a great place for medicine and health care. An added plus, besides learning the German language, is that the medical schools and universities, once they accept students, including foreigners, do not charge tuition. No post-graduation debt in Germany. That has proved to be a great policy for Germany. It attracts brainy students from all over the world and ensures the continuing high level of the German health system.

American doctors, Canada is an excellent option for escaping from the threat of autocracy. It can be a very positive step to leave the USA after realizing that the world is open to you and your family. Canada fits Americans comfortably. As our Prime Minister Mark Carney told President Donald Trump in his Oval Office, “Canada will never, never, never be your 51st state.” So, American doctors, pack your luggage, come on over and join us. We will welcome you very warmly and help you in every way we can!

— Philip Maxwell, Victoria, British Columbia

A Seattle reader delivered a diagnosis on X:

So I guess this article and the Dr. Interviewed are far left progressive. The US is better off without them.

— Daniel Arroyo (@danielarrmaga)

— Daniel Arroyo, Seattle

Tellin’ It Like It Is, Baby

The article “The New Old Age: Honey, Sweetie, Dearie: The Perils of Elderspeak” (May 9), hit home for me.

Several years ago, my health plan referred me to an ophthalmologist’s practice. After one appointment, the woman who was supposed to schedule me for my next one called me “Sweetie.” I don’t remember what I said, but I took umbrage and walked out.

There were other problems (the doctor who examined me didn’t introduce himself, for one thing). I went home and wrote a complaint letter to my health plan. They gave me another referral and reported the practice to Medicare.

I only wish I had read this article a month ago. I had a biopsy in a hospital last month, and one of the nurses spoke to me as if I were a 2-year-old. I would have been prepared to deal with this then.

— Sue Kamm, Los Angeles

The director of the Pitt Band at the University of Pittsburgh threw down the gauntlet on X:

Any who addresses me with “Elderspeak” will be dealt with harshly. You’ve been warned.

— Harry Bloomberg (@pittbandphoto)

— Harry Bloomberg, Pittsburgh

Don’t Gamble With Children’s Lives

Concerning Health and Human Services Secretary Robert F. Kennedy Jr.’s recommendation that healthy children needn’t receive the covid vaccine (“Trump’s Team Cited Safety in Limiting Covid Shots. Patients, Health Advocates See More Risk,” May 23), have pre-vaccine complications such as multisystem inflammatory syndrome in children been forgotten? A western lost both hands and both feet to MIS-C and will go through life with prostheses. Please remind people of these serious complications which, though infrequent, cannot be reversed. Not vaccinating is playing Russian roulette with your child!

— Gloria Kohut, Grand Rapids, Michigan

An upbraiding on X came from a reader Down Under:

This decision – apparently made without any expert consultation – will have international ramifications, especially among the vaccine sceptical.

— Lesley Russell Wolpe (@LRussellWolpe)

— Lesley Russell Wolpe, Sydney, Australia

Core to California’s Prosperity: The Fruits of Immigrant Labor

I found your article to be incomplete when it comes to offering the perspective of undocumented immigrants (“After Promising Universal Health Care, California Governor Must Reconsider Immigrant Coverage,” May 13). According to the Institute on Taxation and Economic Policy, undocumented immigrants to the California economy. It is disingenuous to present the cost of medical expansion to undocumented immigrants as a type of handout, when it is widely known that undocumented immigrants work without any prospect of receiving the benefits of their work in social programs. The fact that Gov. Gavin Newsom made the effort to expand benefits to undocumented workers was the right thing to do, and we should work toward rearranging funding to continue the expansion and not retrench during a time when unidentified people are apprehending undocumented workers on their way to work and more than ever face the possibility of suffering human rights abuses. If you, as a news organization, don’t do them justice by inserting their contributions into the discussion, then you are being complacent to their dehumanization.

I grew up in Oxnard, California, and my entire life was surrounded by the fruits of farmworkers’ labor, many of whom were undocumented. If you drive up and down Rice Road at 5 a.m. every day, you will see hard-working people who, during the wintertime, have to stay during the night to warm up the crops. That type of love and dedication to their work — not for their benefit, but for their families and the state of California — should be recognized. I invite your readers to look for “” by Seth Holmes to start understanding the physical toll that working in the fields takes on young immigrants, even when they arrive as healthy bodies. Still, after years of working in the fields, they face a multitude of health problems and overall physical deterioration. They give their bodies in exchange for an American dream that may or may not materialize.

Undocumented farmworkers fill just one essential sector of the American labor economy that does not stop even during fires or pandemics, so please do better in highlighting the humanity of folks who are more than just the work they produce. It is essential to state that if it weren’t for their cheap labor, the Golden State would not be so golden. Look at Florida, where the criminalization of undocumented workers is leading to labor shortages now intended to be filled by children.

Health care is a minimum that can be provided for undocumented workers, not because of any other reason than health care is a human right, and undocumented workers pay their fair share in unclaimed social benefits. Health care for all!

— Jennifer Diana Figueroa, Oxnard, California

A sociologist who directs social policy at the Niskanen Center, a nonpartisan think tank, weighed in on X:

No matter what advocates told themselves and policymakers, it was never politically sustainable:

“It’s making people look at the health care that they can’t afford and ask, ‘Why the hell are we giving it for free to people who are here illegally?’”

— Josh McCabe (@JoshuaTMcCabe)

— Josh McCabe, Lowell, Massachusetts

Improving a Prisoner’s Life Sentence

I was very impressed with “Prisons Routinely Ignore Guidelines on Dying Inmates’ End-of-Life Choices” (May 15), authored by Renuka Rayasam. I have visited prison twice: once to San Quentin as a member of the Berkeley YMCA wrestling team in 1963.

Then, in 1999, I was privileged to be appointed to a new American Hospital Association committee, the Circle of Life Awards Committee, which was created to recognize the most outstanding and innovative hospice and palliative care programs in the country. Among the many applicants in the first year was the Louisiana State Penitentiary Hospice, and it was selected as one of five finalists for a site visit in 2000. I indicated my interest in being a member of the site visit team. This prison, commonly known as Angola, is the nation’s largest maximum-security facility, and we were told prisoners sentenced to life will die there because there was no parole in Louisiana for such a sentence. We were also informed that there was a long waiting list of inmates wanting to be hospice volunteers because the program was so highly valued.

My most distinct memory of our visit was a conversation with a volunteer who said he had just come from bathing and feeding a terminally ill inmate who said, “I love you.” The volunteer was visibly emotional when noting he had never heard these words before, not from his father whom he never met nor even his mother. These comments clearly demonstrated the beneficiaries of the program were not just the patients; they were also the volunteers.

— Paul B. Hofmann, Moraga, California

On X, another reader from Australia dove into a discussion about fluoridation of drinking water in response to our coverage:

RFK making tooth decay great again

— Dan Jago (@dj1au)

— Dan Jago, Melbourne, Australia

How Fluoride May Hijack Thyroid Health

Stories about fluoride seem not to mention the chemical’s impact on thyroid health (“With Few Dentists and Fluoride Under Siege, Rural America Risks New Surge of Tooth Decay,” March 27). This seems an oversight because it’s estimated that 10%-20% of the population will have thyroid issues in their lifetimes.

