ʻAIEA, Hawai‘i — Christian Alameda used a cane to push himself up out of bed in his cell at the Halawa Correctional Facility in Honolulu. He has been recovering in the prison’s medical infirmary since a January stroke left the right side of his body mostly paralyzed.
In February, Hawai‘i’s parole board granted the now-52-year-old compassionate release, which allows prisoners to receive early probation to seek medical attention for severe conditions.
But without a long-term care facility willing to accept him, Alameda has not been able to leave.
As of June, at least three other prisoners granted release to tend to their medical needs were living indefinitely in the infirmary after long-term care facilities were unwilling to accept them, primarily because of their criminal backgrounds, the state parole authority said.
“This is a challenge across the country,” said Molly Crane, an attorney for FAMM, which advocates for fairness in prison policies.
Every state allows compassionate release for prisoners, though Hawaiʻi is the only one without a specific law, relying instead on an internal policy. The prisoners who typically qualify for compassionate release can’t care for themselves or have terminal illnesses and may need an assisted living center, a nursing home, or hospice.
But many long-term care facilities nationwide decline to take such prisoners, leaving them incarcerated for months — or years — after they were granted release.
In Rhode Island, a study found that rejections from nursing homes soared after they were told that a patient was coming from prison. In Colorado, prisoners with extensive medical needs stayed an average of 200 days after being granted parole, because of denials from long-term care centers. And in New York, prisoners granted parole sued the state when they couldn’t get placed in nursing homes.
President Donald Trump’s signature One Big Beautiful Bill Act further strains long-term care providers’ ability to take people from incarceration. Prisoners don’t qualify for Medicaid, so parolees often need to apply after they’re granted the release. The law, enacted last summer, reduces the window in which facilities can get reimbursed retroactively for new Medicaid patients from three months to as little as 30 days before they apply. That means facilities risk not getting paid for new Medicaid patients whose applications are not submitted within the reduced timeframe.
The Centers for Medicare & Medicaid Services “encourages providers and beneficiaries to prioritize timely application submission to maximize coverage,” CMS spokesperson Timothy Foster said.
‘Risk Is Just Too High’
Most nursing homes nationwide already have a waiting list for new residents, according to a 2024 report by the American Health Care Association and the National Center for Assisted Living. Those waitlists are another hurdle to getting prisoners placed, said Bob Merce, a former attorney who advocates for prisoners’ compassionate release.
“We tell the nursing homes that most of the people who we are talking about cannot hurt somebody,” Merce said.
Some of the prisoners staying at the Halawa infirmary in June couldn’t walk or dress themselves. One man couldn’t recall what his illness was. Another with brain cancer couldn’t coherently respond to questions.
Sean Sanada, the Oʻahu Region CEO with the Hawaiʻi Health Systems Corp., oversees the region’s two state-funded long-term care facilities, Leahi Hospital and Maluhia. Sanada said that the health system has reviewed dozens of compassionate release referrals but has never accepted any of them.
Sanada said the facilities don’t discriminate based on where the resident comes from. His main concerns, he said, were his staff’s safety and the lack of resources to adequately care for the patient.
“The risk is just too high in most of those instances,” Sanada said.
Violent incidents in long-term care facilities have been well documented. A 2024 study observing 14 assisted living facilities found that in just one month, 15% of residents experienced resident-to-resident aggression.
When long-term care facilities refuse to accept prisoners who have been granted compassionate release, it leaves state taxpayers footing a larger bill. The annual cost to incarcerate an individual in Hawai‘i with complex needs is up to eight times the $112,505 average of housing one person in prison, according to FAMM. In comparison, the average Medicaid reimbursement for a long-term care patient at a Hawaiʻi Health Systems Corp. facility is about $135,000 a year.
Four states — Connecticut, Georgia, Massachusetts, and Vermont — contract with nursing facilities to take prisoners who are granted compassionate release, according to FAMM.
The iCare Health Network’s MissionCare Health, which operates nursing homes for people coming out of prison, secured contracts in three of those states. David Skoczulek, iCare’s vice president of business development and communication, estimated that its rates are $100 to $350 a day more per patient than the average nursing home rates in the states where they operate.
In Hawaiʻi, the correctional department determines recommendations to send to the parole board, which decides whether to grant the release. Prisoners who are granted the early probation can be released to family members who commit to caring for them or to a long-term care facility.
Corey Reincke, head of the Hawaiʻi Paroling Authority, said that in his 24-year career he couldn’t recall getting anyone placed into a long-term care facility without family intervening, for instance by contacting facilities themselves.
