(photo courtesy CDCR)
1. Is overcrowding the primary cause for the medical system's dysfunction?
The court reponds in the affirmative. It starts by noting that "[a] prison system’s capacity is not defined by square footage alone; it is also determined by the system’s resources and its ability to provide inmates with essential services such as food, air, and temperature and noise control". It then moves on to explain the causal link between overcrowding and poor medical services, not before mentioning that four former CA prison administrators testified in support of this assertion.
The testifying administrators pointed out to several ways in which overcrowding hinders health care. First, the decision mentions that, in general, overcrowding leads to a set of priorities impacted by various emergencies, thus relegating health services to a lower place in the list of priority.
Second, the court emphasizes several problems stemming from the lack of space: the inadequate use of reception centers to house inmates rather than treat them, the severe shortage of treatment space, and the inability to place inmates according to classification because of space constraints. This is a problem particularly with respect to mentally ill inmates, who "languish in clinically inappropriate settings".
Third, overcrowding directly impacts the quality of care: "Bad bed" areas are understaffed, unsanitary (thus exacerbating the risk of spreading infectious diseases), and toxic for the severely mentally ill.
Fourth, there are other ways in which overcrowding hinders care. Understaffing is a problem not only with respect to medical and mental health stuff, but also with respect to the custodial stuff expected to keep the peace and escort inmates to receive medical treatment; the pharmaceutical system is unable to keep up with delivery demands; there are huge backlogs in receiving specialty medical care; and the growing need to rely on lockdowns as a way to keep the order hinders the provision of medical care during such times.
Finally, the impossibility of manually filing the huge number of medical records leads to inadequate record keeping, which leads to chaotic administration.
The panel then draws a line of causality between the overcrowding and some of the horrendous examples of preventable misdiagnoses, disease exacerbation and preventable deaths. It also points out that overcrowding exacerbates the plight of mentally ill prisoners. A variety of experts - including former prison administrators, prison scholars, administrators, physicians, and psychologists - are cited as supporting the causal link. Moreover, the court points to the litigation history in the Plata and Coleman cases as proof of the worsening of the situation, due to overcrowding, despite efforts to improve medical care with other measures.
2. Is there really no other way?
The court's response, in a word, is no. As support, the panel examines a series of alternative measures, pointing out their inadequacy as solutions to the problem.
First, the panel states the inadequacy of further construction as a remedy to the problem. Currently, there are no plans to build new prisons; re-entry facilities would take years to build and would not provide immediate relief; and building medical facilities is now compounded by the financial crisis. In general, construction is inadequate because it could not be completed in a timely manner, though if it were to be completed, it could be part of the solution.
Second, additional hiring is, according to the panel, impractical, given the difficulty of filling in current vacancies. As the decision points out, the overcrowding issue in itself discourages new hires, and a less crowded system would be more conducive to quality hiring.
Third, the court responds to the state's argument that the appointment of the receiver and special masters has been enough. While some progress has been achieved, it hs been slow. The receiver and special masters themselves testified as to how overcrowding has hindered their ability to improve the system. In addition, since solving the crowding problem will not immediately make the medical system's deficiencies disappear, their services will still be needed after the acute difficulties are resolved.
The panel also rejects the state's reliance on shipping inmates out of state as a solution, not only because of the small numbers that can be accommodated, but also because of the unknowns regarding the standard of care in those states.
More in Part III.