When I was an unmedicated hypothyroid person — not taking any supplemental thyroid hormone — I frequently had cavities. After filling the cavity, my dentist would do me the favor of treating my teeth with fluoride. And then followed a period of lassitude so severe I felt my job was at stake, definitely placing me in the “fat and lazy” category, as described by Ozark Mountain Regional Public Water Authority Chairman Andy Anderson in your article. It took me several treatments to make the connection.

I don’t get cavities now and haven’t for about 20 years. I think my now-appropriate dosage of supplemental thyroid plays a role in that.

Studies about thyroid and fluoride vary in their conclusions. Thyroid deficiencies can have widely varied effects on our widely varied population. There may never be widely accepted guidelines. But people should be careful about what they put in their bodies.

— Joy Mullett, Houston

A self-described information technology health care entrepreneur stated his opinion simply while sharing the article on X:

FLOURIDE is poison! Daily Health Policy Report&utm_medium=email&_hsenc=p2ANqtz–TOtkdDDnhvAyd8nDZIAFejJobpsKBnLP5smKnlslyZjSC6tT9BHFfvtjE8tnngMhNn7huZCl4MKi1CdAi0QtZkvWmew&_hsmi=353879828&utm_content=353879828&utm_source=hs_email

— Earl Winter (@EarlWinter8)

— Earl Winter, Nashville, Tennessee

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

The funds come from nearly $200 million in federal fines imposed because of California’s lack of progress in hiring sufficient mental health staff. They are being used for hiring and retention bonuses, including an extra $20,000 for psychologists and psychiatric social workers — roles with the highest vacancy rates — and $5,000 boosts for psychiatrists and recreational therapists.

“I think it’s important to point out that this is the money that the state saved by not hiring people for these positions,” said Michael Bien, an attorney representing the roughly one-third of California prisoners with serious mental illness in a class action lawsuit. “And we know that not hiring caused suffering, harm, and even death.”

The cash is aimed at countering a scarcity of mental health workers and . State officials blame this dearth of workers for their chronic inability to meet hiring levels required by the long-running suit — a failure that led a federal judge to hold top officials in contempt of court last year. The funds are being distributed after an appeals court in March, saying staffing shortages affect whether prisoners have access to “essential, even lifesaving, care.” The spending plan was jointly developed by attorneys representing prisoners and state officials.

Janet Coffman, a professor at the University of California-San Francisco Institute for Health Policy Studies, said planned improvements in working conditions should help with hiring, but she was skeptical of the impact of bonuses.

“What I don’t see is the sustained increases, the increases in salaries over the long term, which is what I think is probably more effective for retention than one-time bonuses,” Coffman said.

The state did not take that view. Its expert witness, labor economist Erica Greulich, testifying during the 2023 trial that led to the fines, said that higher salaries were unlikely to meaningfully increase hiring.

Facing a $12 billion deficit, Gov. Gavin Newsom in May proposed across state government that would “make it extremely difficult to fill chronically vacant mental health positions,” said Abdul Johnson, chief negotiator for the bargaining unit representing health and social service professionals in prisons and other agencies. He said he believes California should add longevity pay to retain veteran workers and pay more in areas with higher costs of living.

On the face of it, the salaries for mental health positions at California prisons are competitive with the private sector’s. For example, the range for is $133,932 to $162,372, while the in California ranged from $117,630 to $137,540 last year. The most recent state contract with prison psychiatrists already includes , on top of other sweeteners, with a state salary range topping $360,000, nearly $34,000 above the California mean salary.

But California prisons are competing for behavioral health workers amid a roughly 40% shortage of psychologists and psychiatrists in the state, and that shortfall is expected . For more than a year before the court’s contempt ruling, the vacancy rate for psychologists never fell below 35% — the state is currently recruiting for nearly 300 such positions — while vacancies among social workers ranged from 17% to 29%.  The court ruling said the state oversaw “adequate” staffing for psychiatrists and recreation therapists but only periodically succeeded in reducing the vacancy rate below the 10% maximum allowed. Officials are in the process of adding several new positions that are eligible for the bonuses.

Further complicating the hiring push is that other organizations recruiting these professionals can offer more competitive packages, which can include signing bonuses and other perks, according to testimony during the 2023 trial.

The state is also adopting a new hybrid work policy that allows mental health staff to spend part of their time working remotely. The policy will let the state better compete with the private sector, particularly in the remote areas where many prisons are located, Coffman said.

Money from the fines will also go to improving a working environment that the appellate decision said “often took the form of windowless converted cells in old and unheated prisons.” One-time payments ranging from $50,000 to $300,000 are going to various prison mental health programs for things like new furniture and improvements to treatment and office spaces.

“Working in a prison is difficult and dangerous work,” Johnson said. “Our members constantly face threats, physical assaults, and extremely high caseloads.”

Angela Reinhold, a supervising psychiatric social worker at the California Correctional Institution in Tehachapi, said during the 2023 hearings that her office was in a closet, featuring furniture from “1970s at best.”

She compared her situation with that of a co-worker who had recently left for a safer, higher-paying job in the private sector.

“She’s very excited that she gets a bathroom with two-ply toilet paper, not to mention the other office equipment that’s state-of-the-art, and treatment space, and an office that has a view,” Reinhold said. “She’s not risking her safety with her patients, and she gets to telework three times a week.”

Alexandra David, chief of mental health at the California Medical Facility in Vacaville, described working in buildings without adequate heating or cooling, with leaky ceilings and flooded clinical offices.

“You know, it’s an old prison. There are smells and sometimes rodents,” David said during the same hearings.

The California Department of Corrections and Rehabilitation did not respond to requests for comment on the spending plan.

In what Bien characterized as a bid to avoid ill will, all prison mental health workers will benefit from the new expenditures, with current employees and new hires each receiving one-time $10,000 bonuses. All corrections department employees, not just mental health workers, are also eligible for $5,000 bonuses for referrals leading to new hires in understaffed areas. The state estimates that the bonuses will cost about $44 million, although the projection does not include the referral bonuses or bonuses paid to new employees hired during the year.

Future bonuses and other incentives are likely to depend on recommendations from a court-appointed receiver who is developing a long-term plan to bring the prison mental health system up to constitutional standards.

“We do think they have to do better with money, but money alone is not the answer here,” Bien said. “And so that’s why we’re trying to do these working-conditions things, as well as bonuses.”

This article was produced by ºÚÁϳԹÏÍø News, which publishes , an editorially independent service of the .Ìý

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .

It was September 2023, and Rigsby, 46, had been brought to Jackson Hospital from an Alabama state prison 10 days earlier after complaining of pain and swelling in his abdomen. Doctors found that untreated hepatitis C had caused irreversible damage to Rigsby’s liver, according to his medical records.

