Overview and Update on the Prison Receivership

AN LAO REPORT Overview and Update on the Prison Receivership GABRIEL PETEK | LEGISLATIVE ANALYST | NOVEMBER 2023 Summary California’s prison medical system has been under direct management of a Receiver appointed by a federal court since 2006 because the state was found to be providing unconstitutional levels of care in a case now referred to as Plata v. Newsom. Since the establishment of the Receivership, the Receiver has implemented significant changes in the delivery of prison medical care in order to bring the state into compliance with constitutional standards. In this brief, we provide an overview of the establishment of the Receivership and the key changes to prison medical care made by the Receiver to date. In addition, we provide a summary of the key steps that the state needs to complete in order to exit the Receivership as outlined by the federal court. Finally, we raise some issues for legislative consideration related to the Receivership. Receivership Established in 2006 on average, one person died every week in state prisons and that many more had been injured by Federal Court Found State Provided the lack of reliable access to quality medical care. Inadequate Prison Medical Care. In 2001, In addition, a federal three-judge panel—created a class-action lawsuit, later renamed Plata v. at the request of plaintiffs in both the Plata case Newsom, was filed in federal court contending and the case now known as Coleman v. Newsom the state violated the Eighth Amendment of the (involving prison mental health care)—in 2009 ruled U.S. Constitution prohibiting cruel and unusual that the state must reduce prison overcrowding as punishment by providing inadequate medical care in it was the primary reason that CDCR was unable to the state’s prisons. The state agreed in 2002 to take provide adequate health care, which was upheld by a series of actions to address the deficiencies in the U.S. Supreme Court. (See the box on the next order to settle the case. These actions included page for additional details on this ruling.) hiring additional medical staff, auditing prison medical records, and staffing emergency clinics in Federal Court Appointed Receiver to Take prisons 24 hours a day year-round. An estimated Over Management of State Prison Medical $194 million was added to the state budget from Care. In February 2006, a few years prior to the 2002-03 through 2006-07 to address the problems state’s fiscal crisis caused by the Great Recession, identified in prison medical care. However, upon the federal court appointed a Receiver to take further review of the state’s performance, the over the direct management and operation of federal court found that the state had failed to the state’s prison medical system from CDCR. comply with its orders. Specifically, the court The appointment of a Receiver is a legal remedy found, among other problems, that the California in lawsuits seeking to reform jails and prisons that Department of Corrections and Rehabilitation is typically used as a last resort by courts. Courts (CDCR) prison medical system was poorly managed; appoint a Receiver in order to place a neutral expert provided inadequate access to medical care; had in control of some aspect of prison or jail operations. deteriorating facilities and disorganized medical The Receiver appointed by the Plata court has record systems; and lacked sufficient qualified a mandate to bring the department’s provision physicians, nurses, and administrators to deliver of medical care into compliance with federal medical services. The court concluded that, constitutional standards. To do so, the federal www.lao.ca.gov 1 AN LAO REPORT Federal Court Orders State to Reduce Prison Overcrowding In November 2006, plaintiffs in the cases now known as Plata v. Newsom (involving prison medical care) and Coleman v. Newsom (involving prison mental health care) filed motions for the federal courts to convene a three-judge panel pursuant to the U.S. Prison Litigation Reform Act to determine whether (1) prison overcrowding was the primary cause of the California Department of Correction and Rehabilitation’s (CDCR’s) inability to provide constitutionally adequate prison health care and (2) a prison release order was the only way to remedy these conditions. In August 2009, the three-judge panel declared that overcrowding was the primary reason that CDCR was unable to provide adequate health care. Specifically, the court ruled that, in order for CDCR to provide such care, overcrowding would have to be reduced to no more than 137.5 percent of the design capacity of the prison system. (Design capacity generally refers to the number of beds that CDCR would operate if it housed only one person per prison cell and did not use bunk beds in dormitories.) At the time of the three-judge panel ruling, the state prison system was operating at roughly 188 percent of design capacity—or about 39,000 people more than the limit established by the three-judge panel. Since that time, the state implemented various policy changes—such as shifting responsibility for various felony populations from the state to the counties through the 2011 realignment—that significantly reduced the prison population. As a result of these actions, the state prison population has been below the 137.5 design capacity limit since February 2015. As of August 30, 2023, the state’s prison population is about 14,000 people below the limit established by the court. court suspended the authority of the Secretary of provide funding for proposals in cases where the CDCR for prison medical care and provided the Receiver