No one was more aware of the rising California prison healthcare costs than Receiver Clark Kelso. The receiver’s office had been created in 2006 in response to appalling conditions inside state prisons: prisoners could wait months to see a doctor, many were denied access to necessary medicines, and it was alleged at least one a week died of preventable causes. Under the Eighth Amendment to the US constitution, which prohibits cruel and unusual punishment, prisoners had a right to adequate medical treatment. In 2002, the state settled a class-action lawsuit (Plata v. Davis/Schwarzenegger) that alleged “deliberate indifference” to prisoners’ medical needs. ^[7] The settlement required CDCR to improve conditions substantially within several years.

But by 2005, there had been no credible progress; in fact, conditions had worsened. So the federal court overseeing the settlement intervened. US District Court Judge Thelton E. Henderson in October 2005 ruled CDCR in violation of the settlement order: the prison healthcare system, he wrote, was "broken beyond repair" and caused an "unconscionable degree of suffering and death." In February 2006, he appointed Robert Sillen as receiver. The receiver’s mandate was to make prison medical care delivery fair, professional, and cost effective or, in the words of its mission statement, move it “from chaotic care that is largely episodic and consists of often untimely and uninformed encounters between patients and clinicians” to “a system of proactive, planned, informed, patient-centered and professional care.” ^[8] The receiver did not govern dental or mental health services, which was under federal oversight but controlled by CDCR.

Staff . Sillen turned his attention first to staff. There were about 300 people involved in running healthcare. The Receiver’s Office absorbed most of them—and added to their numbers. There simply were not enough personnel, and many of those in the system performed poorly. Prison doctors, for one, were notoriously bad. Most were not board certified. Many had come to prison service after the California Medical Board offered them prison doctoring as an alternative to losing their licenses or other disciplinary action. There were also not enough medical staff: one prison had a single doctor for 7,000 patients. Nursing vacancies ranged from 50 to 80 percent.

Sillen put $6 million into a serious recruiting effort. He doubled doctor salaries that had been capped at $135,000 a year, meaning the job now paid slightly more than the average for community doctors. He also required board certification or a review of competence. Results were swift: some 85 percent of existing doctors retired or resigned. The average physician’s age dropped to 51 from nearly 70, a third were women, and over 90 percent were board-certified But Sillen, despite these notable achievements, proved overly abrasive. His reforms were expensive, and his deteriorating relationship with the legislature threatened the receivership’s success.