A proposal to privatize jail health services comes with a potentially steep cost to inmates and the public
Rita Connolly, a registered nurse who has worked with inmates in San Francisco jails since 1985, says she'll never forget the time she had to act fast to save a prisoner's life.
The man had just arrived from a different jail and was waiting to go through intake. He was slumped over and looking ill, too weak to voice a complaint. Several worried inmates beckoned Connolly over, and once she examined him, she realized he was in the midst of a heart attack. He was rushed to the emergency room. He lived — but sustained irreversible heart damage.
"He could have been someone who didn't live," Connolly told the Guardian, but he also could have had a better outcome. The inmate had alerted someone that he was having chest pains earlier in the day, she later learned, as he was boarding a bus from an Alameda County Jail. A medical services worker examined him just before the bus left, but allowed him to proceed. By the time he arrived in San Francisco, the warning signals had progressed to a full-blown heart attack.
The story highlights an extreme example of a trend Connolly said she observes regularly — inmates from counties that use privatized jail health services aren't receiving the same standard of care that San Francisco provides. Sometimes, there are obvious signs that the care is inadequate, placing inmates' health at risk.
Alameda's jail health services contractor, Tennessee-based Prison Health Services Inc. (PHS), has made headlines before for a track record marred by inmate deaths and lawsuits alleging negligence. PHS has expressed interest in contracting with San Francisco if the city opened the door to privatization, which Mayor Gavin Newsom has once again proposed in his latest budget.
That budget also calls for cuts to community-based health and human service programs that threaten to erode the safety net for those battling mental health issues, drug addiction, and chronic health problems, all proposals now being weighed by the Board of Supervisors Budget and Finance Committee.
But it is the debate over whether to make a $11 million cut to jail health services that raises the most thorny and telling questions about what sacrifices are considered acceptable — and what populations can be the most easily targeted — in the quest to balance a budget without the tax increases that Newsom opposes.
In San Francisco, the city's Department of Public Health contracts with the Sheriff's Department to address inmates' medical needs. Privatized jail health care would be cheaper, though by how much is a moving target. But nobody is arguing that the care would be better.
Newsom's budget proposes switching to a private firm as early as January 2011 to help solve a daunting budget deficit. The proposal originated with the Mayor's Office, and Sheriff Mike Hennessey — whose department would realize the potential savings — went along by including the item in his departmental budget.
In years past, the Board of Supervisors has repeatedly resisted the proposal and is likely to do so again — but rejecting it would mean finding up to $11 million in savings elsewhere.
"The fear is that when you bring privatization into the picture, there is a financial pressure to cut corners. And even though that may end up saving some money ... the price that comes with it is too high," Sup. David Campos said at a recent budget hearing. Referencing stories about inmates who died needlessly in jail under the care of for-profit firms, Campos said he isn't willing to risk a similar tragedy occurring in San Francisco.
The proposal has been floated repeatedly since as far back as the early 1990s, according to healthcare workers whose jobs have been jeopardized by privatization before. Newsom proposed the cut last year, and the year before.
"In absence of the budget problem, [Hennessey] probably would not have proposed this, nor would we have proposed this," Newsom's budget director, Greg Wagner, told members of the Budget and Finance Committee at a May 26 hearing, adding that the mayor shares concerns about prisoner safety. Newsom's office did not return multiple calls requesting comment for this story.
The U.S. Supreme Court recently agreed to a hear an appeal by the state of California to the federal court ruling that substandard medical care in California prisons constitutes cruel and unusual punishment and necessitates the early release of about 40,000 prisoners. At the May 26 hearing, healthcare workers familiar with the interiors of county jails and state penitentiaries came forward with horror stories.
"Every week I receive at least one inmate who has an open gunshot wound. They have not seen medical care in the county jails," Dr. Elena Tootell, chief medical officer at San Quentin state prison, told committee members. "It's quite surprising to me that they send inmates with gunshot wounds to prison. They just walk off the bus. They often have paper towels stuck to their bodies, seeping the blood. And then we are obligated to take care of them. This does not happen from San Francisco County, I'm going to tell you that right now."
Tootell said she'd observed a significant difference between those counties using private firms and those using public health care. "They will have a fracture — they've never been splinted, they've never seen a doctor. They're on anticoagulation [medication], but haven't had their blood checked in weeks and have bruises all over their body."
Connolly echoed similar concerns. For example, she told the Guardian, she's found herself asking questions like, "You were on AIDS medication before you got arrested and now you're not?"
Susanne Paradis, a healthcare research contractor with SEIU Local 1021, rejects the premise that the same services could be provided at a lower price. Under a private model, she says, the priority is to keep costs low — and that means doing less.
A key issue, Paradis said, is that private firms tend to rely more heavily on licensed vocational nurses (LVNs) — lower-paid medical staffers who aren't trained to assess patient's medical needs and cannot administer the same care that registered nurses (RNs) can. Using PHS data, Paradis found that in Alameda, there is one RN for every 92 inmates, compared with one RN per 32 inmates in San Francisco.
