TO:AJLM
FROM:Jeff Cravens
RE:Note Final Draft
DATE:April 8, 2010
Obstacles to the Judicial Overhaul of California’s Prison Health Care System
In 1995, the U.S. District Court for the Eastern District of California found that the California Department of Corrections and Rehabilitation (“CDCR”)’s inadequate mental health care system violated the Eighth Amendment rights of state prisoners suffering from serious mental disorders and appointed a Special Master to remedy the constitutional violations.[1]
Ten years later, the U.S. District Court for the Northern District of California found the CDCR’s medical care system “broken beyond repair” and granted control of the system to a judicially appointed Receiver to oversee comprehensive reforms ensuring constitutionally adequate care for the state’s 165,000 inmates.[2]
The Receiver and Special Master ordered sweeping reforms, but California legislators and administrators failed to implement or fund the judicial decrees.[3] Meanwhile, California’s prison population ballooned to 200% of design capacity, prompting Governor Arnold Schwarzenegger to declare a state of emergency with twenty-nine of the state’s thirty-three prisons posing a “substantial risk to the health and safety” of inmates and corrections staff.[4]
In light of this crisis and the ongoing failure of the Special Master and Receiver to rectify the constitutional violations, a three-judge court, including the judges in the Coleman and Plata cases, convened to determine a new remedy under the Prison Litigation Reform Act (“PLRA”).[5] Finding overcrowding to be the primary cause of the unconstitutional health care conditions in the CDCR, the court ordered what it considered the only adequate remedy: a state prison population cap at 137.5% of design capacity, which would require the release of approximately 46,000 inmates (about a quarter of California’s prison population) by 2012.[6]
This drastic remedy, combined with the prior establishment of the federal Receiver and Special Master, reflects an unprecedented attempt by the federal judiciary to overhaul a state’s prison health care system. The efforts by the consolidated Coleman and Plata courts in California, regardless of the Supreme Court decision whether to uphold the three-judge court’s prison reduction order in its upcoming term, reveal the substantial legal and public policy obstacles to obtaining constitutionally adequate health care in state prisons through judicial means.
Part I of this paper will review the history of the constitutional right to prison health care under the Eighth Amendment and the underlying lawsuits in Coleman and Plata and. Part II will explore the Coleman, Plata, and the three-judge court decisions, including their application of the correct legal standards in proving and remedying the “cruel and unusual punishment” in California’s prison health care systems. Part III will identify three obstacles hindering the judiciary’s attempt to provide constitutionally adequate health care in the CDCR, including: (1) the restrictive procedural and substantive requirements of the PLRA; (2) the limited scope and effectiveness of the population reduction order; and (3) the refusal of the California legislature to support prison reform. Finally, Part IV will offer recommendations for overcoming the above obstacles to provide constitutionally adequate health care in the CDCR and other states prison systems.