believes it to be necessary. Receiver with executive authority in hiring and firing Changes to Prison Medical medical staff, entering contracts with community providers, and acquiring and disposing of property. Care Under the Receivership In addition, the court granted the Receiver the To remedy the issues identified by the courts, authority to “determine the annual CDCR medical the Receiver has changed various aspects of health care budgets” and to spend money to prison medical care. Many of the changes received implement changes in medical care. The court funding through the state’s annual budget process. requires the state to pay “all costs incurred in the Below, we highlight a few of the significant changes implementation of the policies, plans, and decisions to prison medical care under the Receivership of the Receiver.” In addition, the Receiver has the (see Figure 1). authority to seek waivers through the court of any Construction of Various Health Care state or contractual requirements that are impeding Facilities. Among the obstacles to providing a progress in improving the prison medical system. constitutional level of care identified by the court However, the creation of the Receivership did were inadequate and insufficient health care not change the Legislature’s role of authorizing facilities. In order to address this, the Receiver positions and appropriating funds for, enacting initiated the construction of health care facilities legislation related to, or exercising oversight of throughout the prison system. These projects prison medical care. For example, each year the were funded both directly from the General Fund Receiver requests funds for proposals through the and borrowing through lease revenue bonds, budget process. The Legislature can and has made which are gradually repaid with interest each year changes to these proposals. However, the Receiver from the General Fund. Some of the major facility may request a court order to require the state to initiatives include: 2 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT Figure 1 Significant Changes to Prison Medical Care Under Receiver  Construction of Various Health Care Facilities  Creation of Integrated Substance Use Disorder Treatment Program  Implementation of Information Technology Improvements  Changes to Pharmaceutical Services  Changes to Improve Recruitment and Retention  Changes to Supervision of Prison Medical Care Staff  Initiation of Office of Inspector General Medical Inspections • Health Care Facility Improvement Program construction, the Receiver indicated the (HCFIP)—$1.5 Billion. HCFIP is a collection facility was necessary to increase CDCR of 31 projects at various prisons to address health care capacity and create efficiencies medical infrastructure deficiencies across by consolidating the population needing the state prison system. According to the the highest levels of care. The facility has a Receiver, these projects are necessary to design capacity of about 3,000 beds largely support timely, competent, and effective for medical and mental health services health care delivery. Projects vary in scope in both inpatient and outpatient settings. and have included construction of new The construction of CHCF started in 2011 and medical buildings that expand treatment was completed in 2013. The state authorized capacity; renovation of existing buildings; and about $900 million in lease revenue bonds for ancillary improvements at facilities, such as the project and spends about $660 million adding clinic workstations for staff or creating annually to operate the facility. soiled and clean utility rooms for infection • Medication Rooms—$90 Million. control. The first project started in 2007 and Medication rooms are rooms inside of or near all projects were originally scheduled to be housing units where medication is prepared completed by 2017. However, the projects and/or distributed to patients. Since being have required numerous changes from appointed, the Receiver has identified various their original design due to various factors, shortcomings with CDCR’s medication rooms. including errors during the design process As a result, medication rooms are being and other changes necessary to bring the constructed or improved at most prisons in projects into compliance with fire, life, and two phases. Phase one started in 2012 and is safety requirements. As a result, 22 of the expected to be completed before the end of 31 projects are currently complete, with the 2023. Phase two is currently underway with remainder expected to be completed by 2025. the last project expected to be complete by The state has authorized a total of about the end of 2024. The state has dedicated a $1.5 billion, primarily in lease revenue bonds, total of about $90 million for the two phases. for these projects. Creation of Integrated Substance Use • California Health Care Facility (CHCF)— Disorder Treatment Program (ISUDTP). ISUDTP $900 Million. CHCF in Stockton was was first funded for systemwide implementation designed to provide care to people with in 2019-20 to provide a continuum of care to the most severe medical and mental people in prison to address their substance use health conditions in prison. At the time of disorder (SUD) and other rehabilitative needs. www.lao.ca.gov 3 AN LAO REPORT This program was spearheaded by the Receiver their prescriptions in a timely manner. To address and received funding for medical positions to these deficiencies, the Receiver took several steps support the implementation. Prior to ISUDTP, to standardize and centralize pharmaceutical CDCR generally assigned people