Rigsby decided to stop efforts to treat his illness and to decline lifesaving care, a decision he made with his parents. And Rigsby’s mother, Pamela Moser, tried to get her son released to hospice care through Alabama’s medical furlough policy, so that their family could manage his end-of-life care as they saw fit.

But there wasn’t enough time for the furlough request to be considered.

After learning that Rigsby was on palliative care, the staff at YesCare, a private prison health company that has a $1 billion contract with the Alabama Department of Corrections, told the hospital it would stop paying for his stay and then transferred him back to Staton Correctional Facility in Elmore, according to the hospital record his mom provided to ºÚÁϳԹÏÍø News.

Moser never saw or spoke to her son again.

“The last day I went to see him in the hospital, I was hoping he would take his last breath,” said Moser, a former hospice nurse. “That is how bad I didn’t want him to go to the infirmary” at the prison.

A week later, Rigsby died of liver failure in the infirmary, according to his autopsy report.

Officials at the corrections department and YesCare did not respond to requests for comment.

As the country’s , thousands die behind bars each year. For some researchers, medical providers, and families of terminally ill people in custody, Rigsby’s situation — and Moser’s frustration — are familiar: Incarcerated people typically have little say over the care they receive at the end of their lives.

That’s despite a broad consensus among standards boards, policymakers, and health care providers that terminally ill people in custody should receive treatment that minimizes suffering and allows them to be actively involved in care planning.

But such guidelines aren’t binding. State policies on end-of-life care vary widely, and they generally give much leeway to correctional officers, according to a . The result is that correctional officers and medical contractors make the decisions, and they focus more on security concerns than easing the emotional, spiritual, and physical pain of the dying, say researchers and families.

People in jails and prisons often die while shackled to beds, separated from loved ones, and with minimal pain medication, said Nicole Mushero, a geriatrician at Boston University’s Chobanian & Avedisian School of Medicine who studies and works with incarcerated patients.

“When you’re coming at this from a health care perspective, it’s kind of shocking,” Mushero said.

Security vs. Autonomy

Patients are often suspended or dropped from their health coverage, including commercial insurance or Medicaid, when incarcerated. Jails and prisons have their own systems for providing health care, often funded by state and local budgets, and therefore aren’t subject to the same oversight as other public or private systems.

The , which accredits programs at correctional facilities across the country, says terminally ill people in custody should be allowed to make decisions about treatment options, such as whether to accept life-sustaining care, and appoint a person who can make medical decisions for them.

Jails and prisons should also provide patients with pain medication that wouldn’t otherwise be available to them, allow extra visits with loved ones, and consider them for medical release programs that let them receive hospice care in their communities, said Amy Panagopoulos, vice president of accreditation at the commission. That approach is often at odds with security and safety rules of jails and prisons, so facility leaders may be heavily involved in care decisions, she said.

As a result, the commission plans to release updated standards this summer to provide more details on how facilities should handle end-of-life care to ensure incarcerated patients are more involved in the process.

State laws on medical decision-making, informed consent, and patient privacy apply even to incarcerated patients, said Gregory Dober, who teaches biomedical ethics and is a prison monitor with the Pennsylvania Prison Society, a nonprofit that supports incarcerated patients and their families.

But correctional officers and their medical contractors often prioritize security instead, Dober said.

The Federal Bureau of Prisons allows guards to override do-not-resuscitate orders if they interfere with the security and orderly operation of the institution, according to the .

“This is a wildly understudied area,” said Ben Parks, who teaches medical ethics at Mercy College of Ohio. “In the end, it’s all about the state control of a prisoner’s life.”

About a third of all people who died in federal custody between 2004 and 2022 had a do-not-resuscitate order, according to Bureau of Prisons data obtained by ºÚÁϳԹÏÍø News through a Freedom of Information Act request.

The prison bureau’s policy of forcing CPR on patients is cruel, Parks said. CPR can , with . That is why people sign do-not-resuscitate orders refusing the treatment, he said.

“This is the inversion of the death penalty,” Parks said. “Resuscitation against your will.”

Cut Off From Family

In addition, corrections officials decide whether and when to reach out to a patient’s friends or relatives, said Erin Kitt-Lewis, a Penn State College of Nursing associate research professor who has studied the care of older adults in prisons. As a result, terminally ill people in custody often can’t involve their families in end-of-life care decisions.

That was the case for Adam Spurgeon, who was incarcerated in a state prison in Tennessee, his mother said. One morning in November 2018, Kathy Spurgeon got a call from hospital officials in Nashville saying her son had only hours to live, she said.

About a month earlier, she had learned from her son that he had had heart surgery and developed an infection, she said. But she didn’t know much about his treatment.

Around noon, she arrived at the hospital, about a three-hour drive west of where she lives. Adam, 32, died that evening.

Dorinda Carter, communications director at the Tennessee Department of Correction, declined to comment on Spurgeon’s case. “It is our policy to not comment on an individual inmate’s medical care,” she said in an email.

Kathy Spurgeon said providers who treated Adam outside of prison were too deferential to guards.

And physicians who work with incarcerated patients say that can be the case: Even when terminally ill people in custody are treated at hospitals, correctional officers still end up dictating the terms of care.

Hospital staff members often don’t understand the rights of incarcerated patients and are unsure about state laws and hospital policies, said Pria Anand, a neurologist who has treated incarcerated patients in hospitals. “The biggest problem is uncertainty,” she said.

Correctional officers sometimes tell hospital staffers they can’t contact next of kin for security reasons, or they won’t tell a patient about discharge plans because of worries they might escape, Anand said.

And care frequently takes place within prisons, which often are not equipped to handle the complexities of hospice decision-making, including types of treatment, when to stop treatment, and who can make those decisions, said Laura Musselman, director of communications at the Humane Prison Hospice Project, which provides training and education to improve end-of-life care for incarcerated patients.

“Our prison system was not designed to provide care for anyone, especially not people who are chronically ill, terminally ill, older, actively dying,” said Musselman, who noted that her group’s training has 15 modules to cover all aspects of end-of-life care, including grief support, hands-on caregiving, and paperwork.

Rigsby struggled with mental health and addiction for most of his adult life, including a stint in prison for a drug-related robbery. A parole violation in 2018 landed him back in prison.

At Jackson Hospital, Rigsby was given hydromorphone, a powerful pain medication, as well as the anxiety drug lorazepam. Before he was transferred back to prison, a nurse with YesCare — one of the country’s biggest prison health care providers, which has been sued over substandard care —assured hospital staffers he would be provided with the same level of pain medication and oxygen he had received at the hospital, his medical records show.

But Moser said she doesn’t know whether he spent his last days in pain or peace. The state wouldn’t provide Moser with Rigsby’s medical records from the prison, she said. She said she wasn’t allowed to visit her son in the infirmary — and wasn’t told why.

