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

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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%. ÌýThe 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 Ñî¹óåú´«Ã½Ò•îl Health News, which publishes , an editorially independent service of the .Ìý

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• .

Céline Gounder, Ñî¹óåú´«Ã½Ò•îl Health News’ editor-at-large for public health, discussed weight loss drugs and covid-19 vaccines on CBS’ “CBS Mornings” on May 22 and May 21, respectively.

Ñî¹óåú´«Ã½Ò•îl Health News senior correspondent Renuka Rayasam discussed end-of-life incarceration on WUGA’s “The Georgia Health Report” onÌýMay 16.

• Read Rayasam’s “Prisons Routinely Ignore Guidelines on Dying Inmates’ End-of-Life Choices.”

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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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 Ñî¹óåú´«Ã½Ò•îl Health 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 Ñî¹óåú´«Ã½Ò•îl Health 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.

Ñî¹óåú´«Ã½Ò•îl Health News data editor Holly K. Hacker contributed to this report.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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Lawmakers backed the bulk of Republican Gov. Greg Gianforte’s multimillion-dollar vision to bolster and expand the system, which has experienced waitlists for care and has been working in recent years to reverse the loss of community-based mental health services and regain federal certification of the state psychiatric hospital, lost in 2022 after a spate of patient deaths. Legislators then went several steps further to fill what they saw as gaps in the governor’s proposals.

They agreed to build a new mental health facility in eastern Montana, add more beds at existing state facilities, fund more crisis beds in communities, revise some civil and criminal commitment procedures, and reimburse counties when criminal defendants ordered to state facilities are held in county jails.

“For our families that struggle in these systems, it gives us so much hope,” said Matt Kuntz, executive director of the National Alliance on Mental Illness’ Montana chapter, about the legislative action.

The state’s behavioral health system faced an array of problems going into the 2025 legislative session. They included shortages in community services, particularly in rural areas, created by deep cuts made in 2017 in response to a state budget shortfall, along with a backlog of criminal defendants waiting for evaluations and services at the state-run psychiatric hospital.

The prospects of the situation improving seemed dim for a long time, Kuntz said. “Then you have the governor’s office, the legislature, the counties, the county attorneys all working together to bring tangible solutions. And they got the votes,” he said.

That support built over time as the state spent money on improvements needed to regain the Montana State Hospital’s federal certification and counties came under increasing pressure due to a lack of services and treatment beds. The legislature and governor committed to review the system in 2023.

In all, lawmakers approved about $124 million in state spending and up to $40 million in federal funds over the next two years for behavioral health services, a new state-owned facility, and additional beds in existing facilities.

“The people that need our support, the people that can’t take care of themselves, the families that are struggling with their family member that can’t take care of themselves at some points in time are going to benefit from what we did,” Republican state Sen. John Esp said in summing up the legislature’s work.

The spending approved by the legislature goes well beyond the money Gianforte requested for behavioral health changes. He included 10 funding requests in his proposed state budget for the next two years that totaled about $43.5 million in state funds and $42 million in federal funds. The requests were based on recommendations from the .

Lawmakers created that commission in 2023 to review state-funded services for people with mental illness, substance use disorders, and developmental disabilities. Legislators that year set aside $300 million to be spent in future years on recommendations made by the commission.

Even before the start of the session, some legislators questioned whether the governor’s budget did enough to address the lack of both community-based crisis services and forensic beds at the Montana State Hospital, which are for people in the criminal justice system.

Two bills introduced in January — and — sought to address lengthy jail holds experienced by some people waiting for mental health evaluations or treatment before their trials can proceed. Defendants generally obtain those services at the Montana State Hospital’s forensic unit.

Both bills failed. But testimony on the measures, as well as on the governor’s budget requests, drew attention to the backlog of people waiting in jails across the state. Legislators heard of prolonged delays — some stretching more than a year — that sometimes led to cases being dismissed because of concerns that the delays had violated the defendants’ constitutional right to a speedy trial.

By April, the legislature was considering possible fixes on several fronts. Some resulted from long hours of discussion among the parties involved.

During an April 15 hearing on to revise criminal commitment procedures, Chad Parker, a state health department attorney, described the measure as “a very robustly negotiated bill.” Nanette Gilbertson, representing the Montana County Attorneys’ Association and the Montana Sheriffs and Peace Officers Association, said it contained elements “that I know were tough pills to swallow for both the associations I work for and the department.”