“Parole has to find a facility that can meet their medical needs and is also willing to take them,” Reincke said. “That’s where we’re hitting the roadblocks.”
For one parolee, Reincke called more than 100 care homes, he said, but they all declined to accept the patient, over safety concerns. According to a 2024 state report, while Hawaiʻi’s long-term care facilities use about 80% of their bed capacity, workforce strains make it difficult to maintain even those levels.
Hawaiʻi Prisoners’ Refuge: Family
Last year, 69-year-old Paul Kupihea died at a hospital five days after the state granted him compassionate release to his family. He died before he could get on a flight to his home island.
In July 2025, Lahela Kruse, the mother of Kupihea’s child, received a call from a Honolulu hospital informing her that his condition had become severe. By then he had been diagnosed with an incurable form of cancer and had been in and out of the hospital while still in custody.
Kruse and their daughter flew to Oʻahu to see him and were shocked when they saw how sick he was. Their daughter agreed to take him into her home in Hilo, on Hawaiʻi Island, despite not having a relationship with him for most of her life.
“She knew he was sick,” Kruse said. “I told her that, but she didn’t know the severity of it. I didn’t truly know.”
Her daughter’s willingness to take him prompted his compassionate release. But Kruse said the notification about Kupihea’s illness came too late.
FAMM’s Crane has been working on expanding compassionate release laws in states to allow for more prisoners to qualify and strengthen transparency in the process. Hawaiʻi lawmakers have tried for years to pass bills on compassionate release, but none has succeeded.
Crane said without a law that outlines a formal process and who qualifies, even family support isn’t enough. Prisoners can still face life-threatening delays, she said.
“The absence of a compassionate release statute means that people who need compassionate release languish and even die in prison,” Crane said.
In Alameda’s cell, two beds stood about 3 feet apart, with a seatless metal toilet in the corner and a window looking out on a concrete wall. The smell of bleach permeated the room. Alameda said he hoped to see his daughter soon. She recently turned 5.
“I made some mistakes in my life,” said Alameda, who has been incarcerated since 2024 for drug possession, driving a stolen vehicle, and jumping bail. “I tried when my daughter was born, but I know I’ll change, because she needs me out of here.”
Merce, the former attorney, is still trying to find a place for Alameda, who committed no violent crimes. Merce became aware of prisoners’ struggles through his work as a trial lawyer. He said he has helped about 15 prisoners leave Hawaiʻi correctional facilities for medical treatment.
He said he’s seen cases in which people have waited years to get out.
“The ones that stick with me, though,” Merce said, “are the ones that I never found placements for.”
KFF 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 KFF.This <a target="_blank" href="https://kffhealthnews.org/health-industry/sick-prisoners-compassionate-release-parole-long-term-care-hawaii/">article</a> first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
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Céline Gounder, KFF Health News’ editor-at-large for public health, discussed the Department of Health and Human Services’ plan to offer compensation for automatic covid vaccine injuries and the drop in enrollment in Affordable Care Act health plans on CBS’ The Takeout With Major Garrett on July 10 and 9, respectively.
KFF Health News Southern correspondent Sam Whitehead discussed abortion telehealth on WUGA’s The Georgia Health Report on July 10.
This <a target="_blank" href="https://kffhealthnews.org/on-air/on-air-july-18-2026-covid-injuries-aca-telehealth/">article</a> first appeared on <a target="_blank" href="https://kffhealthnews.org">KFF Health News</a> and is republished here under a <a target="_blank" href="https://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License</a>.<img src="https://kffhealthnews.org/wp-content/uploads/sites/8/2023/04/kffhealthnews-icon.png?w=150" style="width:1em;height:1em;margin-left:10px;">
<img id="republication-tracker-tool-source" src="https://kffhealthnews.org/?republication-pixel=true&post=2261557&ga4=G-J74WWTKFM0" style="width:1px;height:1px;">One year after the Trump administration announced that dozens of health insurers had signed a six-part pledge promising to reduce barriers to doctor-recommended care, some insurers now say they won’t implement all the promised initiatives.
Meanwhile, patients, their advocates, and clinicians say little has improved.
“It has never been this bad for patients,” said U.S. Rep. Greg Murphy (R-N.C.), a physician who co-chairs the GOP Doctors Caucus.
The overarching intent of the June 2025 pledge was to improve a controversial process called prior authorization, which regularly requires patients or someone on their medical team to seek approval from insurers before proceeding with treatment.
According to AHIP, the health insurance industry trade group, health plans have eliminated 6.5 million prior authorizations for patients — equal to an 11% reduction — since the announcement.