Moser called the infirmary to comfort her son before his death, but staffers told her he couldn’t make it to the phone and they couldn’t take one to him, she said.

Instead, Moser said, she left messages for prison officials to tell her son she loved him.

“It breaks my heart that he could not talk with his mother during his last days,” said Moser, whose son died on Oct. 4, 2023.

Two weeks later, she drove to Woodstock, Alabama, to collect his remains from a crematorium.

ºÚÁϳԹÏÍø News data editor Holly K. Hacker contributed to this report.

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The unilateral termination is drawing protests from attorneys representing prisoners and the author of the state’s medical parole legislation, who say it unnecessarily puts this vulnerable population at risk. The move is the latest wrinkle in a long-running drive to free those deemed so ill that they are no longer a danger to society.

“We have concerns that they cannot meet the needs of the population for things like memory care, dementia, traumatic brain injury,” said Sara Norman, an attorney who represents the prisoners as part of a nearly three-decade-old federal . “These are not people who are in full command and control of their own surroundings, their memories — they’re helpless.”

Caring for a prison population is a growing problem across the United States. It is twice as expensive to imprison older people than those younger, according to , and prisoners 55 and older are more than twice as likely to have cognitive difficulties as non-incarcerated older adults.

Medical parole is reserved for the sliver of California’s 90,000 prisoners who have a “significant and permanent condition” that leaves them “physically or cognitively debilitated or incapacitated” to the point they can’t care for themselves, . Prisoners who qualify — excluded are those sentenced to death or life without parole — can be placed in a community health care facility instead of state prison.

Attorneys said the roughly 20 parolees the state has returned to lockup need significant help performing basic functions of daily life, with some in wheelchairs or suffering from debilitating mental or physical disabilities. They say outside facilities have the capacity to provide more compassionate and humane care to very ill prisoners.

Kyle Buis, a California Correctional Health Care Services spokesperson, characterized the program as “on pause” as patients return to in-prison facilities and as officials anticipate increasing their use of the compassionate release program. Prisoners granted compassionate release have their sentences reduced and are released into society, while those on medical parole remain technically in custody.

“There were multiple considerations that went into this decision,” Buis said. “Our growing ability to support those with cognitive impairment inside of our facilities was one factor.” Democratic Gov. Gavin Newsom also cited “eliminating non-essential activities and contracts” to save money.

While now has a medical parole law, they are , according to the National Conference of State Legislatures. One common reason is eligibility. Texas, for instance, screened more than 2,600 prisoners in 2022 but approved just 58 people. Officials also often face procedural hurdles, according to the Vera Institute of Justice, a national nonprofit research and advocacy group.

Some states, however, have tried to expand medical parole programs. because an earlier version of the law proved too difficult to use, resulting in the release of just one person. New York has some of the nation’s for release but is among states struggling to find for parolees.

California’s first effort to free prisoners deemed so incapacitated that they are no longer dangerous began in 1997 with a little-used process that allowed corrections officials to seek the release of dying prisoners. But that program resulted in the release of just two prisoners in 2009. The medical parole program was officially created by a that took effect in 2011 and was expanded in 2014 to help reduce prison crowding so severe that federal judges ruled it was harming prisoners’ physical and mental health.

Nearly 300 prisoners had been granted medical parole since July 2014, . The average annual cost per medical parolee was between about $250,000 and $300,000 in 2023, Buis said. And despite when they started the program, he said, Medi-Cal — California’s Medicaid program, which is partly funded by the federal government — did not reimburse the state for their care because they were still considered incarcerated.

California has had a with its sole nursing home contractor for medical parolees. The state ended its contract with in Sylmar at the end of 2024, Newsom reported in January .

In 2021, prison officials said they were sending dozens of paralyzed and otherwise disabled prisoners back to state prisons and , blaming a federal rule change that barred any restrictions on prisoners in such facilities. The move came after state public health inspectors fined Golden Legacy for to the bed in violation of state and federal laws.

Golden Legacy did not return repeated telephone and email requests for comment. Buis said state officials “continuously monitored care at Golden Legacy, and we never had concern for the quality of care provided.”

Attorney Rana Anabtawi, who also represents prisoners in the class-action suit, toured Golden Legacy’s medical parole building with Norman in November and saw caregivers offering memory care patients special art classes and a “happy feet” dance party.

She felt it “was a much better place for our patients than being in prison — there appeared to be regular programming aimed at engaging them, there were no officers walking around, the patient doors were open and unlocked, patients had general freedom of movement within their building.”

Over the past several years, the California Department of Corrections and Rehabilitation has built up its capacity to service those with severely compromised health. The state created two of its own memory care units in men’s prisons, a 30-bed unit in the California Health Care Facility in Stockton in 2019 and a 35-bed unit in the California Medical Facility in Vacaville in 2023. The Central California Women’s Facility in Chowchilla provides up to 24-hour skilled nursing care for women with life-limiting illnesses including dementia.

Yet Norman fears the in-prison facilities are a poor substitute.

“They’re nowhere near enough and they are inside prisons, so there’s a limit to how compassionate and humane they can be,” she said.

In addition to the 20 returned to state prisons when the contract expired, Buis said, one was paroled through the standard process, while 36 were recommended for compassionate release. Of those, 26 were granted compassionate release, eight were denied, and two died before they could be considered.

The use of compassionate release increased under passed in 2022 that , including by adding dementia patients. , 87 prisoners received compassionate release. By contrast, during the six years before the new law, just 53 were freed. Officials expect about 100 prisoners each year will qualify for compassionate release, Buis said.

Compassionate release would allow them to “sort of die with dignity,” said Daniel Landsman, vice president of policy for the criminal justice advocacy group FAMM, previously known as , and ensure “that the California prison system is not turning into a de facto hospice or skilled nursing facility.”

Mark Leno, who authored California’s medical parole law when he was a Democratic state senator, criticized prison officials for ending their use of the law without legislative approval and instead just terminating the Golden Legacy contract. He also railed against returning very ill patients to prisons, a decision he called “perfectly inhumane.”

“Is it just cruel punishment and retribution or is this thoughtful execution of the law put in place by the legislature?” he said.

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Senior U.S. District Judge Kimberly Mueller issued her order March 19, identifying Colette Peters as the nominated receiver. Peters, who was Oregon’s and , ran the for 30 months until President Donald Trump took office in January. During her tenure, she in Dublin, east of Oakland, that had become known as the “rape club.”

Michael Bien, who represents prisoners with mental illness in the long-running prison lawsuit, said Peters is a good choice. Bien said Peters’ time in Oregon and Washington, D.C., showed that she “kind of buys into the fact that there are things we can do better in the American system.”

“We took strong objection to many things that happened under her tenure at the BOP, but I do think that this is a different job and she’s capable of doing it,” said Bien, whose firm women who were housed at the shuttered federal women’s prison.

California corrections officials called Peters “highly qualified” in a statement, while Gov. Gavin Newsom’s office did not immediately comment. Mueller gave the parties until March 28 to show cause why Peters should not be appointed.

