Inmates in the Riverside County jails served a federal class-action lawsuit last month, claiming the county is subjecting them to cruel and unusual punishment by depriving them of basic medical and mental health care. A similar lawsuit was filed against Fresno County in 2011, and a lawsuit alleging inadequate jail facilities and services for the disabled was filed against Alameda County late last year. More lawsuits are expected to be filed against other California counties as they adjust to the growing challenges stemming from the state’s public safety realignment legislation, known as AB 109.

Signed into law in 2011, realignment sought to relieve overcrowding in state prisons by shifting responsibility for those convicted of nonviolent, non-serious and non-sex crimes to county custody. However, increasing jail populations associated with the realignment may strain staffing resources and facility capabilities. In addition, increased sentences may require the implementation of more sophisticated health care programs addressing chronic diseases and other long-term health care problems.

The impact of overcrowding on the delivery of health care is familiar territory in California. In 2011 the U.S. Supreme Court affirmed a District Court order directing the state to limit its prison population. Overcrowding, according to the Supreme Court, had “overtaken the limited resources of prison staff; imposed demands well beyond the capacity of medical and mental health facilities; and created unsanitary and unsafe conditions that make progress in the provision of care difficult or impossible to achieve.” Specific examples included suicidal inmates being held for pro-longed periods in cages the size of telephone booths due to shortages in treatment beds. Other mentally ill inmates awaiting care were held for months in “administrative segregation,” where they endured harsh and isolated conditions, and received only limited mental health services. Prisons failed to implement necessary suicide-prevention procedures due, in large part, to severe understaffing. Inmates with physical illnesses waited, in some cases, more than a year for needed specialty referrals outside the prison, and less fortunate inmates died waiting to see their specialists.

The Prison Law Office, together with other law firms, successfully challenged unconstitutional deprivations of health care in California’s prison system, related to the overcrowded conditions. The same lawyers represent inmates in the Riverside and Fresno county cases. These lawyers haven’t singled out overcrowding as the cause of the alleged deficiencies in Riverside County’s jails but they said, in comments to The Press-Enterprise, that they believe the alleged problems have been exacerbated by longer sentences. In the Fresno County case, it is alleged that, in addition to suffering from inadequate health care, inmates are frequently harmed in fights or assaults arising from low staff-to-inmate ratios and poor visibility in the prisons—conditions that may worsen when inmate populations soar.

Common legal concerns cut across the state and county correctional health care cases. In particular, allegations consistently focus on: the quality of the professionals employed, staffing levels, intake screening, access to physicians, timeliness of care, medication management and health records administration. County officials may wish to renew their attention on these areas of their jail health care programs before lawsuits come calling.

Fortunately, counties don’t have to reinvent the wheel to assess and improve their jail health programs. After decades of litigation and process improvement, the state can be a valuable source of information. Although some critical work remains outstanding in the prisons, U.S. District Court Judge Thelton E. Henderson, who is presiding over the state prison medical care case, recently found “significant progress” in the resolution of the prisons’ constitutional deficiencies. Similarly, U.S. District Court Judge Lawrence K. Karlton, who is presiding over the prison mental health care case, recently acknowledged the tremendous improvements achieved by the state. Inmate advocates and the state disagree on whether the state has completely satisfied the requirements of the law. There is no question, though, that a pathway out of the woods has emerged, which may provide guidance to those in charge of county jails.

Among other improvements, the state has developed a “Health Care Services Dashboard,” which measures performance in dozens of areas including chronic disease management, access to providers, staffing, provider workload, per inmate costs and prescription practices. Performance is measured statewide and on a prison-by-prison basis. Scores are posted publicly at and updated on a monthly basis, fostering transparency and a bit of healthy competition between the institutions. While the information is rolled up on the public view of the dashboard, prison managers can drill down into the dashboard to view, for example, the prescribing practices of individual providers or the chronic disease burden in the various yard clinics of a prison.

Technical assistance and jail health standards are also available from a number of reputable sources, like the National Commission on Correctional Healthcare. It is likely that county jail administrators already know exactly where to look for help. But some degree of additional political will and financial resources may be necessary to implement process improvements. County officials, of course, have competing priorities to consider. However, when weighing the costs and benefits of an increased focus on jail health, counties may want to look again to the state. In addition to the tragic human costs of poor jail health care programs, the legal cost of neglecting such programs can be crippling. According to The Associated Press, the state has spent more than $83 million in legal fees related to the two lawsuits that resulted in the cap of the state’s prison population. The old adage recommending an ounce of prevention may be good medical advice for the jails.
Jared A. Goldman is a health care attorney at Best Best & Krieger LLP in Sacramento. Since 2006, he has served as chief counsel for the receiver of the court-supervised turnaround of the California prison medical system. In addition to his receivership work, Goldman’s practice focuses on providing general counsel services and specialized advice to health care providers on operations, compliance, government and commercial contracts, and government audits and investigations. He can be reached at