California Prison Receiver split from prisons agency argument
A Pandemonium Shadow Show?
Richard Krupp, Ph.D.
October 1, 2010
In February 2006 the federal court in Plata v. Schwarzenegger appointed a Receiver to take over the management and operation of the state’s prison medical health care delivery system for the California Department of Corrections and Rehabilitation (CDCR). According to the Legislative Analyst Office, spending on inmate medical care from fiscal years 2005/2006 through 2008/2009 was more than $5 billion. The Receiver is now proposing to formally remove the operational part of prison health care from the management of CDCR.
On September 14, 2010, the Sacramento Bee (Bee) ran an editorial viewpoint written by the federal receiver for California’s Prison Healthcare Services entitled “Split off health care from prisons agency.” The September 2010 report, “Analysis of year 2009 Inmate Death Reviews – California Prison Health Care System was the primary source of data for the editorial. As with the previous annual death review reports there was some information missing or presented in an unusual way.
The following problems with the 2009 death review report and the Bee editorial are noted:
- The overall inmate mortality rate in California prisons Increased in 2009; from 216 per 100,000 inmates in 2008 to 232 per 100,000 in 2009. In prior death review reports annual inmate mortality rates were provided, but are now missing. Now only the unusual quarterly and annualized quarterly rates are provided.
- There are several different numbers of inmate deaths cited in the 2009 report. The report indicates there were 395 deaths, but then states 2 are under review so the total number is 393. However in the death rate trend table, adding the numbers for each quarter in 2009 shows the total number of deaths was 391. The total number of 2009 inmate deaths listed by CDCR is 364. Certainly there can be only one correct number.
- The report indicates the number of people on the Death Review Committee has been reduced and only 5 people produce 50% of the reviews. This may minimize some of the variation in the determination of preventability of death, but may also create more bias in the determination. This change should be reviewed and analyzed.
- Changes in definitions. The Death review report for 2007 had 5 definitions for preventability of death. In the 2008 and 2009 there were 7 definitions. Some Suicide and Homicide deaths were listed as likely/possibly preventable in 2007 and 2008, but in 2009 all suicide and homicide deaths were considered non-preventable. Changing definitions makes it difficult to compare data.
- The Bee editorial indicates the number of likely preventable deaths was reduced in 2009 by 83%. However, it is difficult to determine where in the 2009 inmate death review report this information originated.
The USDOJ Bureau of Justice Statistics report on State Prison Deaths from 2001 through 2006 lists the mortality rate per 100,000 state prisoners by state. The national average was 250 inmate deaths per 100,000 state prisoners. The rate for California during that time period was 213 per 100,000 state prisoners and reflects that 37 states have higher mortality rates than the CDCR. Some highlights of the report include this following:
- “State prison inmates had a 19% lower death rate than the adult U.S. resident population; among blacks the mortality rate was 57% lower among prisoners.”
- “Two-thirds of illness deaths resulted from pre-existing conditions.”
- The top three causes of death in State prison inmates 2001-2004 were; Heart diseases ( 27%), Cancer (23%), and Liver diseases (10%).
The number and rate of deaths per 100,000 inmates held in custody varies from year to year. For CDCR the rate per 100,000 should be adjusted to reflect the number of inmates that cycle through the prisons each year. There are about 264,000 inmates in California state prisons each year, not the static 165,000 or so that are used to develop the mortality rate per 100,000. This would effectively lower the mortality rate considerably. Approximately one-third of the CDCR inmate deaths actually occur in community hospitals where they are sent on temporary release status for medical care.
CDCR Inmate Deaths 2001 – 2009
Year CDCR Inmate Deaths1 Average Daily Prison Population2 CDCRRate/100,0003 NationalRate/100,0003 2001 290 157,142 178 242 2002 327 159,695 213 246 2003 315 161,785 207 258 2004 332 163,939 213 253 2005 352 168,035 223 254 2006* 397(428) 172,528 242(249) 250 2007* 368(397) 171,444 215(230) 2008* 345(369) 171,264 201(216) 2009* 364(395) 169,958 214(232) 1 CDCR, Data Analysis Unit 2 CDCR Data Analysis Unit 3 USDOJ
* Data from 2006-2009 from CPHCS in ( )
The number of inmate deaths reported by CDCR and by CPHCS (in parentheses) is not consistent. For example, in the table above the number of inmate deaths for 2006-2009 indicates different reported totals. An audit should be conducted to determine the actual number of inmate deaths each year. The different numbers also produce different inmate mortality rates.
The numbers of “Preventable/Possibly Preventable” and “Non-preventable” are listed in the following table for 2006-2009. The death review process was less standardized in 2006. No conclusions can be drawn from this data.
NUMBER OF DEATHS BY PREVENTABILITY – CPHC DATA
Year Likely Preventable/
2006 18 / 48 (total 66) 358 43 / 16 (total 59) 2007 3 / 65 (total 68) 327 33 / 22 (total 55) 2008 5 / 61 (total 66) 303 38 / 7 (total 45) 2009 3 / 43 (total 46) 348 25 / 9 (total 34)
In the latest report on 2009 death reviews, CPHCS indicates 88% of the CDCR inmates deaths were judged to be “non preventable.” Of the remaining 46 deaths, 43 were “possibly preventable”, and 3 were “likely preventable.” The determination of preventability is more of an art than a science. A Journal of the American Medical Association study found the inter-rater reliability among reviewers was low with agreement about one-third of the time. Given these loose parameters, it does not appear there should be any precise conclusions drawn.
According to the Journal of the American Medical Association (JAMA) study mentioned in the CPHCS report, almost a quarter (22.7%) of active-care patient deaths were rated as at least possibly preventable by optimal care, with 6.0% rated as probably or definitely preventable. If the level of medical care in CDCR is similar to care in the community, it would be within prevailing rates to expect approximately 90 or 23% of the 395 deaths from the above-referenced table. In fact there were much fewer in CDCR.
The in-custody death rates for CDCR are lower than national prison rates and California community rates. Almost three times as many people die each year while on parole than in prison. It appears that individuals incarcerated in the correctional system are less likely to die while under the supervision of in-prison correctional staff than when they are in the community under less scrutiny and left to their own devices.
It is difficult to justify spending taxpayer dollars to improve what appears to be an expected rate of inmate deaths in prison when there are certainly higher priorities for healthcare or other improvements in the community. It is sometimes overlooked that most of the inmates we incarcerate are locked up precisely because they have victimized people that certainly are more deserving of any tax dollars that we may consider spending on lowering the in-prison death rate. All CDCR inmates in effect have complete medical insurance coverage at no cost to them, but a high cost to the taxpayers. There is no evidence that the high prison medical expenditures contribute anything to reduce inmate mortality rates.
The management of inmate medical care by the federal receiver for the past few years has demonstrated no benefit to the inmate population, the prison operation or the California taxpayers. Rather than have the health care operation split off from the prisons agency, the receivership should be terminated. The operation of inmate medical care should be returned to the control of the CDCR.