Full opinion text
OPINION AND ORDER STEPHEN REINHARDT, Circuit Judge, LAWRENCE K. KARLTON, Senior District Judge, THELTON E. HENDERSON, Senior District Judge. TABLE OF CONTENTS I. INTRODUCTION......................................................887 II. FACTUAL AND PROCEDURAL BACKGROUND........................889 A. Plata (Medical Care)................................................890 1. Complaint, Stipulation, and Order for Injunctive Relief...............890 2. Appointment of Court Experts and Their Findings..................892 3. Periodic Status Conferences......................................893 4. Proceedings To Determine Whether a Receiver Should Be Appointed....................................................893 5. Findings of Fact and Conclusions of Law Concerning Continuing Failure To Meet Constitutional Standards and Necessity of a Receivership .................................................895 6. Interim Remedies...............................................897 7. Appointment of the Plata Receiver................................897 B. Coleman (Mental Health Care).......................................897 1. Findings of Eighth Amendment Violations..........................898 2. Remedial Orders................................................900 a. Mental Health Care Beds and Treatment Space.................902 b. Transfers to Appropriate Level of Care........................905 c. Staffing....................................................905 3. Special Master’s 2006 Monitoring Reports..........................906 C. Crowding in California’s Prison System................................908 1. The Increasing California Prison Population........................908 2. Studies Commissioned by the State of California To Examine Prison Crowding..............................................909 3. Defining the Capacity of California Prisons.........................909 4. Crowding in Relation to Capacity .................................911 D. Governor Schwarzenegger’s Emergency Proclamation...................912 E. Motions To Convene Three-Judge Court and Subsequent Prison Studies by the State of California...................................912 1. Motions To Convene and Initial Proceedings........................912 2. Intervening Reports on Prison Crowding...........................913 3. Final Hearing and Rulings.......................................914 F. Proceedings Before this Three-Judge Court ...........................916 III. LEGAL FRAMEWORK................................................916 A. The PLRA Standard for Prisoner Release Orders: Primary Cause and No Other Relief..............................................917 B. The PLRA Standard for All Prospective Relief: Need-Narrowness-Intrusiveness and Consideration of Public Safety.....................918 C. The Remedial Nature of the Three-Judge Court Proceeding.............919 IV. CROWDING AS PRIMARY CAUSE.....................................920 A.General Problems in the Delivery of Medical and Mental Health Care Caused by Crowding..............................................922 ' B. Space Issues Affecting the Delivery of Care............................923 1. Reception Centers ..............................................923 2. Treatment Space................................................927 3. Inability To House Inmates by Classification .......................928 4. Beds for Mentally 111 Inmates.....................................929 C. Conditions of Confinement...........................................930 D. Other Access to Care Issues .........................................932 1. Staffing........................................................932 a. Medical Staff...............................................932 b. Mental Health Staff.........................................934 c. Custodial Staff..............................................935 2. Medication Management.........................................936 3. Specialty Medical Care ..........................................937 4. Lockdowns.....................................................937 E. Medical Records....................................................938 F. Increasing Acuity of Mental Illness...................................940 G. Extreme Departures from the Standard of Care and Preventable or Possibly Preventable Deaths, Including Suicides......................941 H. Expert Opinions Regarding Causation.................................942 I. Findings and Conclusions............................................949 V. NO OTHER RELIEF .....:............................................950 A. Alternatives to a Prisoner Release Order..............................951 1. Inadequacy of Construction as a Remedy...........................951 a. Prison Construction .........................................951 b. Construction of Re-entry Facilities ............................952 c. Medical Facilities and Prison Expansion........................953 d. Construction as a Means of Compliance........................955 2. Inadequacy of Additional Hiring..................................955 3. Insufficiency