Reporting from San Quentin -- Fifteen years ago, Jackie Clark was so disgusted with the healthcare at San Quentin prison that she quit her job there as a nurse consultant.
"We didn't have sinks. We didn't have appropriate medical equipment," she recalled recently. "We were in converted offices and converted cells."
The care there and elsewhere in California's overcrowded lockups was so poor that in 2006 a federal judge, saying that an inmate was dying unnecessarily every week, put a receiver in charge of the health system. A cascade of court decisions that followed forced the state to begin lowering the country's largest state prisoner population by almost 25%.
Today, Clark is back at San Quentin Correctional Facility as its top medical official, overseeing a new $135-million clinic that is the showcase for six years of progress. The judge who once said California's dismal prison medical care constituted cruel and unusual punishment now says federal control could soon end.
"Many of the goals of the receivership have been accomplished," U.S. District Judge Thelton E. Henderson wrote last month, ordering up a plan for transferring control back to the state.
But advocates for inmates and some medical officials question whether the system will continue to improve without federal oversight. Despite San Quentin's new clinic, many of California's 33 prisons are still stuck with outdated or cramped facilities.
State officials say they are ready. Subpar doctors have been replaced with board-certified physicians. The state is converting reams of paper files into digital records, and aging computers have been tossed. Prescription drugs are no longer handed out haphazardly by overworked staff members with dangerously incomplete patient records.
Corrections Secretary Matt Cate said Gov. Jerry Brown's administration, not an unelected federal receiver, should be deciding how the state spends roughly $1.8 billion a year on inmate medical care.
Californians "voted for Jerry Brown, and that's who should run government," he said. The court should "have some faith that we'll be able to get this done without backsliding into conditions that were found unconstitutional to begin with."
But the receiver, J. Clark Kelso, isn't sure. The Brown administration has suspended plans for new medical buildings and $750 million in upgrades of existing clinics, and Kelso said that getting adequate facilities has been a constant challenge.
"I keep getting pressure from the state — 'Are you done yet, are you done yet?' " Kelso said. "Look in the mirror! I would have been done if you had just followed through on the things you said you were going to do."
Donald Specter, director of the Prison Law Office, the advocacy group that filed the lawsuit that led to the receivership, fears that the financially strapped state may stop investing in inmate healthcare.
"Jerry Brown has cut almost every social service for free people in order to balance the budget," Specter said. "So I'm concerned what he would do to the prison medical care budget without a court order."
Before the court took over in 2006, California's vast prison healthcare system was dangerous and unsanitary. Cate, who was state inspector general then, said it was substandard "for any human being, regardless of whether you're incarcerated."
In addition to the physicians' shortcomings, clinical space was decrepit and technology was inadequate. Ceilings leaked. Doctors and nurses had no reliable way to track patients.
Sam Johnson, who has been incarcerated at San Quentin for nearly 14 years for murder, said inmates waited months for a checkup and often didn't get the care they needed. He recalled a fellow prisoner who complained of chest pains, was given Pepto-Bismol for heartburn and was dead in his cell by the end of the day.
"We didn't matter to them," Johnson said.
State statistics show that prison deaths considered preventable or likely to have been preventable dropped from 18 in 2006 to five in 2010, a 72% decrease. Spending on inmate healthcare jumped from $948 million before the receiver arrived to a peak of nearly $2.3 billion in the 2008-09 fiscal year. Prison medical spending is projected at almost $1.8 billion in Brown's proposed budget for the next fiscal year, which begins in July.
The state is now working to reduce its inmate population by 33,000 by mid-2013 under a U.S. Supreme Court ruling last year. Low-level offenders now remain in county jails instead of being sent to state prisons.
Cate said he wants to continue upgrading medical facilities, but he questions the need for more building as the prison population drops. "How do we know we're not going to overbuild with a declining population?" Cate said.
The state and the receiver are examining the issue. But Kelso, who earned $280,000 last year, said some parts of the prison system still lack adequate facilities.
"I'd like to have hot water. I'd like to have clinic space that is actually clinic space and not a converted linen closet," Kelso said. "I'd like to see facilities that are designed to deliver healthcare. It's not an outrageous request, it seems to me. Unfortunately, to do any kind of construction in a prison is costly."
At Deuel Vocational Institution in Tracy, inmates are examined in a sparsely equipped room once used for receiving packages. Drugs are sorted in a converted arsenal, and a closet became a nurses' office.
The prison's chief medical officer, Michael Kim, said a recent power outage forced pharmacists to throw out some drugs as they struggled to keep the refrigerator running.
"We're like a duct-tape institution," Kim said.
Inmates complained that the medical staff cuts corners.
"They try to save money in everything they do to treat you," said John James, 35, who is serving time for weapons possession. He said doctors delayed treatment he needed for a broken ankle for months and did not give him adequate painkillers.
"They're kind of callous to inmate suffering and pain," he said.