The bill would allow involuntary medication of defendants in county jails under certain circumstances — an idea state officials initially opposed — and prohibit the filing of a contempt charge if someone isn’t admitted to the Montana State Hospital for treatment because a bed isn’t available, which was important to the state to include.

Gilbertson told the House Judiciary Committee the bill was just one of several that, “taken in a package, are going to create immense change in the mental health and behavioral health system in the state of Montana.”

They include bills to reimburse counties for the costs of holding people waiting for state mental health services, allow short-term mental health holds in the community, improve delivery and payment for community services, and create more beds in state facilities for people committed through both criminal and civil procedures.

Legislators also approved money for , expected to be built in eastern Montana, that will include more forensic beds.

Gianforte spokesperson Kaitlin Price said Gianforte would carefully consider the bills passed in addition to his proposals.

The governor’s original budget request focused primarily on community services. Legislators approved all but one, which would have created an electronic bed registry. The approved requests will revise reimbursement rates for developmental disability services, residential youth psychiatric treatment, and crisis and outpatient behavioral health services. They also will reopen clinics for early diagnosis of developmental disabilities in children, provide workforce incentives, and seek to improve delivery of services to people with developmental disabilities who have complex needs.

Esp, who served on the behavioral health commission and sponsored several of the bills, cautioned that the success of this year’s efforts will depend on whether future legislatures and governors spend the money needed to continue the new services.

“The problem we’ve always had around here is we look at things in two-year increments and towards the next election instead of looking at what’s the best policy for the state of Montana, long term,” he said.

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Prisoners, some held in this isolation cell for months, have scratched initials and the phrase “love hurts” into the metal door’s brown paint. Their pacing has worn a path into the cement floor. Many are held in a sort of limbo, not convicted of a crime but not stable enough to be released. They sleep on a narrow cot next to a toilet. The only view is a fluorescent-lit hallway visible through a small window in the door.

Lake County Attorney James Lapotka stood at the cell’s center talking about the people he helps confine here. He stretched out his arms, his fingertips just shy of touching opposite walls. “I’m getting anxiety just being in here,” Lapotka said.

Last year, a man sentenced for stealing a rifle stayed in that cell 129 days. He was waiting for a spot to open at Montana’s only state-run psychiatric hospital after a mental health evaluator deemed he needed care, according to court records.

A man in the next cell around the same time was on the same waitlist roughly five months. He faced near-daily stints in the jail’s emergency restraint chair — a steel contraption wrapped in foam with straps for his shoulders, arms, and legs. He regularly saw the jail’s mental health doctor. Still, Joel Shearer, a Lake County detention commander, said the man routinely experienced psychotic episodes and asked to be locked in the chair when he felt one coming on and stayed there until his screams subsided.

“Somebody who’s having a mental health crisis — they don’t belong here,” Lapotka said. “We don’t have anywhere else.”

Lake County’s two, roughly 30-square-foot isolation cells are an example of how communities nationwide are failing to provide mental health services — crisis care, in particular. locked in local jails in the U.S. have a mental illness.

More than half of Wyoming’s 23 sheriffs that they were housing people in crisis awaiting mental health care for months, WyoFile reported in January. Nevada despite for each jailed patient whose treatment is delayed. Disability Rights Oregon delays in that state continue after two people while on the state’s psychiatric waitlist.

In Montana, counties are jailing mental health patients they’re not equipped to handle when the Montana State Hospital is at capacity. Few local hospitals have their own inpatient psychiatric beds. As a result, people arrested for anything from petty theft to felony assault can be jailed for months or longer as their mental health worsens. Many haven’t been convicted of a crime.

Montana officials have known for years they have a problem. State officials have said they don’t have space for all the people ordered to the hospital. The psychiatric hospital has 270 beds, with 54 for people in the criminal justice system. Staffing shortages can shrink that capacity further.

The Montana Department of Public Health and Human Services backed this legislative session that the state from liability for delays when the Montana State Hospital is full. Ahead of the bills, the hospital has “struggled to maintain appropriate levels of care” due to money and staffing constraints, a lack of community-based services, and having no control over the flow patients Montana courts send its way.

The agency also announced April 23 that $6.5 million was available through one-time grants to help set up jail-based mental health stabilization services.

Officials have said patients deserve care closer to home, in less restrictive settings. But counties say the local services needed don’t exist.

“You have to do the hard things first,” said Matt Kuntz, executive director of the Montana chapter of the National Alliance on Mental Illness. “You have to build the beds.”