Peters is not talking to the media at this time, Bien said. The judge said Peters is to be paid $400,000 a year, prorated for the four-month period.

About 34,000 people incarcerated in California prisons have been diagnosed with serious mental illnesses, representing more than a third of California’s prison population, who face harm because of the state’s noncompliance, Mueller said.

Appointing a receiver is a rare step taken when federal judges feel they have exhausted other options. A receiver took control of , and they have otherwise been used to govern prisons and jails only , mostly to combat poor conditions caused by overcrowding. Attorneys representing inmates have asked a judge to take over prison health care there.

Mueller’s appointment of a receiver comes nearly 20 years after a different federal judge of California’s prison medical system and installed a receiver, currently J. Clark Kelso, with broad powers to hire, fire, and spend the state’s money.

California officials initially said in August that they would not oppose a receivership for the mental health program provided that the receiver was also Kelso, saying then that federal control “has successfully transformed medical care” in California prisons. But Kelso withdrew from consideration in September, as did two subsequent candidates. Kelso said he could not act “zealously and with fidelity as receiver in both cases.”

Both cases have been running for so long that they are now overseen by a second generation of judges. The original federal judges, in a legal battle that reached the U.S. Supreme Court, more than a decade ago forced California to significantly in a bid to improve medical and mental health care for incarcerated people.

State officials in court filings defended their improvements over the decades. Prisoners’ attorneys countered that treatment remains poor, as evidenced in part by the system’s record-high suicide rate, topping 31 suicides per 100,000 prisoners, nearly double that in federal prisons.

“More than a quarter of the 30 class-members who died by suicide in 2023 received inadequate care because of understaffing,” prisoners’ attorneys wrote in January, citing the prison system’s own analysis. One prisoner did not receive mental health appointments for seven months “before he hanged himself with a bedsheet.”

They argued that the November passage of a ballot measure increasing criminal penalties for some drug and theft crimes is likely to increase the prison population and worsen staffing shortages.

California officials argued in January that Mueller isn’t legally justified in appointing a receiver because “progress has been slow at times but it has not stalled.”

Mueller has countered that she had no choice but to appoint an outside professional to run the prisons’ mental health program, given officials’ intransigence even after she held top officials in and levied fines topping $110 million in June. Those extreme actions, she said, only triggered more delays.

The 9th U.S. Circuit Court of Appeals on March 19 upheld Mueller’s contempt ruling but said she didn’t sufficiently justify calculating the fines by doubling the state’s monthly salary savings from understaffing prisons. It upheld the fines to the extent that they reflect the state’s actual salary savings but sent the case back to Mueller to justify any higher penalty.

Mueller had been set to begin additional civil contempt proceedings against state officials for their failure to meet two other court requirements: adequately staffing the prison system’s psychiatric inpatient program and improving suicide prevention measures. Those could bring additional fines topping tens of millions of dollars.

But she said her initial contempt order has not had the intended effect of compelling compliance. Mueller wrote as far back as July that additional contempt rulings would also be likely to be ineffective as state officials continued to appeal and seek delays, leading “to even more unending litigation, litigation, litigation.”

She went on to foreshadow her latest order naming a receiver in a preliminary order: “There is one step the court has taken great pains to avoid. But at this point,” Mueller wrote, “the court concludes the only way to achieve full compliance in this action is for the court to appoint its own receiver.”

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Iglesias, a trans woman who had been incarcerated for more than 25 years, was transferred from a men’s prison to a women’s one in 2021. And in 2022, she with the Federal Bureau of Prisons to receive gender-affirming surgery, which the agency said it had never provided for anyone in its custody.

By the time she got the surgery 10 months later, another federal inmate had also received a procedure to align their body with their gender identity. No other such surgeries for people in federal custody are publicly documented, although some people in state prisons have also received gender-affirming surgery, including at least and within a U.S. prison population that .

Still, those procedures loomed large in the 2024 presidential election. Political advertising for President Donald Trump and other Republicans included , according to media tracking firm AdImpact. One such ad declared that Democratic presidential nominee Kamala Harris supported “taxpayer-funded sex changes for prisoners,” and concluded, “Kamala is for they/them. President Trump is for you.” Some Democrats the election.

In the run-up to the Nov. 5 election, 55% of voters felt support for trans rights had gone too far, according to VoteCast, a survey by The Associated Press and partners including KFF, the health policy research, polling, and news organization that includes ºÚÁϳԹÏÍø News.

On Inauguration Day, Trump issued a flurry of executive orders that to bar federal spending on gender-affirming care in federal prisons and to “ensure that males are not detained” in federal women’s facilities.

“President Trump received an overwhelming mandate from the American people to restore commonsense principles and safeguard women’s spaces — even prisons — from biological men,” White House spokesperson Anna Kelly wrote in an email. “Forcing taxpayers to pay for gender transition for prisoners is the exact sort of insanity that the American people rejected at the ballot box in November.”

But for Iglesias, 50, Trump’s order was a shocking reversal.

“It puts someone’s life in danger being in a men’s prison as a trans woman,” she said from Chicago, where she’s lived since her release in 2023. “It’d be like putting sheep in a hyenas’ den.”

Iglesias said she faced emotional and physical abuse from her father for her desire to be female. When she was 12, she said, he put a gun in her mouth after finding her wearing her sister’s clothes. Iglesias said she ran away from home, stole checks, cars, and jewelry, and ended up in jail.

Lockup was not fun, Iglesias said, but it was the first place she got to be treated as a woman. So, she said, she wanted to stay. In 1994, she landed in federal prison after writing threatening letters to federal judges and prosecutors, according to court filings. In 2005, records show, she pleaded guilty to sending a letter to British officials that she falsely claimed contained anthrax. She told investigators .

“I was reading these things where they were allowing trans females to start living with females,” Iglesias said.

She said her outlook changed after the death of her mother in 2010, which prompted her to get serious about having a life outside of prison, and about improving her life inside it.

She began requesting hormone therapy in 2011 and was approved for it in 2015, according to court records. The 2019 lawsuit that led to her transfer to a women’s prison and her surgery was initially handwritten and prepared with the help of only another inmate.

“The lawsuit was the foundation for everything that I am today,” Iglesias said. “For the first time in my life, instead of digging myself in these holes, I was digging myself out.”

Along with her settlement, Iglesias from the Federal Bureau of Prisons to create a timeline for considering other inmates’ requests for gender-affirming care, and to recognize permanent hair removal and gender-affirming surgery as medically necessary treatments for gender dysphoria — a in which the discrepancy between a person’s gender identity and their sex assigned at birth causes significant distress.

In February, in response to Trump’s executive order, the bureau requiring prison staffers to refer to inmates’ “legal name or pronouns corresponding to their biological sex,” and ending clothing requests “that do not align with an inmate’s biological sex.” The guidelines end referrals for gender-affirming surgery but allow inmates already receiving treatment, such as hormone therapy, to continue.