to SUD treatment practices across the prison system. For example, based on whether they had a “criminogenic” the Receiver established a drug formulary to need for the program—meaning the person’s improve consistency in prescribing practices and SUD could increase their likelihood of recidivating introduced a central-fill pharmacy to coordinate (committing a future crime) if unaddressed through pharmaceutical services across prisons. Notably, rehabilitation programs. In contrast, ISUDTP is from 2004-05 (the year before the Receivership) designed to transform SUD treatment from being through 2021-22 (the most recent year for which structured as a rehabilitation program intended to complete data exist), the pharmaceutical budget reduce recidivism into a medical program intended increased from $212 million to $319 million after to reduce SUD-related deaths, emergencies, and adjusting for inflation—an increase of 50 percent. hospitalizations. For example, under ISUDTP, (The pharmaceutical budget reflects only the cost medication assisted treatment is made available at of pharmaceuticals and not the cost of medication all prisons to people with an assessed SUD need. management or administration.) The level of The state currently spends about $281 million inflation-adjusted spending on pharmaceuticals annually on ISUDTP. per person also increased over this time period Implementation of Information Technology from $1,300 in 2004-05 to $3,200 (more than (IT) Improvements. The federal court found double) by 2021-22. that the IT (such as electronic files that track Changes to Improve Recruitment and appointments) to complete essential medical care Retention. The court expressed concern about tasks was “practically non-existent” in California vacancy rates in medical positions and noted that prisons. To address these deficiencies, the there were vacancy rates as high as 80 percent Receiver procured various IT systems. The largest for registered nurses at some prisons. To reduce of the IT projects was the Electronic Health Record the chronic medical vacancies, the Receiver System (EHRS). The EHRS was developed to increased salaries across several medical provide an electronic health record for each patient positions to be more competitive and to improve that would (1) be available at all prisons, (2) eliminate recruitment and retention. In order to expedite the need for paper files that must be transported the salary increases that are typically subject to between prisons, (3) provide real-time data on bargaining agreements between the state and the level of care provided, and (4) standardize a union, the Receiver used executive authority and coordinate medical record entries that were to waive state laws and regulations in 2006 to previously difficult to access in the paper-based increase the compensation levels of medical staff system. Development of the EHRS began in 2013 between 5 percent and 64 percent. For example, and was first implemented statewide in 2017, with the Receiver increased physician base pay from additional improvements to the system in later $150,000 to as much as $300,000. The state years. The has state dedicated a total of about provided about $30 million in 2007-08 for these $400 million to the project including the addition salary increases. The Receiver has also increased of functionality after completion. The state spent work flexibility to improve recruitment, such as about $34 million in 2022-23 to operate the EHRS, expanding the use of telemedicine in CDCR, including maintenance and vendor licensing fees. which is the delivery of health care via interactive Changes to Pharmaceutical Services. When audio and video technology. This allows staff to establishing the Receivership, the federal court be hired in areas where medical providers are found that there were “serious, long-standing easier to recruit while allowing such providers problems with dispensing medication, renewing to treat people in remote prisons. The efforts to prescriptions, and tracking expired prescriptions” improve recruitment and retention have resulted in and that chronically ill patients were not able to refill reduced vacancies, though CDCR still has difficulty 4 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT recruiting permanent state civil service employees. evaluate nursing staff and review any departures This has often required the Receiver to rely on from standards in prison nursing care. contract staff—rather than permanent state civil Initiation of Office of Inspector General service employees—to address workload when (OIG) Medical Inspections. At the request of the there are vacancies. Despite the use of contract federal court and the Receiver, the OIG—which is staff, vacancies in many medical positions remain tasked with conducting various types of oversight notably high, as shown in Figure 2. of CDCR—developed an inspection program Changes to Supervision of Prison Medical to evaluate the quality of medical care at each Care Staff. The federal court found “that the prison. These inspections result in the care at each lack of supervision in the prisons is a major prison being classified as proficient, adequate, contributor to the crisis in CDCR medical delivery.” or inadequate and serve as an additional tool for Accordingly, the Receiver has established about the Receiver to monitor medical care. In 2008, the 200 new executive medical positions to oversee OIG began its statewide inspections using teams medical operations within prisons and statewide. of physicians, registered nurses, deputy inspector In doing so, the Receiver geographically grouped generals, and