by John E. Dannenberg

"Good care is less costly than bad care." This maxim, from prison healthcare Receiver Robert Sillen, set the tone when he announced his master plan on May 10, 2007 to constitutionally repair the California Department of Corrections and Rehabilitation's (CDCR) ailing healthcare system. In the 50 page plan to the federal court, Sillen detailed his objectives, including use of teams of medical experts traveling by chartered plane to prisons in medical crisis; reorganizing regions of CDCR's 33 prisons to 3-5 prisons, versus 11 now; creating quality control mechanisms; developing monthly medical score cards for each prison; converting medical records from paper to electronic; implementing human resource programs to hire essential medical staff; overhauling medical fiscal management practices; improving custody medical escort teams; and providing proper clinical space at all 33 prisons. Sillen boasted, "The plan is comprehensive, responsible and best of all, achievable. ... The new system will eliminate the unconscionable human suffering currently taking place in our prisons, and make California communities safer from disease as inmates revolve in and out of the institutions."

The plan expressly provides for specialty clinics, including pain management, chronic care, infectious disease/prevention; pre-natal care; telemedicine services; and aging/disabled prisoner care. Special attention would be given to public health (communicable disease prevention), pharmacy services, nutrition, and X-ray/laboratory services. Additionally, quality control would attend all facets of the healthcare delivery program, to include medical ethics, safety, evaluation, and physician clinical review/discipline.

Accompanying the 50 page plan were two documents filed with the federal court. One was a summary, Receiver's Report re Plan of Action, and the other -- incredibly -- was a motion to curtail the activities of the prisoner class' civil rights attorneys (whose decades of efforts created Sillen's office in the first place), claiming that their constant monitoring efforts created too much busywork for Sillen's staff. Donald Specter, lead attorney with the Prison Law Office near San Quentin, retorted that he would defend the oversight rights accorded by Judge Henderson at the outset of the receivership.

Sillen began by reporting the success of his first year in operation. This included raising medical staff salaries to competitive levels; expediting the clinical hiring process; turning around the pharmacy system; fixing medical contracting procedures; beginning repairs on a broken discipline system that reduced staff morale; personally visiting 24 (of the 33) CDCR prisons; delivery of sorely needed medical equipment/supplies; initiating projects to construct 5,000 medical beds and 5,000 mental healthcare beds statewide; replacing CDCR Medical Technical Assistants with Licensed Vocational Nurses (saving $39 million/yr.); and gaining court approval to narrow waivers of state law to address staff hiring/firing, discipline and contracting.
Significantly, Sillen chose nearby aging San Quentin State Prison as a pilot project, where a new $1.3 million emergency Triage and Treatment Area was inaugurated in June 2007, and where clinical areas were instituted for reception center and mainline prisoners to provide timely initial screening and 24 hour/day medical services availability. A new $164 million hospital is scheduled to be built, replacing San Quentin's condemned, empty 1884 historical landmark building.

The plan not only names the objectives to be achieved, but states them with sufficient specificity to permit meaningful measurement of success over time. Sillen reviewed the federal court's 61 original stipulations and now recommends retaining all 28 that spell out standards of care, but eliminate 17 others that had directed CDCR's implementation of changes. The latter were ditched because they were, in large, simply "never done."

Legislative Democrats welcomed "the new sheriff in town," but critics of Sillen emerged, not surprisingly, in Republican clothing. One omission from the plan was any mention of budget or funding. Legislative analysts wet-thumbed estimates ranging from $3 billion to $8 billion. Sillen admitted it might take 20 years to get everything done. But this was all couched in the remaining imponderable variable -- prison overcrowding.
Sillen has repeatedly stated that there are two competing forces tempering his successful completion of the federal court's mandate: either increase medical services or reduce the population to match available levels of medical resources.

In July 2007, two federal judges overseeing CDCR mental healthcare and medical healthcare deficiencies for the past 20 years asked the Ninth Circuit U.S. Court of Appeals to appoint a three-judge panel for the purpose of eventually seizing CDCR so as to put a population cap on it that would permit constitutionally responsible conditions of confinement throughout the prison system. If this comes to pass, the medical Receiver's job will become less daunting, cost less and happen sooner.
Most importantly, prisoners will not continue to die unnecessarily at the rate of 60+ per year inside the walls of CDCR for want of constitutionally adequate health care.

Sources: Prison Medical Care System Reform, Plan of Action, May 2007 (California Prison Health Care Receivership Corp.); Plata v. Schwarzenegger, U.S.D.C. (N.D. Cal.) No. CO1-1351 TEH, Receiver's Report re Plan of Action, May 2007; Sacramento Bee; Los Angeles Times; Associated Press.

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