However, in a , a trans prisoner alleged the hormone therapy she had been receiving since 2016 was stopped on Jan. 26.

Spokespeople for the bureau did not respond to requests for comment.

The bureau on hormone therapy in fiscal year 2022, its former director told Congress, 0.01% of its total spending on health care.

The new guidelines on trans inmates say that Trump’s executive order “does not supersede or change” the obligation to comply with federal regulations. But the executive order calls for amending them to prevent trans women from being housed in women’s prisons.

“It hurt my heart when I seen that because I do know other girls that are still in prison,” said Iglesias, who spent more than 25 years in male facilities. “Female prison is safe for a trans woman, and you can be who you are. You’re not penalized because you’re feminine.”

But requesting a transfer to a facility matching inmates’ gender identity , and few prisoners had been moved before the order. A 2025 said that federal prisons house 2,198 trans prisoners out of . Of those, the filing said, 22 are trans women housed in female facilities, and one is a trans man in a men’s facility. Although courts have blocked attempts to move that small subset of trans prisoners after the order, a trans prisoner not included in those suits had been relocated, news outlet reported.

A Department of Justice report from 2014 estimated that trans inmates in state and federal prisons were as other prisoners to report incidents of sexual victimization.

Iglesias said she experienced such violence firsthand. Included in her suit was a copy of a 2017 psychological report that said Iglesias reported being the victim of sexual misconduct or abuse in 1993, 2001, 2013, 2015, 2016, and 2017. Later filings included allegations of having been raped in 2019 and 2020, and a series of in 2021 before she was transferred to a female facility. Iglesias said she faced more abuse than she officially reported.

“Just because you commit a crime doesn’t mean you deserve to have violence against you,” said Michelle García, deputy legal director of the and one of the attorneys who ultimately represented Iglesias.

Federal law requires all inmates to be protected from abuse. A acknowledged trans inmates as particularly vulnerable to attack. Regulations from the , passed unanimously by Congress in 2003, contain , including allowing them to shower separately from other inmates and requiring prison officials to consider their health and safety when deciding whether to house them in male or female facilities.

Courts also that “deliberate indifference” to an inmate’s “serious medical needs” violates the Eighth Amendment’s ban on “cruel and unusual” punishments. The quality of overall medical care for federal prisoners has of inmates going without needed medical care and preventable deaths.

Iglesias successfully argued in court that gender-affirming surgery was necessary for her gender dysphoria. She was diagnosed with what was then called “gender identity disorder” soon after entering federal custody in 1994, according to court filings. Her diagnosis was updated to gender dysphoria in 2015.

Iglesias’ court filings documented her having been assessed for the risk of suicide 33 times and placed on suicide watch 12 times, as well as an attempt at self-castration in 2009.

“Defendants are aware of Iglesias’s suffering, but have delayed her treatment without evaluating her medically,” the .

García called the Trump administration’s targeting of care for trans inmates cruel, unnecessary, and illogical.

“They’re not assessing the constitutional rights of people,” García said. “They’re making choices because this is a vulnerable community that they can rally people behind to hate.”

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Three years later, he landed in an inpatient hospital after expressing suicidal thoughts.

After more than a decade cycling through juvenile detention, foster care placements, and state prisons, Valdez realizes now that treatment for his mental health conditions would have made life on his own much easier.

“It’s not until you’re put in, like, everyday situations and you respond adversely and maladaptive,” he said, “you kind of realize that what you went through had an effect on you.”

“I was struggling with a lot of mental stuff,” said Valdez, now 27.

For years, people like Valdez have often been left to fend for themselves when seeking health care services after their release from jail, prison, or other carceral facilities. Despite this population’s high rate of mental health problems and substance use disorders, they often return to their communities with no coverage, which increases their chances of dying or suffering a lapse that sends them back behind bars.

A new federal law aims to better connect incarcerated children and young adults who are eligible for Medicaid or the Children’s Health Insurance Program to services before their release. The goal is to help prevent them from developing a health crisis or reoffending as they work to reestablish themselves.

“This could change the trajectory of their lives,” said Alycia Castillo, associate director of policy for the Texas Civil Rights Project. Without that treatment, she said, many young people leaving custody struggle to reintegrate into schools or jobs, become dysregulated, and end up cycling in and out of detention facilities.

Medicaid has historically been prohibited from paying for health services for incarcerated people. So jails, prisons, and detention centers across the country have their own systems for providing health care, often funded by state and local budgets and not integrated with a public or private health system.

The new law is the first change to that prohibition since the Medicare and Medicaid Act’s inception in 1965, and it came in a spending bill signed by President Joe Biden in 2022. It took effect Jan. 1 this year, and requires all states to provide medical and dental screenings to Medicaid- and CHIP-eligible youths 30 days before or immediately after they leave a correctional facility. Youths must continue to receive case management services for 30 days after their release.

More than 60% of young people who are incarcerated are eligible for Medicaid or CHIP, according to from the Center for Health Care Strategies. The new law applies to children and young adults up to age 21, or 26 for those who, like Valdez, were in foster care.

Putting the law into practice, however, will require significant changes to how the country’s thousands of correctional facilities provide health care to people returning to communities, and it could take months or even years for the facilities to be fully in compliance.

“It’s not going to be flipping a switch,” said Vikki Wachino, founder and executive director of the Health and Reentry Project, which has been helping states implement the law. “These connection points have never been made before,” said Wachino, a former deputy administrator of the Centers for Medicare & Medicaid Services.

The federal CMS under the Biden administration did not respond to a question about how the agency planned to enforce the law.

It’s also unclear whether the Trump administration will force states to comply. In 2018, President Donald Trump signed legislation requiring states to enroll eligible youths in Medicaid when they leave incarceration, so they don’t experience a gap in health coverage. The law Biden signed built on that change by requiring facilities to provide health screenings and services to those youths, as well as ones eligible for CHIP.

Even though the number of juveniles incarcerated in the U.S. has dropped significantly over the past two decades, more than 64,000 children and young adults 20 and younger are incarcerated in state prisons, local and tribal jails, and juvenile facilities, according to estimates provided to ºÚÁϳԹÏÍø News by the Prison Policy Initiative, a nonprofit research organization that studies the harm of mass incarceration.

A ‘Neglected Part of the Health System’

The federal estimates that about a fifth of the country’s prison population spent time in foster care. Black youths are nearly five times as likely as white youths to be placed in juvenile facilities, according to , a nonprofit that advocates for reducing prison and jail populations.

Studies show that children who receive treatment for their health needs after release are less likely to reenter the juvenile justice system.

“Oftentimes what pulls kids and families into these systems is unmet needs,” said Joseph Ribsam, director of child welfare and juvenile justice policy at the Annie E. Casey Foundation and a former state youth services official. “It makes more sense for kids to have their health care tied to a health care system, not a carceral system.”