of the Plata Receivership and Coleman Special Mastership...................................................956 4. Other Proposals.................................................957 B. Expert Testimony..................................................959 C. Findings and Conclusions............................................962 VI.NARROWLY DRAWN, LEAST INTRUSIVE REMEDY THAT EXTENDS NO FURTHER THAN NECESSARY .......................962 A. Scope of Relief.....................................................963 B. Form of Relief.....................................................964 C. The Required Population Reduction...................................965 VII.POTENTIAL POPULATION REDUCTION MEASURES AND THEIR IMPACT ON PUBLIC SAFETY AND THE OPERATION OF THE CRIMINAL JUSTICE SYSTEM.......................................970 A. Criminogenic Nature of Overcrowded Prisons..........................971 B. Potential Population Reduction Measures..............................974 1. Early Release Through Expansion of Good Time Credits.............975 2. Diversion of Technical Parole Violators ............................979 3. Diversion of Low-Risk Offenders with Short Sentences..............982 4. Expansion of Evidence-Based Rehabilitative Programming in Prisons or Communities........................................984 5. Sentencing Reform and Other Potential Population Reduction Measures............................................... .985 C. Impact of Proposed Measures on Communities.................... .987 1. Investigation and Prosecution of Crime....................... .987 2. Effect on Jail Population.................................... .989 3. Effect on Parole Supervision Resources....................... .990 4. Impact on Community Corrections, Rehabilitative Services, and Re-entry Programs....................................... .991 5. Impact on Integrity of Criminal Justice System................ .993 6. Weight To Be Given Public Safety............................ .993 D. Feasibility Notwithstanding the Present Fiscal Crisis .............. .994 E. Inclusion of Mentally 111 Inmates in Any Population Reduction Order .994 F. Empirical Evidence on Incarceration and Crime Rates ............. .997 G. Findings and Conclusions....................................... 1000 VIII. CONCLUSION.................. 1003 ORDER ................................ 1003 I. INTRODUCTION “California’s correctional system is in a tailspin,” the state’s independent oversight agency has reported. Ex. P3 at i (Jan. 2007 Little Hoover Commission Report, “Solving California’s Corrections Crisis: Time Is Running Out”). Tough-on-crime politics have, increased the population of California’s prisons dramatically while making necessary reforms impossible. Id. at ii, 2-5, 9, 20. As a result, the state’s prisons have become places “of extreme peril to the safety of persons” they house, Ex. PI at 7-8 (Governor Schwarzenegger’s Oct. 4, 2006 Prison Overcrowding State of Emergency Declaration), while contributing little to the safety of California’s residents, Ex. P3 at ii. California “spends more on corrections than most countries in the world,” but the state “reaps fewer public safety benefits.” Id. at 14. Although California’s existing prison system serves neither the public nor the inmates well, the state has for years been unable or unwilling to implement the reforms necessary to reverse its continuing deterioration. In this proceeding, we address two particular problems that every day threaten the lives and health of California prisoners. First, the medical and mental health care available to inmates in the California prison system is woefully and constitutionally inadequate, and has been for more than a decade. The United States Constitution does not require that the state provide its inmates with state-of-the-art medical and mental health care, nor does it require that prison conditions be comfortable. California must simply provide care consistent with “the minimal civilized measure of life’s necessities,” Rhodes v. Chapman, 452 U.S. 337, 347, 101 S.Ct. 2392, 69 L.Ed.2d 59 (1981) — care sufficient to prevent the unnecessary and wanton infliction of pain or death, Estelle v. Gamble, 429 U.S. 97, 103-04, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976). Tragically, California’s inmates have long been denied even that minimal level of medical and mental health care, with consequences that have been serious, and often fatal. Inmates are forced to wait months or years for medically necessary appointments and examinations, and many receive inadequate medical care in substandard facilities that lack the medical equipment required to conduct routine examinations or afford essential medical treatment. Seriously mentally ill inmates languish in horrific conditions without access to necessary mental health care, raising the acuity of mental illness throughout the system and increasing the risk of inmate suicide. A significant number of inmates have died as a result of the state’s failure to provide constitutionally adequate medical care. As of mid-2005, a California inmate was dying