- TheConstitutional Right to Prison Health Care, Coleman, and Plata
Despite the recent enactment of federal health care legislation, prisoners remain the only population in America with a constitutional right to health care.[7] In Estelle v. Gamble, the Supreme Court established this right, reasoning: “[i]t is but just that the public be required to care for the prisoner, who cannot by reason of the deprivation of his liberty, care for himself.”[8] In the underlying case, a Texas state prisoner brought a complaint alleging that a prison medical director and other prison officials subjected him to cruel and unusual punishment in violation of the Eighth Amendment by inadequately treating his back injury.[9] The Court did not find a violation, at least with respect to the medical director, but held that “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ proscribed by the Eighth Amendment.”[10]
The Court acknowledged that while the drafters of the Eighth Amendment were originally concerned with “torture(s)” and other “barbar(ous)” punishments, the amendment now prohibits less egregious punishment.[11] Thus, when denial of medical care in prison results in pain and suffering that does not serve any penological purpose, such punishment violates the amendment because it “offends the evolving standards of decency that mark the progress of a maturing society.”[12] However, although a prison doctor’s accident or negligencemay constitute medical malpractice, the doctor’s actionsdo not constitute a valid Eighth Amendment claim “merely because the victim is a prisoner.”[13]
Five years later, Rhodes v. Chapman elaborated on the objective prong of the Estelle “deliberate indifference” standard.[14] In holding that “double celling” (the practice of housing two inmates in a single cell) of Ohio prisoners did not constitute cruel and unusual punishment, the Court cited Estelle’s reliance on the contemporary standard of decency, such as the recognition by the common law and state legislatures that “[a]n inmate must rely on prison authorities to treat his medical needs.”[15] The Court noted that, when determining the contemporary standard of decency, “generalizedopinions of experts cannot weigh as heavily . . . as ‘the public attitude toward a given sanction.’”[16]The Court also referred to its prior decisions in capital punishment cases, where it looked at “objective indicia” from history, state legislatures, and jury sentencing to determine whether a punishment comported with the contemporary standard of decency.[17] The Court found that conditions that are not merely “restrictive” or “harsh” but that “deprive inmates of the minimal civilized measure of life’s necessities” may offend this standard of decency. However, the Court held that double celling in the circumstances at issue, while submitting prisoners to cramped conditions, did not deprive them of “essential food, medical care, or sanitation” or inflict on them “unnecessary and wanton pain.”[18]
Wilson v. Seiter elucidated the subjective prong of the “deliberate indifference” standard.[19] The Court held that to establish an Eighth Amendment violation, prison officials must act with a state of mind characterized as “obduracy and wantonness, not inadvertence or error in good faith.”[20] This state of mind requirement applies to acts of individual prison officials as well as to system-wide conduct regarding prison conditions or medical care.[21] In assessing system-wide conditions, the long-standing existence of a “cruel prison condition may make it easier to establish knowledge and hence some form of intent,” but does not itself satisfy the requisite state of mind to establish an Eighth Amendment violation.[22]
In Farmer v. Brennan, the Court equated this state of mind with “subjective recklessness, as used in the criminal law.”[23] Accordingly, in this particular case, the Court held that prison officials displayed deliberate indifference by placing a transsexual inmate in the general population because officials knew the inmate faced a substantial risk of serious harm and disregarded that risk by failing to take “reasonable measures to abate it.”[24]
The deliberate indifference standard announced by the Court in the above cases has appeared in lower federal courts across the country. But no state has witnessed more prolonged and expensive litigation over prison health care than California, as demonstrated by the following two cases.
B. Coleman v. Wilson (later Coleman v. Schwarzenegger): Mental Health Care
In 1991, California state prisoners with serious mental disorders brought a class action against Governor Pete Wilson and state prison leaders under 42 U.S.C. § 1983, alleging that the CDCR provided constitutionally inadequate mental health care in violation of the Eighth and Fourteenth Amendments.[25] The court found that CDCR’s mental health care system violated the Eighth Amendment’s prohibition against cruel and unusual punishment for several reasons[26] and ordered recommendations to remedy the violations, such as the “development and use of standardized screening forms andprotocols” and the “development and implementation of medication protocols.”[27] In addition, the court ordered the magistrate judge below to appoint a Special Master pursuant to Federal Rule of Civil Procedure 52(c) to monitor the implementation of the court-ordered remedies.[28]