Yet many state and local facilities and state health agencies nationwide will have to make a lot of changes before incarcerated people can receive the services required in the law. The facilities and agencies must first create systems to identify eligible youths, find health care providers who accept Medicaid, bill the federal government, and share records and data, according to state Medicaid and corrections officials, as well as researchers following the changes.

In January, the federal government began handing out around $100 million in grants to help states implement the law, including to update technology.

Some state officials are flagging potential complications.

In Georgia, for example, the state juvenile justice system doesn’t have a way to bill Medicaid, said Michelle Staples-Horne, medical director for the Georgia Department of Juvenile Justice.

In South Dakota, suspending someone’s Medicaid or CHIP coverage while they are incarcerated instead of just ending it is a challenge, Kellie Wasko, the state’s secretary of corrections, said in on the new law. That’s a technical change that’s difficult to operationalize, she said.

State Medicaid officials also acknowledged that they can’t force local officials to comply.

“We can build a ball field, but we can’t make people come and play ball,” said Patrick Beatty, deputy director and chief policy officer for the Ohio Department of Medicaid.

States should see the law as a way to address a “neglected part of the health system,” said Wachino, the former CMS official. By improving care for people transitioning out of incarceration, states may spend less money on emergency care and on corrections, she said.

“Any state that is dragging its feet is missing an opportunity here,” she said.

‘Our System Is Making People Worse’

The Texas Department of Family Services took custody of Valdez when he was 8 because his mother’s history of seizures made her unable to care for him, according to records. Valdez said he ran away from foster care placements because of abuse or neglect.

A few years later, he entered the Texas juvenile justice system for the first time. Officials there would not comment on his case. But Valdez said that while he was shuffled between facilities, his antidepressant and antipsychotic medications would be abruptly stopped and his records rarely transferred. He never received therapy or other support to cope with his childhood experiences, which included sexual abuse, according to his medical records.

Valdez said his mental health deteriorated while he was in custody, from being put in isolation for long periods of time, the rough treatment of officials, fears of violence from other children, and the lack of adequate health care.

“I felt like an animal,” Valdez said.

In August, the U.S. Department of Justice that claims the state exposes children in custody to excessive force and prolonged isolation, fails to protect them from sexual abuse, and fails to provide adequate mental health services. The Texas Juvenile Justice Department has said it is to improve safety at its facilities.

In 2024, 100% of children in Texas Juvenile Justice Department facilities needed specialized treatment, including for problems with mental health, substance use, or violent behavior, according to the department.

Too often, “our system is making people worse and failing to provide them with the continuity of care they need,” said Elizabeth Henneke, founder and CEO of the Lone Star Justice Alliance, a nonprofit law firm in Texas.

Valdez said trauma from state custody shadowed his life after release. He was quick to anger and violence and often felt hopeless. He was incarcerated again before he had a breakdown that led to his hospitalization in 2022. He was diagnosed with post-traumatic stress disorder and put on medication, according to his medical records.

“It helped me understand that I wasn’t going crazy and that there was a reason,” he said. “Ever since then, I’m not going to say it’s been easy, but it’s definitely been a bit more manageable.”

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Chief U.S. District Judge Kimberly Mueller on June 25 ordered the state to pay $112 million in fines at a time when the state is trying to close a deficit. The fines have been accumulating since April 2023, after Mueller said she was fed up with the state prison system’s inadequate staffing despite years of court orders demanding that the state address the issue.

“The sanctions imposed here are necessary to sharpen that focus and magnify defendants’ sense of urgency to finally achieve a lasting remedy for chronic mental health understaffing in the state’s prison system,” Mueller said in her order in the long-running class-action lawsuit.

The ongoing harm “caused by these high vacancy rates is as clear today as it was thirty years ago and the harm persists despite multiple court orders requiring defendants to reduce those rates,” she added.

Mueller ordered the state to pay the fines within 30 days and said they “will be used exclusively for steps necessary to come into compliance with the court’s staffing orders.” She ordered California to keep paying additional fines for each month the state remains in violation of court orders.

The ruling was unwelcome news for Gov. Gavin Newsom, who is struggling with a budget deficit that’s forcing reductions in numerous state programs.

The contempt finding “is deeply flawed, and it does not reflect reality,” said Diana Crofts-Pelayo, a Newsom spokesperson. “Amid a nationwide shortage of mental health therapists, the administration has led massive and unprecedented efforts to expand care and recruit and retain mental health care professionals.”

California Department of Corrections and Rehabilitation spokesperson Terri Hardy said the state will appeal Mueller’s order. Prisoners “often have greater access to mental health care in custody than what presently exists for people outside” because of the state’s “extraordinary steps to expand access to mental health care,” Hardy said.

Mueller’s contempt finding comes as Newsom, a Democrat, statewide, partly to combat California’s seemingly intractable homelessness crisis. His administration has argued that Mueller is setting impossible standards for improving treatment for about 34,000 imprisoned people with serious mental illnesses — more than a third of California’s prison population.

Attorneys representing prisoners with mental illness vehemently disagree.

“It’s very unfortunate that the state officials have allowed this situation to get so bad and to stay so bad for so long,” said Ernest Galvan, one of the prisoners’ attorneys in the long-running litigation. “And I hope that this order, which the judge reserved as an absolute last resort, refocuses officials’ attention where it needs to be: bringing lifesaving care into the prisons, where it’s urgently needed.”

As part of her tentative contempt ruling in March, Mueller ordered Newsom personally, along with five of his top state officials, to read testimony by prison mental health employees describing the ongoing problem during a trial last fall.  

The other five were the directors of his departments of Corrections and Rehabilitation, State Hospitals, and Finance; the corrections department’s undersecretary for health care services; and the deputy director in charge of its statewide mental health program.

Mueller limited her formal contempt finding to Corrections Secretary Jeff Macomber and two aides, Undersecretary Diana Toche and Deputy Director Amar Mehta.

“Fundamentally, the overall record reflects defendants are following a ‘business as usual’ approach to hiring, recruitment and retention that does very little if anything to transform the bureaucracy within which the hiring practices are carried out,” Mueller wrote.

Mueller had ordered state officials to calculate each month what they owe in fines for each unfilled position exceeding a 10% vacancy rate among required prison mental health professionals. The fines are calculated based on the maximum annual salary for each job, including some that approach or exceed $300,000.

The 10% vacancy limit dates to a court order by Mueller’s predecessor more than 20 years ago, in 2002, in the class-action case filed in 1990 over poor treatment of prisoners with mental disorders.

The $112 million in pending fines for understaffing is one of three sets of fines Mueller imposed.

She imposed $1,000-a-day fines in 2017 for a backlog in sending imprisoned people to state mental health facilities. But that money, which now tops $4.2 million, has never been collected, and Mueller postponed a planned hearing on the fines after prisoners’ attorneys said the state was making improvements.

In April 2023, Mueller also began assessing $1,000-a-day fines for the state’s failure to implement court-ordered suicide prevention measures. A court-appointed expert said his latest inspection of prisons showed the state .