analysts. In 2011, the Legislature prisons to establish prison health care regions. codified in statute the OIG’s medical inspection Each region was established with dedicated staff function. To date, the OIG has completed six audit to provide oversight, coordination, and additional cycles. As of October 2023, there are no prisons support to the prisons in the region. In addition, at categorized as proficient, 23 as adequate, and both the prison and headquarter level, the Receiver 11 as inadequate. While the state has spent about created managerial positions to establish more $3.8 million annually on the medical inspection clear lines of accountability among the health unit, the 2022-23 budget included an additional care staff working in the prisons. Additionally, the $3.3 million annually for three years to increase processes for providing supervision to medical staffing in order to reduce the amount of time staff changed as well. For example, the Nursing medical inspections take to complete. The OIG Professional Practice Program was established to reports that this funding will allow it to complete an audit cycle in two rather than three years. Changes in Prison Figure 2 Medical Care Some Medical Classifications Have Notable Vacancies Rates Spending and Vacancy Rate Staffing Under the Receivership 100% State Spending Has 90 Increased Substantially 80 Since the Receivership. 70 As a result of the various 60 changes initiated by 50 the Receiver, including 40 those discussed above, 30 state spending on 20 35% prison medical care has 10 24% 24% increased substantially since 2005-06 (the first Statewide Medical Dietary Services Nursing Vacancies year of the Receivership). The state spent about June 2023 $1.3 billion from the General Fund—about www.lao.ca.gov 5 AN LAO REPORT $7,400 per person in prison—on medical care in increased. Specifically, CDCR staffing of health 2005-06, adjusted for inflation. In contrast, the care positions has increased from about 3 positions state spent about $3.3 billion (more than double) for every 100 people in prison in 2005-06 to about and $32,700 per person (four times more) in 15 positions for every 100 people in 2021-22. 2021-22. (We note that about $170 million of this Exiting the Receivership—Steps increase is due to spending related to the COVID-19 pandemic in 2021-22.) As shown in Figure 3 Specified by Federal Court below, inflation-adjusted spending on medical care Several orders have been issued by the Plata increased every year over this time period, with the court outlining the benchmarks that must be met for exception of 2009-10 and 2010-11—when spending the state to take full responsibility for prison medical was reduced in response to the Great Recession— care back from the Receiver. The most recent court and 2012-13—when spending declined due to a order, issued in October 2021, supersedes the reduction in the prison population associated with previous orders and clarifies the current procedure the 2011 realignment. to end the Receivership and terminate the Plata Prison Medical Staffing Has Also Increased court case. Below, we summarize the steps that the Substantially. A significant portion of the increased court has indicated the state must complete before spending is related to increases in staffing. This exiting the Receivership. is because the number of prison health care State Must Adopt Laws and Regulations to positions (including medical staff such as doctors Reduce or Eliminate Need for Waivers. When and nurses) per person in prison has dramatically the Receivership ends, the executive authority used Figure 3 Prison Medical Care Spending Has Increased Medical Care Expenditures in 2022 Dollars (In Billions) $3.5 $35,000 Expenditures Per Person 3.0 30,000 2.5 25,000 Total Expenditures 2.0 20,000 1.5 15,000 1.0 10,000 0.5 5,000 2005-06 2007-08 2009-10 2011-12 2013-14 2015-16 2017-18 2019-20 2021-22 Personal Consumption Expenditures Health Index. 6 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT by the Receiver to waive state laws and regulations delegate all existing headquarter and systemwide will expire. Accordingly, the October 2021 order functions under the authority of the Receivership specifies that the state and the Receiver shall back to the state. The Receiver’s staff indicated implement any changes in laws and regulation that 14 headquarter and systemwide functions necessary to eliminate the need for the waivers remain to be delegated. Some of these systemwide implemented by the Receiver as much as possible. functions include managing and overseeing As such, there may need to be various changes prison medical and nursing services, human made to CDCR regulations and state law prior resources activities, as well as quality and risk to the end of the Receivership. For example, the management. To date, the Receiver has delegated Plata court waived laws that specify disciplinary two systemwide functions: construction and proceedings of state employees and established activation of prison health care infrastructure and new policies related to the delivery of prison the procurement of medical vehicles. However, no medical care as proposed by the Receiver. It is additional systemwide delegations have happened possible that some of the changes will be need to since 2012. Based on conversations with Receiver be made permanent through modification to statute staff, the Receiver could delegate responsibility or regulations. for headquarter and systemwide functions on a Receiver Must Delegate Responsibility piecemeal basis or all at once. for Each Prison Back to the State. Over the Receivership Ends One Year After past