Health advocates have backed a proposal that would for community commitments. That measure is headed to Republican Gov. Greg Gianforte after passing the state House and Senate. Another bill that was still pending would for people in the justice system. But implementing those ideas could take years.

The number of inpatient beds for people with a serious mental illness nationwide . At one time, that drop was intentional, part of a movement away from locking people up in state-run mental hospitals. But the intended fix, local homelike centers, hasn’t filled the void.

One of Montana’s biggest providers, Western Montana Mental Health Center, had to close some of its crisis sites because of money problems, said Western’s CEO, Bob Lopp. That includes a facility less than a mile from the Lake County jail.

“If that’s not where the funding is, you can’t just do it for the sake of argument and hope that it comes,” Lopp said.

Gianforte has promised to pour money into rebuilding the state’s behavioral health system. Mental health workers in small towns find such promises hard to trust after seeing local services come and go for years.

Health department spokesperson Holly Matkin said the agency is proud of its work to fix “systems that have been broken for too long” and that it will improve services for people who need inpatient care in their communities.

Lake County is known to outsiders as an Instagram-worthy stop on their way to Glacier National Park. It overlaps with the , land of the Bitterroot Salish, Upper Pend d’Oreille, and Kootenai tribes. It’s home to a slice of the Rocky Mountains and a gateway to millions of acres of wilderness. Polson, the county seat and site of the jail, is a town of 5,600 on the southern shore of Flathead Lake, one of the largest lakes west of the Mississippi River.

Vincent River has worked as the jail’s sole mental health clinician for 25 years. He said he’s not always available because he’s the only psychologist in four northwestern Montana counties evaluating whether a person in jail needs psychiatric care.

Some are released without care if they linger too long on the state hospital’s waitlist.

“I talk to these family members. I hear them plead with me with their fear in their voices and tell me all that’s been going on for days or weeks or months,” River said. “And then I can’t get people into the hospital. That is a giant crisis.”

It’s not just the state hospital. River said he can’t get people into any psychiatric bed in Montana because there are too few. Instead, he tries to stabilize people while they’re jailed. That has shortfalls.

The jail can’t force someone in psychosis to take medication without a court order and a qualified doctor on hand to administer the prescription. Lake County’s aging facility has because of poor conditions amid overcrowding, and River has to see patients wherever there’s room.

There isn’t even space for the jail’s restraint chair. Jail workers leave strapped-down prisoners in a hallway or locker room.

River said many gradually get better and leave isolation. Some don’t.

“They languish there, psychotic and lonely,” he said, “at the mercy of what the voices are telling them.”

Locals are working to fill some gaps. A mobile team launched in February is staffed by people who have lived with mental and substance use disorders to provide peer support. But someone truly in crisis has only two options: jail or an emergency room.

The room reserved for people in crisis at Providence St. Joseph Medical Center in Polson leaves patients both isolated and without privacy. The locked door’s thick glass looks onto a busy emergency room hallway.

Those who deteriorate enough to be deemed dangerous to themselves or others are sent down the road to jail.

Rebecca Bontadelli, an ER physician, said patients can be housed in the room for days as hospital staffers scour Montana and nearby states for an open psychiatric bed. Some reject care in the meantime.

“We’re not really helping them,” Bontadelli said. “They feel like they’re in prison.”

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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 Ñî¹óåú´«Ã½Ò•îl Health 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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Tres años después, terminó internado en un hospital luego de expresar pensamientos suicidas.

Después de más de una década pasando por centros de detención de menores, hogares temporales y prisiones estatales, Valdez ahora se da cuenta que haber recibido tratamiento para sus problemas de salud mental le habría hecho la vida mucho más fácil.

“No es hasta que te ponen en situaciones cotidianas y respondes de forma adversa y desadaptada”, dijo, “que te das cuenta de que lo que pasaste tuvo un efecto en ti”.

“Estaba luchando con muchos problemas mentales”, dijo Valdez, que ahora tiene 27 años.

Durante años, personas como Valdez a menudo han tenido que valerse por sí mismas cuando buscaban servicios de atención médica después de salir de la cárcel, prisión u otros centros carcelarios.

A pesar de la alta tasa de problemas de salud mental y trastornos por adicciones en esta población, la mayor parte de las veces regresan a sus comunidades sin cobertura, lo que aumenta sus posibilidades de morir o sufrir una recaída que los lleve de nuevo a la cárcel.

