Prison Health Care
What is a Receiver?
In June 2002 the California prison system
was found to be delivering constitutionally inadequate health care in the
federal class action lawsuit Plata v. Schwarzenegger. As a result of
the inability of the Department of Corrections and Rehabilitation to make
significant improvements in the delivery of health care, the court appointed
a Receiver to oversee the prison health care system. The sweeping powers of
the Receiver include the ability to waive state laws and regulations and
void labor contracts. To this point the Receiver has
expressed a general unwillingness to work within state processes unless
those processes meet his expectations. However, it must also be
pointed out that the Administration has encouraged this to some degree by
asking for court orders instead of trying to make requested changes. There
seems to be an overall attitude from the Receiver that existing systems
suffer from “paralysis and trained incapacity”, and as such, it is better to
avoid existing processes.
Impact of Prison Crowding.
Prison crowding also has a direct impact on
the provision of health care in state prison. Existing facilities were not
designed to handle the number of inmates or the level of health acuity that
currently exists. Additionally, with longer sentences such as the three
strikes law, the prison population is getting older, and medical needs are
becoming more acute. The Department failed to plan for this, which led to
many of the current difficulties.
As a result of this failure to address the
effects of prison crowding on Plata, the plaintiffs have filed a
motion to a have three judge panel consider placing a population cap on the
Department. This could result in the early release
of tens of thousands of inmates. The Receiver also is likely to put
population caps on individual facilities depending on the institutions
ability to provide health care, which could exacerbate the existing prison
crowding crisis. The judge has given the Receiver until May to make
comments as to the impact of prison crowding on his operations.
In addition to not being able to provide
adequate health care, the system has become remarkably inefficient.
Costs have more than doubled in the last six years.
For example, inefficiency has led to ever increasing pharmaceutical
expenditures. Three previous pharmacy audits were conducted and reforms
were never implemented, which could have reduced costs while providing
better services. The Receiver is taking actions to address the
inefficiencies in the system which could partly offset some of the costs to
his other changes.
Criticism of Other
State Entities. To this point
the Receiver has been highly critical of the role other state entities have
played in exacerbating the problems in the health care system.
He has criticized the State Personnel Board, both for
being a roadblock to position conversions, and also for reinstating
individuals who are not competent to perform their job duties. He
also criticized the Department of Personnel Administration for not taking
earlier action to address salary issues that have led to high vacancy rates
in medical classifications. The Receiver has also been critical of the
Legislature for not accomplishing anything during the special session, and
not approving the $250 million originally called for in the 2006-07 State
Budget (it was reduced to $100 million) to support the Receivers activities.
As a result of these barriers the Receiver
has taken several actions to limit the influence of other agencies. This
attitude also extends to his relationship with the Legislature where he has
expressed a willingness to work within the process only to the degree that
it does not result in delays or changes. This could
result in significant erosion of Legislative control over the Department and
No Plan Yet.
The order establishing the Receiver
required that a plan be developed within 180 to 210 days. To this point the
Receiver has not submitted his plan for addressing the problems in the
health care system. However, the Receiver recently requested a one year
extension to that time frame given the magnitude of the problems encountered
in his initial activities. However, despite the lack of a plan to address
medical care deficiencies, the Receiver has still proposed a number of
changes that point to his intentions:
5,000 health care beds at a cost to the state that will likely exceed $2
500 beds for sub-acute care patients in a short time period to relieve
crowding in acute beds, and reduce reliance on expensive acute hospital beds
for sub-acute patients,
salaries for health care professionals in order to recruit staff, and reduce
reliance on costly contract staff,
out pharmacy operations, to reduce waste and inefficiency,
the Medical Technical Assistant (MTA) classification which is a combination
clinical custody position, in favor of Licensed Vocational Nurses,
the Reception Center process to ensure quicker identification of sick
inmates, and get treatment sooner,
adequate treatment and administrative space for clinicians,
the number of clinicians in individual prisons based on need,
the management of the health care division within the Department, and ensure
Current Costs for Receivers Actions.
Currently the 2007-08 Governor’s Budget
includes $380 million for operational costs directly as a result of the
Plata settlement. This does not include ancillary costs that are driven
by the requirements of the settlement including over $400 million in
contract costs, and over $130 million in drug costs.
Future costs will grow substantially as the Receiver restructures the entire
medical care delivery system. In addition, costs for Mental
Health care as a result of the Coleman lawsuit have also accelerated
as the courts in that case have used some of the same methodologies as the
Receiver (e.g., drastic pay increases).
It is clear that ultimately the efforts of
the Receiver are going to result in significantly increased state costs.
While the Receiver is approaching this from the standpoint of designing the
most efficient system, the magnitude of the problems being tackled will
require significant resources. Already the Receiver has approved 30 new
positions at San Quentin. If this were the average number of new positions
approved per institution this would result in almost 1,000 new positions for
prison health care at a cost exceeding $150 million. He has also decided to
build new clinical and office space at a cost of over $100 million,
which if modeled at other facilities could result in
billions of dollars for additional building costs. To support 7 new
facilities with 5,000 beds, the operational costs will likely exceed $400
million and debt service costs for $3 billion in facilities construction
exceeding $330 million.
the expectation of the Receiver that the state not interfere in his plans in
any way, it will be crucial that the Legislature maintain active oversight
of all of the Department’s functions including the delivery of medical
care. Given the nature of the changes being implemented by the Receiver and
the high costs of those changes, oversight becomes even more important. The
Receiver should be held accountable for the changes that he initiates, and
the cost of those changes. To this point the Administration has not been
willing to push for any level of accountability. This is not acceptable.
Further, adequate oversight and accountability of the Department’s actions
are also critical to ensuring that this type of loss of control is not
spread to other aspects of the Department’s operations up to and including a
federal takeover of the entire system. Action must be taken to ensure
accountability by the Administration and the Receiver in all areas of prison
operations, and to ensure adequate levels of Legislative oversight. The
Receiver should be required to provide a document that outlines goals and
objectives and a timeline for achieving them, and demonstrate how the funds
being spent relate to those goals and objectives. It is reasonable to call
for a select committee for Receiver accountability to review the Receiver’s
actions and to ensure Legislative participation in the changes that are
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