decade, the court has refined the process Delegations and After Post-Receivership Plan for assessing the adequacy of medical care at Established. After delegation of individual prisons individual prisons. The current process requires as well as headquarter and systemwide functions to plaintiffs in the Plata case, CDCR staff, and the state, the Receiver continues to monitor them the Receiver to meet and confer on whether for compliance and has the ability to revoke any responsibility for medical care at a specific prison is ready to be delegated back to the state. Figure 4 The Receiver identifies which prisons are suitable Prisons Delegated Back to State for these meet and confer discussions based on regular reviews of about 25 medical care indicators, 2015 Folsom State Prison including the OIG’s medical inspection reports 2016 Correctional Training Facility and medical care data collected by CDCR staff. Chuckawalla Valley State Prisona After the parties meet and confer, the Receiver California Correctional Institution Pelican Bay State Prison determines whether a prison is adequately Centinela State Prison providing medical care and can continue to do so Sierra Conservation Center without the direct management of the Receiver. California Institution for Men If the Receiver decides that a prison meets these Avenal State Prison criteria, the responsibility for medical care at the 2017 San Quentin Rehabilitation Center California Institution for Women prison is restored back to the Secretary of CDCR. Kern Valley State Prison Otherwise, the prison’s provision of medical California City Correctional Facilityb care continues to be managed by the Receiver. Pleasant Valley State Prison As shown in Figure 4, the Receiver has delegated Calipatria State Prison responsibility for care at 21 prisons to date. (We 2018 California Correctional Centerc note that one of these prisons has been deactivated California Men’s Colony Valley State Prison and two are scheduled to be deactivated.) California State Prison Corcoran Receiver Must Delegate Responsibility 2022 Wasco State Prison for Headquarter and Systemwide Medical 2023 Ironwood State Prison Functions Back to the State. In addition to a To be deactivated in 2025. delegating responsibility for care at individual b To be deactivated in 2024. prisons back to the state, the Receiver must also c Deactivated in 2023. www.lao.ca.gov 7 AN LAO REPORT delegation granted. Within 30 days of the Receiver those functions. As a result, there is no way certifying that all prisons, headquarter, and to estimate how close the Receiver is to systemwide functions have been delegated back delegating such functions back to the state. to the state, the state must file a post-Receivership • Further Health Care Infrastructure Delays plan with the court outlining how the state will Could Extend Receivership. As previously maintain a system of providing constitutionally discussed, health care infrastructure adequate medical care. The 2021 court order projects—most notably the HCFIP projects— encouraged the parties to begin meeting and have required numerous changes from conferring on such a plan. If the Receiver leaves their original design due to errors and these all delegations in place for one year after certifying changes have led to substantial delays all delegations—and the plaintiffs do not raise and cost increases. Receiver staff have additional objections at least 120 days before that indicated that the infrastructure projects are year is over—the Receivership and the Plata v. an important factor in determining whether Newsom case will end. CDCR is able to provide constitutionally adequate care. To the extent there are further Issues for Legislative Consideration delays in HCFIP projects, medication rooms, Below, we provide issues for the Legislature to or other construction projects, it could delay consider as it continues to monitor prison medical delegations of care at individual prisons, care under the Receiver. We also raise other issues which could extend the Receivership. for consideration as the state moves closer to Despite it being unclear when the Receivership exiting the Receivership. will end, the Legislature can exercise oversight Time Line for End of Receivership Unclear. to ensure the state is progressing toward the Although notable progress has been made by benchmarks specified by the courts. For example, the state, the following factors make it difficult to the Legislature could request periodic updates from pinpoint exactly when the Receivership could end: the Receiver at budget hearings on various issues • Delegation of Care at Remaining Prisons such as planned meet and confer dates and the Could Be Lengthy Process. The Receiver development of a post-Receivership plan. Such would be unlikely to delegate care at a prison hearings could help the Legislature oversee and found by OIG to be inadequate. Accordingly, facilitate the end of the Receivership. when a prison is found to be inadequate— Ensure Legislative Priorities Are Reflected as California State Prison, Sacramento in Post-Receivership Plan. As mentioned above, was in October 2022—it will not likely be CDCR will need to develop a post-Receivership delegated until OIG finds it to be adequate. plan for the court to approve. Because this plan However, under the OIGs current approach to is supposed to guide prison medical care delivery inspections, such a prison will not be reviewed after the end of the Receivership, it will likely again for roughly two years. Moreover, the have significant fiscal and policy implications for prisons that remain to be delegated will CDCR. Accordingly, the