needlessly every six or seven days. California’s inmates face a second everyday threat to their health and safety: the unprecedented overcrowding of California’s prisons. Since reaching an all-time population record of more than 160,000 in October 2006, the state’s adult prison institutions have operated at almost double their intended capacity. As Governor Schwarzenegger observed in declaring a prison state of emergency that continues to this day, this creates “conditions of extreme peril” that threaten “the health and safety of the men and women who work inside [severely overcrowded] prisons and the inmates housed in them____” Ex. PI at 1, 8. Thousands of prisoners are assigned to “bad beds,” such as triple-bunked beds placed in gymnasiums or day rooms, and some institutions have populations approaching 300% of their intended capacity. In these overcrowded conditions, inmate-on-inmate violence is almost impossible to prevent, infectious diseases spread more easily, and lockdowns are sometimes the only means by which to maintain control. In short, California’s prisons are bursting at the seams and are impossible to manage. It is the relationship between these two critical problems that lies at the heart of the cases before us. We must answer the question whether overcrowding is the primary cause of the unconstitutional medical and mental health care to which California prison inmates are currently subjected. Two federal lawsuits have brought the crisis in California’s prisons to this three-judge court. Plaintiffs in the two lawsuits contend that a reduction in the prison population is necessary to bring the California prison system’s medical and mental health care into constitutional compliance. In both Plata v. Schwarzenegger and Coleman v. Schwarzenegger; the federal courts initially issued narrow orders requiring California to develop and implement remedial plans to meet this objective. However, as the state time and again failed to meet its own remedial targets— let alone to achieve constitutional compliance — both courts were forced to adopt increasingly drastic remedies, culminating in the Plata court’s 2005 appointment of a receiver to manage the prison medical system. Ultimately, by late 2006 it became apparent that the overcrowding in California’s prisons rendered the efforts of the courts, the Coleman Special Master, and the Plata Receiver utterly insufficient. At the request of the Plata and Coleman courts, the Chief Judge of the United States Court of Appeals for the Ninth Circuit convened this three-judge court to consider the plaintiffs’ request for a court-ordered reduction in the California prison population. During the pendency of this proceeding, the outlook for California’s prisons has only grown dimmer. The state is now in the throes of a fiscal crisis that renders it unable or unwilling to commit the necessary resources to fix the problems in its prisons. As Matthew Cate, Secretary of the California Department of Corrections and Rehabilitation and a defendant here, recently put it, California “cannot at this time become further indebted for correctional healthcare.” Ex. 1 to Defs.’ July 1, 2009 Response to Court’s June 18, 2009 Order, filed in Coleman, at 1. Federal law makes any prisoner release order, including the population reduction order requested by plaintiffs, a “remedy of last resort,” H.R. Rep. No, 104-21, at 25 (1995) (report of the House Committee on the Judiciary on the Violent Criminal Incarceration Act of 1995), and imposes various conditions upon the issuance of such an order. See 18 U.S.C. § 3626(a)(3). As we explain below, those conditions have been met here: (1) crowding is the primary cause of the state’s failure to provide its inmates with constitutionally sufficient medical and mental health care; (2) no relief besides a prisoner release order can bring the California prison system into constitutional compliance; (3) an order requiring the state to reduce the population of its adult institutions to a lower percentage of their combined design capacity than presently exists — a population cap — is narrowly tailored to the constitutional violations identified by the Plata and Coleman combs, extends no further than necessary to remedy those violations, and is the least intrusive possible remedy; and (4) the state can comply with such an order with little or no impact on public safety and the operation of the criminal justice system. There are numerous means by which the state can reduce the prison population, from parole reform and the diversion of technical parole violators and low-risk offenders to sentencing reform and the expansion of good time credits and rehabilitative programming. There is no need for the’ state to release presently incarcerated inmates indiscriminately in order to comply with our order. Much of the relief can be achieved instead by reducing prison intake in a manner recommended by the state’s own experts. We recognize the gravity of the population reduction order we issue herein, and we do not intervene in matters of prison population lightly. Nonetheless, when federal court intervention