In January, U.S. District Court Judge Thelton Henderson fired Bob Sillen, the federal receiver who had been appointed to fix California's prison healthcare system. Henderson praised Sillen's reconnaissance and understanding of the scope of the problem but criticized him for not moving quickly enough.

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In 2001, 10 inmates at nine prisons, including San Quentin, accused the state of violating the Eighth Amendment with medicine that amounts to cruel and unusual punishment. In 2002, Henderson agreed with the inmates, pronouncing California's prison healthcare system unconstitutional.

More than 170,000 inmates crowd California's 33 state prisons. That's about as many people as live in Tempe, Ariz., and it's more than double the number the prisons were built to hold. Inside those bars, one inmate dies every six to seven days because of "deplorable" medical care, according to Henderson. The state settled the case, agreeing to fix the problems. But by mid-2005, after six days of hearings, Henderson concluded the state had made no progress.

Henderson seized control, appointing Sillen to hire new people, change processes and install basic information technology found even in small rural hospitals in the United States. The aim of the receivership (officially the California Prison Health Care Receivership) isn't to offer criminals state-of-the -art health care. It's to do no harm.

In a "Plan of Action" he filed in November, Sillen outlined 22 objectives, from building more physical buildings at various prison sites to piloting a new grievance investigation procedure to installing systemwide IT. Though he devised milestones for each objective at intervals six months to three years out, Sillen didn't envision returning the prison medical system to state control for a decade. (See Sillen's Strategic Plan, >Part 1 and Part 2).

Furthermore, Henderson noted, the receivership "must work more closely at this stage with all stakeholders." While Judge Henderson gave the receiver wide powers to make change and hand the state the bill, the money must be appropriated by state lawmakers. Right now, the state is running a $14.5 billion deficit that halted budget talks between Gov. Arnold Schwarzenegger and the legislature for two months last summer Sillen is known to be prickly and confrontational—a style unlikely to persuade state legislators and Schwarzenegger, among others, to come together to support expensive prison overhaul projects. (More from Governor Schwarzenegger on Prison Overcrowding and Parole Proposals). Sillen could not be reached for comment.