Prison Health Care Receiver

 

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. 

Inefficiencies.  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 its activities. 

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: 

Ø     Build 5,000 health care beds at a cost to the state that will likely exceed $2 billion,

Ø     Find 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,

Ø     Increase salaries for health care professionals in order to recruit staff, and reduce reliance on costly contract staff,

Ø     Contract out pharmacy operations, to reduce waste and inefficiency,

Ø     Eliminate the Medical Technical Assistant (MTA) classification which is a combination clinical custody position, in favor of Licensed Vocational Nurses,

Ø     Revamp the Reception Center process to ensure quicker identification of sick inmates, and get treatment sooner,

Ø     Build adequate treatment and administrative space for clinicians,

Ø     Increase the number of clinicians in individual prisons based on need,

Ø     Reorganize the management of the health care division within the Department, and ensure adequate oversight.

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).   

Future Costs. 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.

Conclusion.  Despite 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 made. 

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