Prison Healthcare Reform on Probation

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.

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.

A CIO in Charge

Replacing Sillen is Clark Kelso, the former CIO of the state. Kelso, who is also an attorney with a degree in philosophy, has a reputation for collaborating and brokering peace between different groups. He has worked in all three branches of California state government, including a tricky job turning around the state Department of Insurance after a corruption scandal in 2000.

“The reason you have to have the receivership is because the state wasn’t able to do it on its own,” Kelso notes. “California is in the midst of a very serious budget crisis. No question that there are going to be some tough discussions ahead. I approach those as opportunities for dispute resolution. I’m not going to look for conflict.”

Then in February, John Hummel, the receivership CIO, quit. He says the move is unrelated to Kelso’s arrival. Hummel returned to Perot Systems as a chief technology officer.

In an interview the day before he resigned, Hummel talked about how his wife, his daughter and his neighbor objected to his work. “People in my own life would come along and say, What are you thinking?” he says. “My wife screamed at me about inmates getting free care.”

However, he says he left not because of any philosophical quandary but, in part, to work with advanced technologies. As to the ethics, Hummel says he was always clear about what he was doing.

“You do not judge people. You treat them. Period.”

Kelso says he admires Hummel. “He has an extraordinary capacity and understanding of what good healthcare IT systems look like,” Kelso says. Hummel’s leaving “is a great loss for the receivership.”

Dan Marshall, staff information systems analyst at San Quentin State Prison, manages much of the prison’s IT. He has yet to meet Kelso, who spent his first several weeks on the job in the state capital reorganizing the receivership. Kelso let go 10 of the highest-paid people who worked for Sillen, including the CFO and the director of communications, but no one from IT. And while Sillen paid himself $775,000 for less than two years’ work, Kelso put his own salary at $224,000.

Marshall knows that some IT plans made by Hummel and Sillen are iffy now. They envisioned the healthcare system running its own network separate from that of the overall department of corrections. But Kelso released a new strategic plan in March that includes aggressive technology deadlines. (See Kelso’s Strategic Plan). Kelso is also considering whether running one network for both medical and corrections applications would be faster and cheaper. “The vision of the new people may be different,” Marshall allows. “But it’ll all go forward.” He’s confident.

So far he hasn’t been told to stop any projects.

An Enterprise on Probation

California citizens consistently vote tough on crime-mandated minimum sentences, three-strikes laws and strict punishment for probation violations. Still, broken-down prisons are just as consistently underfunded and understaffed, state and federal analyses show. And the state overall remains intermittently paralyzed by budget crisis after budget crisis, going on two decades.

About the California Department of Corrections

• Highest-ranking executive: Secretary James Tilton
• IT executive: Joseph Panora, assistant secretary, enterprise information services

The Prisons

• Number of prisons: 33
• Designed capacity: 82,936 inmates
• Population over designed capacity: 194%
• 2007 budget: $8.75 billion
• Staff: 57,641
• Oldest prison: San Quentin, a multiple-security facility built in 1852. Includes the state’s only death row. Population exceeds designed capacity by 174%.
• Newest prison: Kern Valley State Prison, a maximum-security facility opened in 2005. Population exceeds designed capacity by 200%.

The receivership has progressed at the prisons where the state had, or could, not. Incompetent doctors, some exposed as unlicensed or under disciplinary action, have been fired. The way care occurs has gotten better; San Quentin’s intake process is one example. New construction, with plans for more, is under way at many prisons. Some software, hardware and networks have been upgraded, or in some cases installed for the first time, in various institutions.

The receivership has spent more than $20 million so far, according to a report in February from the state Office of the Inspector General, with about $8.7 million of it going to IT, systemwide, and construction at San Quentin specifically. Maxor has been paid $2.8 million so far, the report says.

But still health care in prisons throughout California “remains below constitutional standards,” Henderson wrote when he removed Sillen.

Other courts have noticed. One San Francisco Superior Court judge recently ruled that a jewel thief with Crohn’s disease didn’t have to go to state prison. He could instead start his 12-year sentence in county jail. The judge, Hummel says, “felt that within 12 years, it was a reasonable thing in treating Crohn’s disease that the inmate would die by medical neglect.” An appeals court overruled the decision, acknowledging the poor healthcare system but saying one cannot conclude “that all persons with serious medical problems…will in fact receive constitutionally inadequate medical care.” A lawyer for the thief told a San Francisco newspaper he plans to appeal.

Meanwhile, the tally of what Henderson calls “needless” death has not dropped. Sixty-six inmates died of preventable or possibly preventable causes in 2006, the latest year for which statistics are available, according to a federal audit. Death row is safer: Just 14 people have been executed in the past 28 years.