becomes the only means by which to enforce rights guaranteed by the Constitution, federal courts are obligated to act. “Without this, all the reservations of particular rights or privileges would amount to nothing.” The Federalist No. 78 (Alexander Hamilton). California’s prisoners have long been denied constitutionally adequate medical and mental health care, often with tragic consequences, and the overcrowding in California’s prisons, which have become criminogenic, must be reduced if the prison system is to achieve constitutional compliance. California’s prisoners, present and future, (and the state’s population as a whole) can wait no longer. II. FACTUAL AND PROCEDURAL BACKGROUND Because the courts’ prior remedial efforts are of profound relevance in understanding the effect of prison overcrowding and the inadequacy of forms of relief that do not address that problem, we begin with a detailed history of the individual Plata and Coleman cases. We then describe the crowded conditions in California’s prison system and the history of the three-judge court proceeding before turning to the legal questions before us. A. Plata (Medical Care) The history of Plata involves extensive remedial efforts over the last seven years that have faltered because of the severe overcrowding in California’s prisons. The Plata class action was filed on April 5, 2001, and plaintiffs filed an amended complaint on August 20, 2001, alleging constitutional violations in the delivery of medical care to inmates confined in California state prisons, as well as violations of the Americans with Disabilities Act and § 504 of the Rehabilitation Act. Ex. D1059. Plaintiffs asserted that the “unconstitutional conditions” caused by defendants’ failure to “properly care for and treat the prisoners in [them] custody ... caused widespread harm, including severe and unnecessary pain, injury and death.” Id. ¶ 1. The Plata plaintiffs and defendants negotiated a stipulation for injunctive relief, which the Plata court approved by court order. However, defendants proved incapable of or unwilling to provide the stipulated relief. Three years after approving the stipulation as an order of the court, the Plata court conducted an evidentiary hearing that revealed the continued existence of appalling conditions arising from defendants’ failure to provide adequate medical care to California inmates. The Court found that defendants had been given “every reasonable opportunity to bring [the] prison medical system up to constitutional standards, and it [was] beyond reasonable dispute that the State ha[d] failed.” Oct. 3, 2005 Findings of Fact & Conclusions of Law Re: Appointment of Receiver (“FF & CL”), 2005 WL 2932253, at *1 (Ex. D 1063). Following that hearing, the Plata court concluded that it had no choice but to place the CDCR’s medical health care delivery system in receivership. The Plata Receivership continues to this date, but, as we explain below, severe crowding throughout California’s prison system renders the Receiver unable to resolve the constitutional violations at issue in Plata. 1. Complaint, Stipulation, and Order for Injunctive Relief In their amended complaint, the Plata plaintiffs alleged that a number of specific deficiencies in the CDCR’s prison medical care system rendered the system as a whole unconstitutional. The alleged deficiencies included inadequate medical screening of incoming prisoners; delays in or failure to provide access to medical care, including specialist care; untimely responses to medical emergencies; the interference of custodial staff with the provision of medical care; the failure to recruit and retain sufficient numbers of competent medical staff; disorganized and incomplete medical records; a “lack of quality control procedures, including lack of physician peer review, quality assurance and death reviews”; a lack of protocols to deal with chronic illnesses, including diabetes, heart disease, hepatitis, and HIV; and the failure of the administrative grievance system to provide timely or adequate responses to complaints concerning medical care. Ex. D1059 ¶ 192. Prior to filing suit, the Plata plaintiffs had been in informal negotiations with defendants since July 1999. Ex. D 1060 ¶ 3 (June 13, 2002 Stip. & Order). After Plata was filed, the parties ultimately agreed to a stipulation for injunctive relief, which the Plata court entered as an order on June 13, 2002. Defendants agreed to and were ordered to implement certain policies and procedures on a staggered basis, with seven prisons to complete implementation in 2003. Id. ¶¶4-5. In each subsequent year, defendants were to complete implementation at five additional prisons, such that statewide implementation would be achieved by the end of 2008. Id. ¶ 5. The stipulated policies and procedures, which defendants filed with the Plata court on February 15, 2002, and supplemented on May 30, 2002, “are approximately 800 pages long and contained in 11 volumes.” Mai*. 