But critics remain skeptical. Sally Nix, a patient advocate who has a chronic disease, described the voluntary pledge as “performative.” And Murphy, who participated in the news conference with Health and Human Services Secretary Robert F. Kennedy Jr. announcing the pledge last year, said it has “no teeth.”
Voluntary insurer pledges rarely make things better for patients, said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University.
“In the absence of clear rules, policies, standards, and mandates,” she said, insurance companies are “going to do what makes sense for them to do financially.”
The Department of Health and Human Services did not respond to questions for this report. It isn’t clear how, or whether, the Trump administration is holding insurers accountable.
‘Zero Faith’
Prior authorization — sometimes called preauthorization or precertification — has been around for decades. The insurance industry has long argued that the practice, which varies by company, helps control costs, reduces waste and fraud, and prevents potential harm to patients. It’s regularly invoked for a huge swath of services, ranging from low-cost urgent care to expensive cancer treatment.
“Prior authorization is a vital patient safeguard,” said Chris Bond, a spokesperson for AHIP.
The 2024 killing of UnitedHealthcare CEO Brian Thompson sparked a national groundswell of anger about insurance denials, with patients and doctors becoming increasingly vocal about the tactics they say insurance companies use to boost profits at the expense of care.
Prior authorization reform is one of the rare healthcare issues Democrats and Republicans tend to agree on. On July 15, the House Ways and Means Committee unanimously advanced a bill that would force Medicare Advantage plans to provide to the federal government a list of all items and services that are subject to prior authorization, and to report data about denials and grievances, among other requirements.
Last year’s industry pledge was organized as a direct response to public anger, Mehmet Oz, administrator of the Centers for Medicare & Medicaid Services, said when it was announced. “There’s violence in the streets over these issues,” he said.
“Americans are upset about it,” Oz said, later adding, “I’m looking forward to seeing the results.”
Mike Gartner, founder of Health Access Innovation, an organization that helps patients overturn insurance denials, said he doubts that insurance companies are changing their policies in meaningful ways. The 11% reduction in prior authorization cited by AHIP “hides a lot of nuance,” Gartner said.
Patients who need the costliest services, such as cancer treatment, are still being disproportionately denied access to doctor-recommended care, he said.
AHIP said its data included reductions in prior authorization for medical services, not prescription medicines. The trade group didn’t provide details explaining which services have been dropped from prior authorization or how those reductions differ across individual insurers.
Last year, Oz said the federal government would be “evaluating progress” toward the pledge and “driving accountability,” and he foreshadowed “public dashboards.” But no such dashboards exist, and federal officials did not respond to questions about how they’re holding companies accountable.
Murphy, the North Carolina congressman, said he has “zero faith” in the industry policing itself.
He didn’t believe insurance companies then, he said, “and I don’t believe them now.”
‘At War’ With an Insurer
In February, days after Betsy Adler and Justin Young’s daughter Coco was born with a serious heart defect, the Stillwater, Minnesota, family received paperwork showing they were racking up out-of-network costs.
During Adler’s pregnancy, the family had switched insurers, moving to Medica, a for-profit company based in Minnetonka, Minnesota, and one of many insurers that initially signed the industry pledge. Adler said she’d checked with her employer’s human resources department and on Medica’s website to make sure her maternal-fetal specialists and hospital were in-network before their new health plan went into effect earlier this year.
But then, the insurance company started processing some claims as out-of-network. By mid-March, the family had accrued more than $4,000 in out-of-network charges, on top of more than $3,000 for in-network bills. And the bills kept coming.
When Adler, a psychotherapist, called to figure out what was going on, she said, an insurance company representative said she hadn’t submitted a referral from her primary care provider beforehand. Attempts to fix the problem went nowhere. At one point, Adler said, Medica required her to visit a clinic she’d never been to before to obtain a referral. But she said a Medica representative told her the referral was never received, because the insurer’s fax machine was down.
“I have a critically ill child,” Adler remembered thinking shortly after Coco was discharged from the cardiovascular intensive care unit. “I can either spend my emotional energy at war with Medica, or I can let it go and just enjoy my time with my daughter.”
Medica spokesperson Greg Bury said he wouldn’t discuss the case, citing patient privacy rules. In an emailed statement, he wrote the company is “committed to working with her to ensure she understands what is covered under her benefits and our responsibilities.”
One of six specific promises all insurers made when they signed the pledge was to honor a 90-day grace period when patients switch insurance plans, starting Jan. 1 of this year. Often called “continuity of care,” this grace period allows patients to temporarily continue receiving services and medications that were authorized under a previous insurer.