Una nueva ley federal tiene como objetivo conectar mejor a los menores y adultos jóvenes encarcelados que son elegibles para Medicaid o el Programa de Seguro de Salud Infantil (CHIP) con los servicios antes de su liberación.

La meta es ayudar a prevenir que desarrollen una crisis de salud o reincidan mientras están en el proceso para reintegrarse a la sociedad.

“Esto podría cambiar la trayectoria de sus vidas”, dijo Alycia Castillo, directora asociada de políticas del Texas Civil Rights Project. Agregó que, sin ese tratamiento, muchos jóvenes que salen del sistema tienen dificultades para reintegrarse a las escuelas o trabajos, no respetan normas, y terminan entrando y saliendo de los centros de detención.

Históricamente, Medicaid ha tenido prohibido pagar los servicios de salud de las personas presas. Por eso, las cárceles, prisiones y centros de detención de todo el país tienen sus propios sistemas de prestación de atención médica, generalmente financiados con presupuestos estatales y locales, no integrados con un sistema de salud público o privado.

La nueva ley es el primer cambio a esa prohibición desde la creación de la Ley de Medicare y Medicaid en 1965, y es parte de un proyecto de ley de gastos firmado por el presidente Joe Biden en 2022. Entró en vigencia el 1 de enero de este año y exige que todos los estados proporcionen exámenes médicos y dentales a los jóvenes elegibles para Medicaid y CHIP, treinta días antes o inmediatamente después de que salgan de un centro penitenciario. Los jóvenes deben seguir recibiendo servicios de manejo de casos durante 30 días después de su liberación.

Más del 60% de los jóvenes presos son elegibles para Medicaid o CHIP, según de septiembre de 2024 del center for Health Care Strategies. La nueva ley se aplica a menores y adultos jóvenes de hasta 21 años, o 26 para aquellos que, como Valdez, estuvieron en hogares temporales.

Sin embargo, poner la ley en práctica requerirá cambios significativos en la forma en que los miles de centros penitenciarios del país ofrecen atención médica a las personas que regresan a las comunidades, y podrían pasar meses o incluso años hasta que las instalaciones cumplan plenamente.

“No se trata de prender y apagar”, dijo Vikki Wachino, fundadora y directora ejecutiva del Health and Reentry Project, que ha estado ayudando a los estados a implementar la ley. “Estos puntos de conexión nunca se han hecho antes”, dijo Wachino, ex administradora adjunta de los Centros de Servicios de Medicare y Medicaid (CMS).

Los CMS no han dicho como planean hacer cumplir la ley.

Tampoco está claro si la administración Trump obligará a los estados a implementarla. En 2018, el presidente Donald Trump firmó una ley que obligaba a los estados a inscribir a los jóvenes elegibles en Medicaid cuando salieran de prisión, para que no experimentaran una brecha en la cobertura de salud.

La ley que firmó Biden se basó en ese cambio al exigir que las instalaciones brinden exámenes y servicios de salud a esos jóvenes, así como a los elegibles para CHIP.

Aunque la cantidad de jóvenes presos en el país ha disminuido significativamente en las últimas dos décadas, más de 64.000 menores y adultos jóvenes de 20 años o menos están en prisiones estatales, cárceles locales y tribales e instalaciones para jóvenes, según estimaciones proporcionadas a Ñî¹óåú´«Ã½Ò•îl Health News por la Prison Policy Initiative, una organización sin fines de lucro que investiga el daño del encarcelamiento masivo.

Una “parte desatendida del sistema de salud”

La estima que aproximadamente una quinta parte de la población carcelaria del país pasó tiempo en hogares temporales. Los jóvenes negros no hispanos tienen casi cinco veces más probabilidades que los jóvenes blancos no hispanos de ser colocados en instalaciones para menores, según , una organización sin fines de lucro que aboga por la reducción de las poblaciones en prisiones y cárceles.

Estudios muestran que los menores que reciben tratamiento para sus necesidades de salud después de la liberación tienen menos probabilidades de volver a ingresar al sistema de justicia juvenil.

“A menudo, lo que lleva a los menores y a las familias a estos sistemas son las necesidades no satisfechas”, dijo Joseph Ribsam, director de políticas de bienestar infantil y justicia juvenil en la Annie E. Casey Foundation, y ex funcionario estatal de servicios para jóvenes. “Tiene más sentido que los niños tengan su atención de salud vinculada a un sistema de atención médica, no a un sistema carcelario”.