The Special Master, appointed on December 11, 1995, helped defendants develop a plan to cure the constitutional deficiencies in the CDCR’s mental health care system, monitored defendants’ compliance with the remedial Coleman court orders, and periodically submitted progress reports to the court.[29] Nevertheless, in 2006, after ten years of remedial action and during a substantial increase in California’s prison population, the Special Master reported that “serious shortages in staffing and bed space” persisted in the CDCR.Moreover, the defendants “still lacked clinical resources to meet the needs of some 25 to 30 percent of inmates identified as seriously mentally disordered.”[30] By the time the Coleman court called for a prison release order in 2009, the Special Master had filed twenty monitoring reports and fifty-six other reports and the Coleman court had issued over seventy remedial orders.[31] Yet, the state’s mental health care system remained unconstitutional, with the state unable to meet about a third of its acknowledged mental health needs due to understaffing, lack of mental health treatment beds, and programming space.[32]
B. Plata v. Schwarzenegger: Medical Care
On August 21, 2001, California state prisoners filed an amended class action alleging that the CDCR’s medical care system caused “widespread harm, including severe and unnecessary pain, injury and death,” and was thus unconstitutional.[33] The complaint alleged a list of systemic deficiencies, including inadequacies in: screening of new prisoners; response to emergencies; staffing; medical records; quality control; and grievance procedures.[34]Plaintiffs and defendants, who had been negotiating informally since 1999, agreed to a stipulation for injunctive relief to be fully implemented by the end of 2008.[35] The stipulation, consisting of eight hundred pages of policies and procedures, included comprehensive reforms ranging from medication administration systems to annual death reviews.[36]
However, as of May 2005, when twelve prisons were scheduled to have completed implementation, “not a single prison ha[d] successfully completed implementation.”[37]The Plata court concluded at an evidentiary hearing that “it is beyond reasonable dispute that the State has failed” to achieve constitutional standards in its medical system.[38] Consequently, the court appointed a federal Receiver in 2006 (and a replacement in 2008) with broad authority to restructure and oversee all aspects of the CDCR’s medical care system in order to bring it up to constitutional standards.[39]Nevertheless, despite limited improvements in medical staffing, inmate screening, and pharmacy capabilities, constitutional violations persisted.[40] In light of these this continuing failures, the plaintiffs and courts turned to a more drastic remedy.
C. Population Reduction Order—Coleman and Plata Consolidated
Plaintiffs in Coleman and Plata, dissatisfied with California’s failure to cure the constitutional violations in its mental health and medical care systems, motioned to convene a three-judge court to consider issuing a prison release order.[41] Under the PLRA, a court may convene a three-judge court to consider this remedy if:
“(i) a court has previously entered an order for less intrusive relief that has failed to remedy the deprivation of the Federal right sought to be remedied through the prisoner release order; and
(ii) the defendant has had a reasonable amount of time to comply with the previous court orders.”[42]
Finding these conditions satisfied, the court granted plaintiffs’ motion to convene the three-judge court.
The court, including the Coleman and Plata judges, was authorized to grant a prison release order under the PLRA if it found “by clear and convincing evidence that (i) crowding is the primary cause of the violation of a Federal right; and (ii) no other relief will remedy the violation of the Federal right.”[43]After looking at expert evidence, conducting its own prison reviews, and considering relevant studies, the three-judge panel concluded that “overcrowding [was] the primary cause of the unconstitutional denial of adequate medical and mental health care to California's prisoners.”[44]
As required by the PLRA, the court explored less intrusive alternatives to a prison release order, such as the ongoing efforts by the Special Master and Receiver.[45] The court found that no such alternatives would suffice and that a prison release order was necessary and narrowly tailored to remedy the constitutional violations in the CDCR.[46] The court acknowledged that reducing the prison population would not alone assure constitutionally sufficient health care but that it was a necessary precondition to achieving this goal.[47]