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He blames his addiction. He started using in middle school, and by the time he was an adult he was addicted to meth and heroin. At various points, he’s done time alongside his mom, his dad, his sister, and his younger brother.

“That’s all I’ve known my whole life,” said Clark, 31, in December.

Clark was at the jail to pick up his sister, who had just been released. The siblings think this time will be different. They are both sober. Shantel Clark, 33, finished earning her high school diploma during her four-month stay at the jail. They have a place to live where no one is using drugs.

And they have Cheryl Swapp, the county sheriff’s new community health worker, on their side.

“She saved my life probably, for sure,” Garrett Clark said.

Swapp meets with every person booked into the county jail soon after they arrive and helps them create a plan for the day they get out.

She makes sure everyone has a state ID card, a birth certificate, and a Social Security card so they can qualify for government benefits, apply to jobs, and get to treatment and probation appointments. She helps nearly everyone enroll in Medicaid and apply for housing benefits and food stamps. If they need medication to stay off drugs, she lines that up. If they need a place to stay, she finds them a bed.

Then Swapp coordinates with the jail captain to have people released directly to the treatment facility. Nobody leaves the jail without a ride and a drawstring backpack filled with items like toothpaste, a blanket, and a personalized list of job openings.

“A missing puzzle piece,” Sgt. Gretchen Nunley, who runs educational and addiction recovery programming for the jail, called Swapp.

Swapp also assesses the addiction history of everyone held by the county. More than half arrive at the jail addicted to something.

Nationally, booked into local jails struggle with a substance use disorder — at least six times the rate of the general population, according to the federal Substance Abuse and Mental Health Services Administration. The incidence of mental illness in jails is more than twice the rate in the general population, federal data shows. At least 4.9 million people are arrested and jailed every year, according to an by the Prison Policy Initiative, a nonprofit organization that documents the harm of mass incarceration. Of those incarcerated, 25% are booked two or more times, the analysis found. And among those arrested twice, more than half had a substance use disorder and a quarter had a mental illness.

“We don’t lock people up for being diabetic or epileptic,” said David Mahoney, a retired sheriff in Dane County, Wisconsin, who served as president of the in 2020-21. “The question every community needs to ask is: ‘Are we doing our responsibility to each other for locking people up for a diagnosed medical condition?’”

The idea that county sheriffs might owe it to society to offer medical and mental health treatment to people in their jails is part of a broader shift in thinking among law enforcement officials that Mahoney said he has observed during the past decade.

“Don’t we have a moral and ethical responsibility as community members to address the reasons people are coming into the criminal justice system?” asked Mahoney, who has 41 years of experience in law enforcement.

Swapp previously worked as a teacher’s aide for those she calls the “behavior kids” — children who had trouble self-regulating in class. She feels her work at the jail is a way to change things for the parents of those kids. And it appears to be working.

Since the Sanpete County Sheriff’s Office hired Swapp last year, recidivism has dropped sharply. In the 18 months before she began her work, 599 of the people booked into Sanpete County Jail had been there before. In the 18 months after she started, that number dropped to 237.

In most places, people are released from county jails with no health care coverage, no job, nowhere to live, and no plan to stay off drugs or treat their mental illness. that people newly released from incarceration face a risk of overdose that is 10 times as high as that of the general public.

Sanpete wasn’t any different.

“For seven to eight years of me being here, we’d just release people and cross our fingers,” said Jared Hill, the clinical director for Sanpete County and a counselor at the jail.

Nunley, the programming sergeant, remembers watching people released from jail walk the mile to town with nothing but the clothes they’d worn on the day they were arrested — it was known as the “walk of shame.” Swapp hates that phrase. She said no one has made the trip on foot since she started in July 2022.

Swapp’s work was initially funded by a grant from the U.S. Health Resources and Services Administration, but it has proved so popular that commissioners in Sanpete County voted to use a portion of its to cover the position in the future.

Swapp doesn’t have formal medical or social work training. She is certified by the state of Utah as a community health worker, a job that has become more common nationwide. There were about 67,000 people working as community health workers in 2022, according to the .

Evidence is mounting that the model of training people to help their neighbors connect to government and health care services is sound, said Aditi Vasan, a senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania who has on the relatively new role.

The day before Swapp coordinated Shantel Clark’s release, she sat with Robert Draper, a man in his 50s with long white hair and bright-blue eyes. Draper has been in and out of jail for decades. He was sober for a year and had been taking care of his ill mother. She kept getting worse. Then his daughter and her child came to help. It was all a little too much.

“I thought, if I can just go and get high, I can deal with this shit,” said Draper. “But after you’ve been using for 40 years, it’s kinda easy to slip back in.”

He didn’t blame his probation officer for throwing him back in jail when he tested positive for drugs, he said. But he thinks jail time is an overreaction to a relapse. Draper sent a note to Swapp through the jail staff asking to see her. He was hoping she could help him get out so he could be with his mom, who had just been sent to hospice. He had missed his father’s death years ago because he was in jail at the time.

Swapp listened to Draper’s story without interruptions or questions. Then she asked if she could run through her list with him so she would know what he needed.

“Do you have your Social Security card?”

“My card?” Draper shrugged. “I know my number.”

“Your birth certificate, you have it?”

“Yeah, I don’t know where it is.”

“Driver’s license?”

“No.”

“Was it revoked?”

“A long, long time ago,” Draper said. “DUI from 22 years ago. Paid for and everything.”

“Are you interested in getting it back?”

“Yeah!”

Swapp has some version of this conversation with every person she meets in the jail. She also runs through their history of addiction and asks them what they most need to get back on their feet.

She told Draper she would try to get him into intensive outpatient therapy. That would involve four to five classes a week and a lot of driving. He’d need his license back. She didn’t make promises but said she would talk to his probation officer and the judge. He sighed and thanked her.

“I’m your biggest fan here,” Swapp said. “I want you to succeed. I want you to be with your mom, too.”

The federal grant that funded the launch of Sanpete’s community health worker program is held by the regional health care services organization Intermountain Health. Intermountain took the idea to the county and has provided Swapp with support and training. Intermountain staff also administer the $1 million, three-year grant, which includes efforts to increase addiction recovery services in the area.

A similarly funded program in Kentucky called First Day Forward took the community health worker model a step further, using “peer support specialists” — people who have experienced the issues they are trying to help others navigate. Spokespeople from HRSA pointed to four programs, including the ones in Utah and Kentucky, that are using their grant money for people facing or serving time in local jails.

Back in Utah, Sanpete’s new jail captain, Jeff Nielsen, said people in small-town law enforcement weren’t so far removed from those serving time.

“We know these people,” Nielsen said. He has known Robert Draper since middle school. “They are friends, neighbors, sometimes family. We’d rather help than lock them up and throw away the key. We’d rather help give them a good life.”

This article first appeared on ºÚÁϳԹÏÍø News and is republished here under a .