But that applies only in some circumstances, Georgetown’s Corlette said. The wording of the pledge suggests that insurance companies aren’t obligated to honor another company’s network parameters. When Adler and Young switched insurers, for example, Medica was not obligated to cover the cost of out-of-network providers as if they were in-network, even though they were in-network under the family’s old plan.
Adler and Young switched insurance companies again when Coco was a month old, to avoid accruing more out-of-network costs.
Denial After Approval
The percentages cited by AHIP don’t tell the whole story, said Nix, the patient advocate. Insurers are “not including the data for the loopholes they create,” she said.
For example, nothing in the pledge prevents insurance companies from retroactively denying payment, even when care is preapproved. “Patients are going to see a lot more retroactive denials,” said Nix, who recently had her insurer process, then later deny, a claim for injections to relieve her nerve pain.
Something similar recently happened to Jocelyn Austin, 49, of Amherst, New York. Over the course of nearly 20 years, she developed an addiction to sleeping and anxiety pills prescribed to her by a doctor. Last year, she spent weeks at an inpatient treatment center for substance abuse. Her insurer, Independent Health, had approved the admission. Austin said she has been substance-free since her discharge.
But the facility sent her a bill for more than $12,000 in December showing her insurer had not paid for the treatment she received, according to documents Austin shared with KFF Health News. This was in addition to the $10,000 she paid at the beginning of her treatment to satisfy her out-of-network deductible. The approval letters from Independent Health had specified that “authorization is not a guarantee of claim payment.”
Frank Sava, a spokesperson for Independent Health, said a denial was issued and upheld in this case because the services provided “were inconsistent with the care that was authorized” and “the medical record did not sufficiently support what was billed.” He said those findings were reviewed and confirmed by an outside consultant.
An explanation of benefits issued by the insurer last summer indicated the “provider,” not the patient, was responsible for the cost of her treatment. And yet the treatment facility has continued to pressure her for payment, she said.
Austin, who has not paid her outstanding bill, said insurance companies “should be held accountable.”
‘Significant Work Ahead’
Another one of the six commitments insurers made last year was to adopt new technology that would standardize the electronic submission of prior authorization requests. During the news conference announcing the pledge last summer, Chris Klomp, the director of Medicare and a deputy CMS administrator, said more than 50% of prior authorizations are still paper-based and processed by phone or fax machine.
In April, AHIP released an update related to that technology initiative, explaining that participating insurers would adopt the new standards on a rolling basis. Health insurers agreed to implement the pledge’s various commitments by predetermined deadlines, and this initiative is scheduled to be operational by Jan. 1, 2027. But eight insurers that initially signed the pledge last year didn’t sign the technology update when it was announced in April, AHIP told KFF Health News.
Those insurers are Alignment Health Plan, EmblemHealth, HealthFirst, Independent Health, Medica, MVP Health Care, Point32Health, and SummaCare. Their beneficiaries span the country, from California to New York. None of those eight insurers agreed to interviews for this report, but most sent KFF Health News emailed statements indicating that they remain committed to prior authorization reform.
AHIP’s approach to continuity of care “would have required the transfer of confidential member health information through a non-standardized process involving third-party participation,” wrote Jerry Slowey, a spokesperson for Alignment Health, which offers Medicare Advantage policies in Arizona, California, Nevada, North Carolina, and Texas. “We do not believe that level of data sharing was contemplated in the original commitment.”
Bury, the spokesperson for Medica, which covers beneficiaries in Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, Oklahoma, South Dakota, and Wisconsin, said the company “supports the goal of these standardization efforts.” But the April update “raised a significant technical and operational hurdle that we are not able to commit to at this time,” he said.
Alex Gomez, a spokesperson for EmblemHealth, said in late June the company “will sign onto the commitment” after KFF Health News posed questions about why it had not endorsed the April update.
“We anticipate more plans will be added over the coming months,” said Bond, the AHIP spokesperson. Health plans are “working continuously to implement their commitments to simplify and improve the experience.” He acknowledged that “there is still significant work ahead.”
The original pledge also included a promise that insurance companies would enhance transparency and use “clear, easy-to-understand explanations” when communicating to patients — something they were already supposed to be doing under the Affordable Care Act.
Yet companies still regularly neglect to explain why care has been denied, and their communications often contain “inconsistent and contradictory information,” said Gartner, of Health Access Innovation. He and Murphy also said they suspect insurance companies are increasingly using artificial intelligence to generate denials.
“They craft the pathways to basically deny things immediately with the hope that people will give up,” Murphy said.
The congressman said he wishes President Donald Trump would sign executive orders addressing some of these issues. “The problem is the insurance industry is the strongest lobby in this town.”
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