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Tyler Amos goes to a lot of meetings at the Yuba County Jail in California. He’s a case manager for Peach Tree Health, a local federally qualified health center. The patients he works with are inmates who are close to being released from the jail in Marysville, 40 miles north of Sacramento. He meets regularly with behavioral health specialists, probation officers, licensed clinical social workers, doctors, and nurses.
“Every day we discuss 15 to 25 people and what is going on with their care,” Amos said. He tries to match up the people’s medical needs with resources to ensure they have what they need to stay healthy when they leave jail.
“The CalAIM program as a whole is the connective tissue that makes this program possible,” he said.
Yuba and Sutter counties, working together, are in the vanguard of a national project to improve access to health care for people coming out of incarceration.
In Historic Shift, Reentry Services Begin
Since the inception of Medicaid in 1965, the government’s “Medicaid inmate exclusion policy” blocked funding of care for people inside jails or prisons. That changed in 2023 when California became the first state to receive permission to spend federal Medicaid dollars on the Justice-Involved Reentry Initiative. The pre-release program is part of CalAIM, the state’s comprehensive effort to connect Medi-Cal enrollees with social services.
Harold Kemper, 67, has been in jail more than once. Most recently, he was released from the Yuba jail in February after serving time for a narcotics conviction. He is a fan of the program and the two community health workers who assisted him, Christina Tejada and Nicole Cuevas.
“CalAIM and these ladies here with Peach Tree Health have been golden,” he said in an interview. “They helped me get going with Social Security and Medicare.”
After previous incarcerations, he said, “you didn’t get any help at all. You were entirely on your own.” This time, he got assistance with his anxiety, diabetes, and attention deficit hyperactivity disorder. “They are trying to get it all coordinated, like here in one place, not all spread out. This is better now, lots better.”
He has an appointment at the hospital for blood work and an appointment with a dentist in June — all organized by a care coordinator from Peach Tree who is funded because of CalAIM. “I get drug counseling too, through the methadone clinic,” he said.
How Medi-Cal’s Reentry Initiative Works
It’s a statewide program that allows California to use federal Medicaid dollars to provide pre-release health care and social services to jail and prison inmates nearing completion of their sentences.
How do these services improve health care access? They coordinate treatments for chronic conditions, mental health, and substance use disorders before a person is released.
How are rural counties leading the CalAIM reentry rollout? Counties like Yuba and Sutter are leveraging strong local partnerships and a shared commitment to public safety, public health, and equity.
What services for clients are included? The program features a “warm handoff” that includes securing a 30-day medication supply, scheduling primary care appointments within 10 days of release, and connecting individuals to housing and food resources.
How does Medi-Cal fund pre-release health care services? Medi-Cal allows enhanced care managers to bill for health care and social needs planning, creating a sustainable pathway for reentry support.
Does health care access increase public safety and reduce recidivism? It gives individuals the resources, stability, and hope they need to successfully rejoin their communities and avoid returning to jail.
Reentry Services Are Launching
All of California’s 31 state prisons and more than half of its counties have started their reentry programs. All other counties must have reentry programs in their jails by October. Yuba and Santa Clara counties were the first two counties to launch pre-release programs in October 2024. Sutter County followed in April 2025.
Because Yuba and Sutter— adjacent counties in the Central Valley north of Sacramento — have limited resources, they merged their reentry programs into a single bi-county effort. Now with strong partnerships and a collaborative spirit, they are fully committed to it. In a conservative part of the state, they have centered public safety, public health, and equity.
Public Health-Law Enforcement Partnership
Yuba and Sutter are under the supervision of one health officer, Phuong Luu, MD, MHS. “We want what is best for these incarcerated persons,” she said. When federal permission was granted, “I raised my hand to county leadership and said, ‘I can lead this effort.’”
Luu understood that this is health care operating within a correction system. “I am a physician,” she said. “I have a passion for integrating health care with other aspects of the delivery system locally.”