Sin embargo, la nueva requerirá muchos cambios. Las instalaciones y agencias primero deben crear sistemas para identificar a los jóvenes elegibles, encontrar proveedores de atención médica que acepten Medicaid, facturar al gobierno federal, y compartir registros y datos, según funcionarios estatales de Medicaid y oficiales correccionales, así como investigadores que siguen los cambios.

En enero, el gobierno federal comenzó a distribuir alrededor de $100 millones en subvenciones para ayudar a los estados a implementar la ley, incluso para actualizar la tecnología.

Algunos funcionarios estatales están señalando posibles complicaciones.

Por ejemplo, en Georgia, el sistema de justicia juvenil estatal no tiene una forma de facturar a Medicaid, dijo Michelle Staples-Horne, directora médica del Departamento de Justicia Juvenil del estado.

En Dakota del Sur, suspender la cobertura de Medicaid o CHIP de una persona mientras está en prisión en lugar de simplemente terminarla es un desafío, dijo Kellie Wasko, secretaria del sistema correcional del estado, en sobre la nueva ley. Ese es un cambio técnico que es difícil de poner en práctica, apuntó.

Los funcionarios estatales de Medicaid también reconocieron que no pueden obligar a los funcionarios locales a cumplir.

“Podemos construir un campo de béisbol, pero no podemos hacer que la gente venga a jugar a la pelota”, dijo Patrick Beatty, subdirector y director de políticas del Departamento de Medicaid de Ohio.

Los estados deberían ver la ley como una forma de abordar una “parte descuidada del sistema de salud”, dijo Wachino, la ex funcionaria de los CMS. Al mejorar la atención para las personas que salen de prisión, los estados pueden gastar menos dinero en atención de emergencia y en los correccionales, dijo.

“Cualquier estado que esté demorando el proceso está perdiendo una oportunidad”, agregó.

“Nuestro sistema está empeorando a la gente”

El Departamento de Servicios Familiares de Texas tomó la custodia de Valdez cuando tenía 8 años porque el historial de convulsiones de su madre la hacía incapaz de cuidarlo, según los registros. Valdez dijo que se escapó de hogares temporales por los abusos o las negligencias.

Unos años más tarde, ingresó al sistema de justicia juvenil de Texas por primera vez.

Los funcionarios allí no hicieron comentarios sobre su caso. Pero Valdez dijo que mientras lo trasladaban de una instalación a otra, sus medicamentos antidepresivos y antipsicóticos se suspendían abruptamente y sus registros rara vez se transferían. Nunca recibió terapia u otro apoyo para hacer frente a sus experiencias de la infancia, que incluyeron el abuso sexual, según sus registros médicos.

Valdez dijo que su salud mental se deterioró mientras estuvo detenido, porque estuvo aislado durante largos períodos de tiempo, por el trato brusco de los funcionarios, los temores de violencia por parte de otros niños y la falta de atención médica adecuada.

“Me sentía como un animal”, dijo Valdez.

En agosto, el Departamento de Justicia de los Estados Unidos publicó que afirma que el estado expone a los niños detenidos a fuerza excesiva y a aislamientos prolongados, no los protege del abuso sexual y no brinda servicios de salud mental adecuados.

El Departamento de Justicia Juvenil de Texas ha dicho que para mejorar la seguridad en sus instalaciones.

En 2024, el 100% de los menores en las instalaciones del Departamento de Justicia Juvenil de Texas necesitaron tratamiento especializado, incluso por problemas de salud mental, adicciones o comportamiento violento, según la entidad.

Con demasiada frecuencia, “nuestro sistema está empeorando a las personas y no les ofrece la continuidad de la atención que necesitan”, dijo Elizabeth Henneke, fundadora y directora ejecutiva de Lone Star Justice Alliance, un bufete de abogados sin fines de lucro en Texas.

Valdez dijo que el trauma de la custodia estatal ensombreció su vida después de su liberación. Se enojaba y se volvía violento con facilidad y a menudo sentía desesperación. Fue encarcelado nuevamente antes de sufrir una crisis que lo llevó a ser hospitalizado en 2022. Le diagnosticaron trastorno de estrés postraumático y le recetaron medicamentos, según su historial médico.

“Me ayudó a entender que no me estaba volviendo loco y que había una razón”, dijo. “Desde entonces, no voy a decir que ha sido fácil, pero definitivamente ha sido un poco más manejable”.

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