10, 2003 Order at 2. Although the stipulated policies and procedures were “designed to meet or exceed the minimum level of care necessary to fulfill the defendants’ obligation to plaintiffs under the Eighth Amendment of the United States Constitution,” the stipulation “requirefs] defendants to provide only the minimum level of medical care required under the Eighth Amendment.” Ex. D 1060 ¶ 4. The stipulation for injunctive relief provided inter alia for regular audits of defendants’ compliance. Id. ¶¶ 19-23. These audits were to include a review of no less than 180 inmate health records at each prison. Id. ¶ 21(a). Medical assessments or treatment plans contained in those records would be deemed substantially in compliance with the settlement agreement if they were consistent with the policies and procedures or with the community standard of care “imposed under the laws of the State of California upon health care providers licensed to practice in California.” Id. ¶ 22(b) & at 11 n. 3. Compliance with the agreement would also require “conducting minimally adequate death reviews and quality management proceedings,” having “tracking, scheduling and medication administration systems adequately in place,” and the absence of any “pattern or practice that is likely to result in serious problems [where] those problems are not being adequately addressed.” Id. ¶¶ 22(c)-(e). Had the stipulated policies and procedures been implemented, they would have resulted in comprehensive improvements to nearly all aspects of the medical delivery system in California’s prisons, including quality management; health records management; infectious disease control; staffing; inter-institution transfers; and the timing and manner in which inmates are provided with physician and nurse care, as well as with necessary medications. Unfortunately, defendants utterly failed to comply with the implementation schedule to which they had stipulated. As of May 10, 2005, when implementation should have been completed at twelve prisons, “not a single prison ha[d] successfully completed implementation.” May 10, 2005 Order to Show Cause (“OSC”), 2005 WL 2932243, at *2 (Ex. D1062). The same remains true now, more than seven years after the court approved the parties’ settlement agreement. As we explain below, this is due in large part to the severe overcrowding in California’s prisons. 2. Appointment of Court Experts and Their Findings In addition to stipulating to an implementation schedule, the parties agreed to the appointment of medical and nursing experts “to advise the Court on the adequacy and implementation of defendants’ Policies and Procedures and any other matter that appropriately may be the subject of the experts’ testimony.” Ex. D1060 ¶¶ 16-17. The experts routinely reviewed defendants’ progress towards implementing the stipulated injunctive relief and periodically communicated their findings and recommendations to the Plata court. In their July 16, 2004 report to the court, the experts identified a pattern of serious deficiencies relating to physician quality at California prisons, and defendants agreed to address those deficiencies in a stipulation entered as an order of the court on September 17, 2004 (“Patient Care Order”), Ex. D1061. The Patient Care Order required defendants to engage an independent entity to (a) evaluate the competency of physicians employed by the CDCR and (b) provide training to those physicians found to be deficient. It also required defendants to undertake certain measures with respect to the treatment of high-risk patients, to develop proposals regarding physician and nursing classifications and supervision, and to fund and fill Quality Management Assistance Teams (“QMAT”) and other support positions. Oct. 3, 2005 FF & CL, 2005 WL 2932253, at *2. However, “[djefendants failed to come close to meeting the terms of the Patient Care Order, even with generous extensions of time from the Court.” Id. The experts noted one example of defendants’ failure to comply after visits to the Substance Abuse and Treatment Facility in February and March 2005: [N]ot only has little progress been made in the implementation of Plata, but the initial morale and enthusiasm in utilizing QMAT has evaporated in large part because of the inability of the California Department of Corrections to provide the necessary staff and support to this process. This has delivered an unspoken message that no change will occur. May 16, 2005 Experts’ Report on Substance Abuse Treatment Center, at 3 (filed in Plata on May 19, 2005). The experts’ reports following visits to San Quentin State Prison were no better. Following a February 2005 visit to that facility, the court’s nursing experts observed that clinics in housing areas were sometimes “nothing more than an office used by correctional officers” and “lacked basic medical equipment and supplies.” Apr. 9, 2005 Nursing Experts’ Report on San Quentin, at 2 (filed in Plata on May 10, 2005). The “[mjost disturbing” conditions were in one unit where [t]he area used for nursing triage [was] a small room at the end of the tier that the nurse accesses by walking through a gate and into the men’s showers.... Because of a clogged shower drain, standing water was present outside the