By Sarah Kang
Individuals returning to their communities after incarceration face acute and often life-threatening health risks. In the first two weeks following release, they are 12 times more likely to die than the general population, most commonly from preventable causes such as untreated mental health conditions, drug overdose, or the absence of timely, coordinated medical care. These tragic outcomes have persisted for decades, largely invisible to the broader public and long overdue for meaningful intervention.
For many years, a federal restriction known as the Inmate Exclusion Rule prohibited the use of Medicaid funds to support most services during incarceration. Recently, however, the Centers for Medicare and Medicaid Services (CMS) opened the door to transformative change by encouraging states to test new approaches through Section 1115 demonstration waivers, allowing Medicaid to play a more active role in supporting the health and reentry needs of justice-involved individuals.
California was the first state to take action. The CalAIM Justice-Involved Initiative establishes a comprehensive framework to improve health outcomes and continuity of care for people transitioning from correctional settings back into the community. The initiative requires counties and correctional facilities to determine Medi-Cal eligibility and initiate or reinstate coverage prior to release, enabling individuals to access benefits as soon as they return to the community. Within the 90-day prerelease period, participating facilities must deliver a suite of services, including behavioral health and substance use disorder assessments, care management, reentry planning, medication-assisted treatment (when clinically indicated), and warm handoffs to community-based providers.
These activities are supported by new expectations for cross-system care coordination, data sharing, and timely referrals designed to ensure that individuals leave custody with an active care plan, scheduled appointments, and uninterrupted access to critical services. Collectively, these requirements operationalize a more seamless, health-focused reentry process aligned with CalAIM’s broader goals of equity, integration, and whole-person care. Under this policy, every county jail, youth correctional facility, and state prison in California is required to have full operational capacity to deliver these services by October 1, 2026.
This represents a significant shift in how California supports the health of people leaving incarceration. Much of the early progress has been fueled by short-term funding that is set to expire, meaning counties need to build programs that can stand on their own. Since the earliest stages of the waiver’s implementation, BluePath Health has partnered with counties such as San Luis Obispo and Fresno to turn policy into durable, operational infrastructure. Through this work, we’ve identified three key lessons that can guide counties as they move from pilot efforts to long-term sustainability.
Coordination only works when the right decision-makers are at the table
Providing health services inside correctional facilities isn’t new. What is innovative about the Justice-Involved Initiative is the scope of the requirements and the sheer number of agencies, workflows, and data systems that must now align for reentry to function as a true continuum of care. Medi-Cal enrollment, clinical assessments, care plans, provider linkages, information exchanges, and billing each involve different departments and stakeholders, often with distinct mandates, cultures, and protocols. And for decades, most of these functions have operated in silos.
CalAIM’s justice-involved policies explicitly call for cross-system coordination, but policy alone doesn’t make collaboration happen. We’ve seen progress accelerate and persist when counties formalize coordination as part of their governance structure. In one county, leaders from Health and Human Services, Probation, the Sheriff’s Office, Behavioral Health, and other key partners created an empowered governance team with clear authority and shared accountability. They meet weekly, jointly own decisions, and rapidly resolve barriers. The result is sustained momentum and a unified approach that brings policy intent to life.
Better data sharing begins with clear processes, not just new platforms
Effective data sharing is foundational to CalAIM’s Justice-Involved Initiative, yet today most information exchanged between jails, health care providers, and county agencies remains manual, inconsistent, and overly dependent on individual staff relationships. Paper records, ad hoc emails, and undocumented workflows leave systems vulnerable; the departure of even one staff member can disrupt enrollment processes, delay clinical assessments, or break reentry handoffs because no shared standards exist to keep the work moving.
Under CalAIM, seamless data exchange is essential to maintaining continuity of care. Without timely information flow, individuals can lose access to medications, behavioral health services, or case management the moment they return to the community, undermining the goals the initiative is designed to advance. A Vera Institute of Justice report found that coordinated care for justice-involved populations can produce a 52% reduction in emergency room costs, a 72% decrease in inpatient admissions, and overall cost reductions of 55–75%, driven by fewer crises and stronger chronic disease management.
The solution is not a single one-size-fits-all technology platform. Starting every agency on the same system is often impractical and can introduce new barriers. What counties need is a shared commitment to integration, aligning partners on the data elements that must be exchanged, establishing clear triggers and timelines, and standardizing workflows across existing systems. In our work, counties that define common data priorities and invest in process-level alignment consistently achieve measurable improvements, including more reliable warm handoffs, better documentation, and stronger transitions from custody to community care.
Sustainability demands early and ongoing financial and operational planning
CalAIM’s Justice-Involved Initiative has pushed counties to stand up entirely new operational capacities, including billing infrastructure, documentation tools, standardized assessment workflows, and cross-system coordination protocols. While these efforts have been critical for meeting early implementation milestones, most have relied on short-term, time-limited funding that is soon coming to an end. As the mandate moves from launch to long-term operations, sustainability can no longer be an afterthought.
A durable program starts with a clear understanding of its financing. For most counties and correctional health partners, this means developing a robust revenue projection model to estimate what services can realistically be reimbursed under Medi-Cal. This model becomes the backbone of a sustainability plan, helping leaders identify which costs can be offset through billing, where structural gaps will remain, and what adjustments may be needed to preserve core functions over time.
Sustainable design also requires deliberate scenario planning. Counties must examine how different billing assumptions affect staffing models, what service volumes are necessary to support ongoing operational costs, and where thin margins signal a need for workflow redesign or efficiency improvements. We have found that counties that engage in this kind of forward-looking financial and operational analysis are better positioned to preserve the infrastructure they have worked hard to build, and to continue delivering consistent, high-quality reentry services well beyond the initial funding window.
This is a substantial undertaking, but it is entirely achievable.
California is the first state in the nation to implement a pre-release Medicaid benefit at this scale, setting a precedent that other states will look to as they design their own justice-involved reforms. The work unfolding here provides a real-time blueprint, illustrating what it takes to operationalize complex policy, translate federal guidance into practice, and build systems that can withstand turnover, funding shifts, and evolving requirements.
Every county starts from a different place. Yet the main challenges they face are consistent: fragmentation, limited capacity, and long-term sustainability. The counties making real progress are not simply checking compliance boxes; they are taking the policy seriously as an opportunity to redesign reentry. They are grounding decisions in the specific needs of their communities, mapping operational workflows in detail, and investing in trust-building across health, behavioral health, corrections, and community partners. They are tracking policy updates closely, understanding the fine print, and planning early for how their work will endure beyond initial funding. In short, they are treating implementation not as a task, but as a long-term systems change effort, and that is what makes a lasting impact.
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“Fresno County Probation’s partnership with BluePath Health has been key to advancing our CalAIM Justice-Involved work. Their expertise has helped us move from concept to implementation, connect individuals to vital health services before release, and build sustainable systems that improve reentry outcomes.” — Kirk Haynes, Chief Probation Officer, Fresno County Probation