The key, she said, is close collaboration with law enforcement, which faces many of the same challenges as health providers and hospitals. What she calls the “disjointed, fractured health and human services system in the U.S.” has to respond to the same people that her public safety partners routinely deal with — “the same individuals who cycle in and out of jail, and the same persons coming in to a public health department, coming into the emergency room, into the mental health center.”
“We are only touching certain parts of the elephant,” she said in an interview. “How do we see all parts of the whole and work together to put the puzzle together? Where is the need for this incarcerated person so we can break the cycle of recidivism?”
How Medi-Cal Pays for Reentry Care
It is helpful to think of the program as health care discharge planning replicated in the correctional system. When a person is released, an enhanced care manager can link them directly to health care to address not only their physical health, mental health, and substance use disorder, but also their social needs, such as homelessness or simply getting reenrolled in Social Security.
“If we can use the Medi-Cal delivery system to ensure a billable, claimable pathway for this assistance,” Luu said, “then it is sustainable.”
Across the state, services are being billed. According to an impact report from the Department of Health Care Services, the pre-release initiative delivered more than 159,000 billable services and prescriptions in its first year and added more than 24,000 people who are incarcerated to the Medi-Cal rolls.
Connecting People to Housing, Care, and Food
Peach Tree Health, Amos’ employer, facilitates the warm handoff between jail health services and Partnership HealthPlan, the Medi-Cal managed care plan that serves many Northern California counties.
Amos asks patients what help they need. A client with mental health challenges might ask for therapy or assistance staying on their medications. If they need housing, he has connections to shelters and short-term stays. They might also get help from Habitat for Humanity or Hands of Hope. If they mention food insecurity, Amos has information on where to get a hot meal or inexpensive groceries.
“If somebody is housed and they suffer from diabetes or hypertension, we can get medically tailored meals sent to their house,” he said. He does a lot of care coordination and works with an enhanced care manager to achieve the warm handoff. “Right now, the housing stuff is really hard,” he said. These services are community supports offered through CalAIM.
Part of the reentry plan is identifying what medications people who are incarcerated will need after their sentence is complete but before Medi-Cal coverage kicks in through the health plan. “We make sure they have a 30-day supply, especially the important ones,” Amos said. He tries to set them up with a primary-care appointment at Peach Tree within 10 days of release.
Law Enforcement Supports Reentry Services
Luu has a strong partner in Capt. Matthew Maples, commander of the Sutter County Jail.
“I support the initiative as much as I can,” he said. “These people, they never had a chance. Their parents were in jail. They’ve been homeless since they were 17 and dropped out of school. They can’t have a job because they don’t have the means to figure that stuff out. This initiative gives them the sense that people actually care.”
Having access to health care, he said in an interview from the jail, “is one of the drivers of having a normal well-being, of being a human good person.”
And yet, challenges remain. “I might not agree with every single part of it,” he said. “There are a lot of programs that come down from the state of California that don’t align with law enforcement.”
The reason this program has come together so successfully is that in a smaller county like Sutter, people know each other, and that makes people more likely to be mutually supportive, Maples said. “It’s my staff and the people connected to CalAIM who make it work. We have a lot of doers in this group, people who just get stuff done.”
Maples thinks this program could be effective anywhere and could help bridge cultural gaps, including political differences. Like many people in law enforcement, he is politically conservative. Last year he attended a conference about the CalAIM program in Southern California and came away feeling “like I was at the Democratic National Convention.”
But none of that dampened his enthusiasm for helping inmates prepare for reentry. People in health care should keep in mind that the program works because officials from law enforcement and correctional facilities cooperate.
“That is why we are so successful,” Maples said. “We work together.”
“We sign them up for health care,” he said. “We give them housing, transportation. ‘Now I can get a job. Now I can support my kids. Now I don’t have to sleep on the side of the road, and break into a mailbox and steal mail.’ Making sure we set people up with the things they need will help achieve the goal of law enforcement. Eventually we should see a reduction in recidivism.”
“Folks inside these facilities are not waking up every morning the happiest individuals,” Maples said. “With that you have emotional issues, depression. With this program, one of the things that has changed is the whole hope thing. Now they have resources. They can see it’s going to help me now, and it’s going to help me when I do get out of this place.”