clinic door. Inside, the room was filthy. The furniture was old and in disrepair. There was no examination table, medical equipment or supplies, or handwashing facilities. According to staff, equipment (otoscope [an instrument used to examine the ear]) requested for this area had been denied. As well, there was no telephone or computer access. Prior to this room being used, a broom closet on the fourth tier was used for nurse triage. These conditions are deplorable and have no resemblance to a medical setting whatsoever. Id. at 2-3. Following their visits to San Quentin in January and February 2005, the medical experts noted that “[mjedical record reviews demonstrate^] multiple instances of incompetence, indifference, cruelty, and neglect. Ten deaths were reviewed. All showed serious problems; most deaths were preventable.... Routine medical care [was] replete with numerous errors resulting from both system failures as well as physician mistakes.” Apr. 8, 2005 Medical Experts’ Report on San Quentin, at 13 (filed in Plata on May 10, 2005). Perhaps most damning was the medical experts’ conclusion that “overall compliance with the Stipulated Order and subsequent Court Orders was non-existent [at San Quentin]. In fact, it was clear that for most areas we reviewed there has been indifference to beginning the process required in the Stipulated Order,” id. at 2— despite the fact that the prison was to have completed that process by the time of the experts’ site visit. The experts ultimately concluded that San Quentin was “so old, antiquated, dirty, poorly staffed, poorly maintained, with inadequate medical space and equipment and over-crowded that it is our opinion that it is dangerous to house people there with certain medical conditions and is also dangerous to use this facility as an intake facility.” Id. According to the experts, “the overcrowding and facility life-safety and hygiene conditions create a public health and life-safety risk to inmates who are housed there.” Id. 3. Periodic Status Conferences Beyond receiving periodic reports from the experts, the Plata court also conducted regular status conferences with the parties to help monitor and facilitate implementation of the stipulated injunctive relief, as well as to assess defendants’ ability and willingness to comply with the court order approving such relief. Based on the experts’ dismal reports of defendants’ progress, the court increased the frequency of these conferences and, in February 2005, started meeting with the parties on a monthly basis. To facilitate these meetings, which typically involved large numbers of CDCR staff housed in Sacramento, the court rotated the location of these meetings between San Francisco and Sacramento. The Court invited the parties during [the] monthly status conferences to contribute ideas as to possible remedies, and the Court especially encouraged defendants to consider ways in which they could take the actions necessary to solve the medical care problems through measures within their, own control, including use of the extraordinary powers of the Governor. The Court went to the length of requesting that defendants present it with a series of proposed orders so that the Court could help empower them to overcome some of their bureaucratic hurdles on their own. Defendants did not submit a single proposed order. Oct. 3, 2005 FF & CL, 2005 WL 2932253, at *26 (citation omitted). 4. Proceedings To Determine Whether a Receiver Should Be Appointed Ultimately, the Plata court found itself with no alternative but to issue an order to show cause (“OSC”) why defendants should not be found in civil contempt and why a receiver should not be appointed to manage medical care delivery for the CDCR. As the court noted when it issued the OSC on May 10, 2005: In the four years since this case was filed, which includes the year and a half that this Court has been meeting with the parties on a regular basis, two things have become ever increasingly clear: (1) the Governor has appointed, and the State has hired, a number of dedicated individuals to tackle the difficult task of addressing the crisis in the delivery of health care in the California Department of Corrections (“CDC”), and, (2) despite the best efforts of these individuals, little real progress is being made. The problem of a highly dysfunctional, largely decrepit, overly bureaucratic, and politically driven prison system, which these defendants have inherited from past administrations, is too far gone to be corrected by conventional methods. The prison medical delivery system is in such a blatant state of crisis that in recent days defendants have publicly conceded their inability to find and implement on their own solutions that will meet constitutional standards. The State’s failure has created a vacuum of leadership, and utter disarray in the management, supervision, and delivery of care in the Department of Corrections’ medical system. Defendants have devised a long-term strategy to contract out health care management and much of the delivery of care. However, full implementation of that plan is, by defendants’ own estimates, years away. In the meantime, roughly 162,000 prisoners are being subjected to an unconstitutional system fraught with medical neglect and malfeasance. Defendants themselves have conceded that a significant number of prisoners have died as a direct result of this lack of care, and it is clear to the Court that more are sure to suffer and die if the system is not immediately overhauled. Since the entry of the Stipulated Injunction in June 2002, the most notable characteristic of this case has been defendants’ failure to achieve any substantial progress in bringing the medical care system even close to minimal constitutional standards. May 10, 2005 OSC, 2005 WL 2932243, at *1-2. “Even following issuance of the OSC — on the brink of possible contempt and the imposition of a Receivership — defendants were able to enact only very limited and piece-meal measures, with no prospect for system-wide reform or restructuring.” Oct. 3, 2005 FF & CL, 2005 WL 2932253, at *26. Beginning on May 31, 2005, and concluding on June 9, 2005, the Plata court conducted a six-day evidentiary hearing concerning the OSC. Id. at *2. The court considered eighty-two exhibits, id., and heard testimony from the court experts; relevant state officials, including Undersecretary of Corrections Kevin Carruth and Dr. Renee Kanan, the Acting Director of Health Care Services for the CDCR; and defendants’ medical expert Dr. Ronald Shansky. Following the hearing, the parties submitted legal briefs addressing both contempt and the appointment of a receiver, and several unions representing state prison medical personnel filed an amicus brief. Id. Defendants did not dispute that the Plata court had the power to appoint a receiver; instead, they argued only that a receivership was an extraordinary remedy to be used only if less intrusive remedies had failed or were likely to fail. Defs.’ June 20, 2005 Response to OSC at 2, 25. On June 30, 2005, the Plata court heard argument on the OSC. Oct. 3, 2005 FF & CL, 2005 WL 2932253, at *2. “Based on the arguments of counsel, the evidence presented, the full record in this case, and the Court’s own observations on prison tours [of two facilities, accompanied by counsel for the parties], the Court delivered an oral ruling at the conclusion of the hearing that it would take control of the medical delivery system of the CDCR and place it under the auspices of a Receivership.” Id. 5. Findings of Fact and Conclusions of Law Concerning Continuing Failure To Meet Constitutional Standards and Necessity of a Receivership On October 3, 2005, the court issued findings of fact and conclusions of law setting forth the detailed reasoning behind its oral ruling. As the court noted in its written decision: By all accounts, the California prison medical care system is broken beyond repair. The harm already done in this case to California’s prison inmate population could not be more grave, and the threat of future injury and death is virtually guaranteed in the absence of drastic action. The Court has given defendants every reasonable opportunity to bring its prison medical system up to constitutional standards, and it is beyond reasonable dispute that the State has failed. Indeed, it is an uncontested fact that, on average, an inmate in one of California’s prisons needlessly dies every six to seven days due to constitutional deficiencies in the CDCR’s medical delivery system. This statistic, awful as it is, barely provides a window into the waste of human life occurring behind California’s prison walls due to the gross failures of the medical delivery system. It is clear to the Court that this unconscionable degree of suffering and death is sure to continue if the system is not dramatically overhauled. Decades of neglecting medical care while vastly expanding the size of the prison system has led to a state of institutional paralysis. The prison system is unable to function effectively and suffers a lack of will with respect to prisoner medical care. Id. at *1. In its order, the court identified a number of serious problems in the care provided to inmates. The court found that the CDCR failed to follow its own policies regarding access to medical care, and inmates routinely lacked timely access to care, both in terms of screening requests and in receiving care once it was determined that an appointment with a physician was warranted. Id. at *13. Inmates needing specialty services to treat serious medical problems were forced to wait inordinate and inexcusable amounts of time for appointments; at one prison, inmates with consultation referrals from early 2004 had yet to be seen in May 2005. Id. at *16. In addition, the CDCR had failed to develop or implement a system to track and treat inmates with chronic care needs, id. at *14, and the court’s nursing expert found that CDCR nurses often “fail[ed] to perform basic functions,” such as taking vital signs, conducting examinations, and identifying urgent medical issues requiring immediate referral to a physician. Id. at *9. Not unexpectedly, death reviews revealed “repeated gross departures from even