California’s prison healthcare mess

The continuing saga of federal court efforts to reform medical care in California’s prisons is a textbook example both of why constitutional courts are unpopular in this country and why we need them. At a hearing Monday, a panel of three federal judges will consider whether the governor and comptroller should be held in contempt of court for failing to provide a cash down payment of $250 million on an $8-billion court-ordered plan to build seven medical facilities for prisoners.

The political timing for this shootout couldn’t be worse if Stephen King had written the script. The U.S. is in the middle of a financial meltdown in which short-term cash for even creditworthy states is endangered. Meanwhile, California’s finances are imploding. The state just passed a budget that cuts spending programs for the poor and the elderly and engineers accounting strategies last seen at Enron.

So now three federal judges demand that California pay out $8 billion to serve rapists and drug pushers ahead of the fiscal and service needs of innocent citizens. How can such an outrage be justified?

The start of this story is the extraordinary growth of prisons in the Golden State -- just under a 700% expansion in less than a generation. The 172,000 prisoners in this system would be the state’s 28th largest city if they were in a central location instead of spread over 33 isolated locations, usually far from medical centers. The cost of this penal explosion has not been modest -- a $10.3-billion operating budget this year alone -- but building and staffing prisons has been the dominant public priority in California since the early 1980s.

The medical problems of California prisoners have been growing even faster than the inmate population. AIDS has provided one set of dangerous complications. Longer prison terms also guarantee an aging and less healthy population.

While filling prisons has been a political priority in California, the care and feeding of convicted criminals hasn’t. The result is dozens of dungeons without any programs of improvement or work for prisoners, and they have been stuffed more than full. The state has just passed a $7.1-billion prison expansion package, but it made no investment in the long-deferred medical facilities. That was democracy at work: Only the control and punishment of criminals carries any priority with the average citizen.

In this court case, two matters are beyond controversy. There is and must be a constitutional duty imposed on states to provide the inmates they lock up with decent medical care. Imprisonment forces the inmate into a total dependency on the state, and once the state chooses to impose this dependence -- as California has on more individuals than any other state -- it cannot abuse its absolute power.

It is equally clear that the current dysfunctional mess of medical services in the California system is dangerously below any civilized minimum standard. The court found that medical neglect in the prisons was not infrequently the cause of unnecessary deaths. The irony here is that inadequate medical care is responsible for far more deaths in 33 prisons than the underemployed executioner at San Quentin. You will read excuses for inaction in this newspaper from the people in charge of the prison system -- but no credible assertion that the state is doing its duty.

But do we really need a federal court to come in and demand that the state fix this mess now? The test question here is how long would it take for the state’s political process to make reform of prison health services a multibillion-dollar priority? One millennium or two? When discrete and unpopular minorities are at risk of exploitation in the political system, it often will be necessary for the legal system to save the minorities (and our standard of civilized government) from the consequences of punitive populism. As long as California continues to build and fill prisons, its government must be compelled to pay the full cost of those prisons before any discretionary spending.

Prison medical care is yet another problem on which government leaders know better than they do. The Legislature may not be able to pass a budget to do the right thing, but a substantial number of well-informed people in Sacramento know that the system must be repaired. When the state is in fiscal crisis, however, they lack the power or the will to push it through.

So perhaps there is less of an angry struggle between the governor and the judges than seems apparent. When governmental actions are necessary but unpopular, external pressure like a court order can provide political cover to do the right thing by giving politicians a federal court to blame for it.

And that is one reason why I suspect a settlement may be closer than the current posturing suggests. There are plenty of decent people in the executive and legislative branches of California’s government who are silently grateful that federal courts have the authority and the courage to rescue this state from its populist excesses.

Franklin E. Zimring is a professor of law at UC Berkeley.