Legislature should ensure likely be those most in need of improvement. that any post-Receivership plan developed and As such, these prisons could take longer to implemented by the administration is consistent reach constitutional levels than those that with its priorities and allows for sufficient legislative have already been delegated. oversight going forward. To do so, the Legislature • Unclear When Delegation of Headquarter could require that the administration (1) provide and Systemwide Functions Could Occur. updates at various stages of the development of The most recent court order does not outline the proposed plan and (2) submit the plan to the a detailed process for delegating headquarter Legislature prior to its submission to the court and systemwide functions. According to along with an estimate of the cost of implementing the Receiver’s staff, the court provides the plan. This would allow the Legislature an the Receiver with discretion in delegating opportunity to ensure prison medical care is 8 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT delivered in a manner consistent with its priorities To the extent that the department is not able to following the end of the Receivership. maintain sufficient medical staff, it could present Prison Medical Care Will Likely a barrier to maintaining adequate care. As such, Require Ongoing Independent Oversight the Legislature will want to continue to provide Post-Receivership. After the Receivership oversight in this area. Some key metrics that the ends, there will likely be a need for some level Legislature could monitor to assess recruitment of independent oversight and evaluation of the and retention challenges in the medical workforce prison medical care provided by CDCR. Failure to include vacancy, turnover, and tenure rates; establish effective oversight mechanisms could limit the number of qualified applicants to jobs; and the ability of the Legislature to ensure that emerging well-designed compensation studies comparing problems are addressed early and the quality of CDCR pay and benefits to those offered by other prison medical care is maintained. This could result medical care providers. Monitoring such metrics in renewed litigation. Moreover, we expect that the could help the Legislature identify factors potentially establishment of independent oversight will also contributing to recruitment and retention difficulties be a priority of the federal court. Given that the and address issues as they are identified. (We note OIG already conducts prison medical inspections that under Chapter 890 of 2023 (SB 525, Durazo), and audits, it could make sense for the OIG to the minimum wage for certain health care facility continue to provide this external oversight following employees in both the private and public sectors the Receivership. However, there are other forms will increase beginning in June 2024. This will of oversight that could supplement or replace the increase CDCR staffing costs. While this could have OIG’s medical inspection monitoring. For example, an effect on prison medical vacancies, the effect is the state could rely on medical accreditation as unclear at this time.) a form of oversight. The accreditation process Prison Medical Care Infrastructure Will Need uses an external, independent body that applies to Be Considered Amid Prison Deactivations. standardized criteria to ensure that organizations As discussed above, the state implemented various provide care consistent with the criteria. policy changes that significantly shrank the prison Once accredited, an organization must continue population, allowing it to achieve compliance with to meet the quality standards every audit cycle to the federal three-judge panel court order on prison maintain its accreditation. The 2023-24 budget overcrowding. As a result of this decline in the includes $3.2 million (increasing to $6.1 million population, the state has deactivated two prisons, annually in 2027-28) to support accreditation from is in the process of deactivating two more, and The Joint Commission, which accredits about will likely be in a position to deactivate additional 80 percent of U.S. hospitals for various types of prisons in the future. While deactivating prisons can health care services. create significant savings for the state, it can also Medical Staffing Could Continue to Be affect the department’s ability to deliver adequate a Challenge. As discussed above, hiring and medical care in the remaining prisons to the extent retaining sufficient permanent state civil service prisons with unique health care infrastructure are medical staff has been a challenge for CDCR deactivated. For example, the California Health including during the Receiver’s tenure. This is Care Facility is critical to delivering adequate care. at least partially due to the fact that statewide Accordingly, the Legislature will want to ensure shortages have been identified for some of the that any future prison deactivations consider the medical classifications CDCR has trouble recruiting, medical needs of the prison population such that such as nurses. Accordingly, it is possible that the state can maintain the infrastructure necessary these challenges will persist post-Receivership. to provide constitutionally adequate medical care. www.lao.ca.gov 9 AN LAO REPORT 10 LEGISLATIVE ANALYST’S OFFICE AN LAO REPORT www.lao.ca.gov 11 AN LAO REPORT LAO PUBLICATIONS This report was prepared by Orlando Sanchez Zavala, and reviewed by Drew Soderborg and Anthony Simbol. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, California 95814. 12 LEGISLATIVE ANALYST’S OFFICE