"An RN has the ability to assess, observe, and determine if there's emergency care needed," Paradis explained. "An LVN does not have the ability to do that."
John Poh, a nurse practitioner stationed at a jail in San Francisco's Hall of Justice, explained the difference this way: "The more RNs you have working for you, the fewer deaths you have."
PHS, an obvious point of comparison with San Francisco since it serves Alameda, declined to answer questions about its services. Instead, media spokesperson Pat Nolan e-mailed a brief statement. "We are excited to hear that San Francisco is considering the contracting of correctional health care," he wrote. "Should the city choose to go through an RFP process, we would look forward to participating. We think it is the right thing to do for the city and its taxpayers."
While those incarcerated in San Francisco jails can be thought of by some as criminals, nuisances, or miscreants, those requiring medical attention are patients in the eyes of the jail healthcare workers.
Inmates routinely enter the system with diabetes, HIV/AIDS, hepatitis C, heart problems, liver disease, and substance abuse issues, Connolly said. On occasion, a woman will arrive in jail only to learn that she is pregnant. Mental health problems are common, and some battle psychiatric issues in combination with physical ailments.
"Overall, our patient population has had little access to health care. For many people, we're the only show in town," Connolly noted.
Poh said some problems could spiral out of control if jail health staff didn't nip them in the bud. If an inmate is exhibiting signs of tuberculosis, for instance, they'll immediately get a mask and be sent to the hospital for screening. Sexually transmitted diseases are also a priority for treatment. "You don't want that person going out infected," Poh explained.
The city takes a proactive stance when it comes to treating inmates, Poh said, because at the end of the day, county jail is a revolving door. "Everybody leaves county jail. They're either going home, to a program, or to prison." If people are released back into the community with contagious, untreated health problems, the risk of exposure can spread beyond jailhouse walls.
San Francisco's current system is considered a first line of defense, in which inmates are "seen as members of the community who happen to be in jail right now," Paradis said.
Privatizing jail-health services would constitute a blow to a wider public health safety net in San Francisco that is already weathering painful cuts. At a June 15 Beilenson Hearing, a state-mandated opportunity for community members to explain the impacts of proposed health and human services cuts to the Board of Supervisors, people came out in droves to protest cuts to programs serving vulnerable residents.
Kristie Miller, executive assistant of the Standing Against Global Exploitation (SAGE) Project, told the Guardian that her organization serves 350 clients a year who are victims of human trafficking and commercial sexual exploitation. The organization stands to lose its mental health funding, so Miller had come out to speak against the cut. "It provides trauma-focused psychotherapy for survivors who've experienced a lot of abuse, violence, and exploitation," she said.
Jeff Schindler, chief development officer for the Haight Ashbury Free Clinics, said he was there protesting a 79 percent funding cut to his organization's 108-bed residential program on Treasure Island. "We won't have a place for people to actually go into residential treatment for their mental health and substance abuse issues," he said. "These are individuals who are going to get their needs met somehow, somewhere, and generally that's going to be at San Francisco General Hospital."
It's in this context that the proposal to contract out for jail health services is being proposed. "It's easy to dismiss prisoners as probably the least valued sector of our society," Deirdre Wilson, of the California Coalition for Women Prisoners, noted at a May 26 hearing. "But the right to health care is a human right."
According to an estimate prepared by the Sheriff's Department, the city could save anywhere from $11 million to $14 million by contracting out for jail health services, and Newsom's budget assumes a savings of "over $11 million per year."
However, the Controller's Office continues to revise that figure as the debate shifts and concerns are raised about the skill mix that a private firm would use. "We don't really know what it would cost to contract out, unless there was an RFP and a response to the proposal and some discussion about what the staffing requirements would be," Deputy City Controller Monique Zmuda explained at a June 17 hearing. She added that the potential range of savings spanned from $3 million to $11 million annually, depending on decisions that would have to be made about acceptable staffing levels.
San Francisco's inmate population has shrunk in the wake of the crime lab scandal, and a city-owned facility in San Bruno has been temporarily shuttered. Sheriff Hennessey told the Guardian he believed medical care in the jails could be provided either by city workers or a private firm, but added that he's "quite happy" with the status quo. Noting that 25 of the 58 counties in California already use private firms, he added, "It's not an unusual or unique thing." Hennessey also said the decision was linked to a broader philosophical and political question, and that he doubted there was support on the board for the proposal to go forward.
Mitch Katz, director of the city's Department of Public Health, did not directly say whether he supported Newsom's proposal. "I think our Jail Health Services does a great job, but I do understand that the city is facing an extremely difficult budget year and that ultimately the budget must be balanced," Katz wrote in an e-mail.
Gabriel Haaland, who represents SEIU Local 1021 union members whose jobs would be affected by the proposal, voiced strong opposition at a June 17 Budget and Finance Committee meeting. "'We don't care about these people because they're poor and they're in jail.' That's the message" in the decision to contract out, Haaland charged. The item was continued and will be revisited as budget deliberations unfold.