Under PLRA requirements, the court also found, after consulting prison and law enforcement officials, that the order would not adversely impact public safety or the operation of California’s criminal justice system.[48] The court agreed with experts that California could safely reduce its prison population, which was overpopulated in part because of “unnecessary and unproductive” policies such as “returning most technical parole violators to prison and denying judges” flexibility in sentencing.[49]Accordingly, the court ordered a reduction of the California prison population to 137.5% of design capacity in two years, requiring the likely release of about 46,000 inmates.[50] The court noted that implementing recommendations by a CDCR expert panel to “divert technical parole violators, implement parole reform, and expand good time credits” would reduce California’s prison population by 38,500 to 43,500 inmates.[51]
California appealed the order, challenging: the court’s jurisdiction to issue a prisoner release order under the PLRA; its finding that overcrowding was the primary cause of ongoing constitutional violations; and its holding that a prison release order is narrowly tailored and does not adversely affect public safety and California’s criminal justice system.[52] Republicans from the California state legislature intervened on behalf of California, and eighteen other states submitted an amicus brief supporting the state’s opposition to the prison release order.[53] The Supreme Court is scheduled to hear the case in its 2010 - 2011 session.[54]
- Coleman and Plata Application of the Deliberate Indifference Standard
A. Coleman: Mental Health Care
When finding California’s mental health care system unconstitutional in 1995, the Coleman court satisfied the objective component of the deliberate indifference standard by finding deficiencies in the “six basic, essentially common sense, components of a minimally adequate prison mental health care delivery system.”[55] As a result of these systemic deficiencies, such as the lack of mental health screening protocol or competent medical staff, the court found that “thousands of inmates suffering from mental illness are either undetected, untreated, or both.”[56] Accordingly, the court found the objective prong of the deliberate indifference standard clearly satisfied.[57]
In satisfying the subjective prong of the deliberate indifference standard, the court applied the Farmer “recklessness” state of mind test by finding “(1) that defendants knew that inmates face a substantial risk of harm as a result of the systemic deficiencies noted above and (2) that defendants have disregarded that risk by ‘failing to take reasonable measures to abate it.’”[58] In making this determination, the court assessed prison authorities’ state of mind in light of their “current attitudes and conduct.”[59] The court inferred the authorities’ knowledge of the substantial risk of harm to prisoners from “the very fact that the risk was obvious,” a rebuttable presumption that prison officials did not disprove.[60] The court concluded that seriously mentally ill prisoners face an “objectively intolerable risk of harm as a result of the gross systemic deficiencies” in the CDCR and have “suffered significant harm as a result of those deficiencies.”[61] The court denied defendants’ arguments that they took reasonable steps to rectify these deficiencies, stating that “patently ineffective gestures purportedly directed towards remedying objectively unconstitutional conditions do not prove a lack of deliberate indifference, they demonstrate it.”[62]
B. Plata: Medical care
The Plata court, in appointing a federal Receiver to take over California’s prison health care system, did not carefully apply the deliberate indifference standard from Estelle and Farmer but did rely on objective and subjective criteria.[63]The court recounted findings by medical experts that the CDCR’s failure to implement stipulated reforms placed prisoners in “serious risk of harm or death,” with a California inmate dying needlessly “every six to seven days due to constitutional deficiencies in the CDCR’s medical delivery system.”[64] The court summarized factual findings of objective deficiencies in fifteen areas, ranging from lack of qualified medical staff to insufficient chronic care.[65] For example, in the area of staffing, the court noted that 80% of higher management positions in the CDCR’s health care division were vacant.[66] In the area of medical facilities, the court found that many prison clinics lacked basic medical equipment and failed to meet basic sanitation standards. For example, a San Quentin medical examination room, where about a hundred men per day underwent medical screening, lacked a sink, alcohol, and other means of sanitation.[67]
The Plata court did not refer to the subjective prong of the deliberate indifference standard but nevertheless established defendants’ requisite state of mind under this standard.[68] In appointing an interim Receiver, the court stated: “The prison medical delivery system is in such a blatant state of crisis that in recent days defendants have publicly conceded their inability to find and implement on their own solutions that will meet constitutional standards.”[69] Court experts, after conducting prison investigations, concluded that the CDCR’s compliance with previously stipulated remedies was “non-existent” in some prisons and that the CDCR demonstrated “indifference” to the compliance process.[70] The court acknowledged this indifference in threatening to hold defendants in contempt and in appointing a Receiver to take over the prison health care system.[71]