minimal standards of care.” Id. at *7. The lack of adequate care also resulted in “an inordinately high level of morbidity,” defined as “any significant injury, harm or medical complication that falls short of death,” among CDCR inmates. Id. at *8-9. For example: [I]n 2004 a San Quentin prisoner with hypertension, diabetes and renal failure was prescribed two different medications that actually served to exacerbate his renal failure. An optometrist noted the patient’s retinal bleeding due to very high blood pressure and referred him for immediate evaluation, but this evaluation never took place. It was not until a year later that the patient’s renal failure was recognized, at which point he was referred to a nephrologist on an urgent basis; he should have been seen by the specialist within 14 days but the consultation never happened and the patient died three months later. Id. (citations omitted). This incident was simply a “representative example[ ]” of the grossly inadequate care that could be found throughout the prison system. Id. at *6. Many prisoners were the victims of similar treatment, or worse. Beyond these quality of care problems, the court noted a number of additional deficiencies in the prison medical system. Prison medical facilities “laek[ed] the necessary medical equipment to conduct routine examinations and to respond to emergencies,” id. at *15, and were also “completely inadequate for the provision of medical care”: Many clinics [did] not meet basic sanitation standards. Exam tables and counter tops, where prisoners with infections such as Methieillin-Resistant Staph Aureus (MRSA) and other communicable diseases are treated, [were] not routinely disinfected or sanitized. Many medical facilities requirefd] fundamental repairs, installation of adequate lighting and such basic sanitary facilities as sinks for hand-washing. In fact, lack of adequate hygiene ha[d] forced the closure of some operating rooms. Id. at *14 (citations omitted). Likewise, the management of prison pharmacy operations was “unbelievably poor.” Id. at *16. No statewide coordination between pharmacies existed, and there were “serious, long-standing problems with dispensing medication, renewing prescriptions, and tracking expired prescriptions.” Id. Medical records in most CDCR prisons were “either in a shambles or non-existent.... mak[ing] even mediocre medical care impossible,” id. at *14 (citation omitted), and the resulting lack of access to inmates’ medical histories “resulted] in dangerous mistakes, delay in patient care, and severe harm.” Id. Furthermore, the reception center intake process, which was designed to allow medical staff to identify inmates’ medical issues, including communicable diseases posing a risk of transmission to other inmates and staff, was woefully inadequate. Id. at *12-13. The court also noted a number of serious personnel problems. Qualified medical staff were sorely lacking at every level. According to one court expert, “20-50% of physicians at.the prisons provide[d] poor quality of care.” Id. at *5. However, the CDCR was incapable of recruiting qualified personnel to fill the significant vacancies that existed throughout the system, id. at *11, and the CDCR’s lack of a medical credentialing policy resulted in many CDCR clinicians’ practicing outside of their areas of medical expertise. Id. at *21. The CDCR also lacked medical leadership, both at the central office and at individual prisons, and the resulting lack of supervision “foster[ed] a culture of non-accountability and non-professionalism whereby the acceptance of degrading and humiliating conditions bec[ame] routine and permissible.” Id. at *10 (internal quotations, citation, and alteration omitted). Bases on these findings, the Plata court concluded that “the establishment of a Receivership, along with those actions necessary to effectuate its establishment, are narrowly drawn to remedy the constitutional violations at issue, extend no further than necessary to correct a current and ongoing violation of a federal right, and are the least intrusive means to correct these violations.” Id. at *33. The court recognized that: the imposition of a Receivership is a drastic measure. But it is not a measure that the Court has sought, nor is it one the Court relishes. Rather, the Court is simply at the end of the road with nowhere else to turn. Indeed, it would be fair to say that the Receivership is being imposed on the Court, rather than on the State, for it is the State’s abdication of responsibility that has led to the current crisis. Since the Court has jurisdiction over this matter, it has no choice but to step in and fill the void. Id: at *31 (citation omitted). The court held the, contempt remedy in abeyance after concluding that a finding of contempt was not a prerequisite to the appointment of a receiver. Id. at *33. Nevertheless, it sought to employ all feasible means other than a prisoner release to remedy the constitutional violations. 6. Interim Remedies On plaintiffs’ motion, the court considered appointing a temporary receiver but ultimately opted instead to appoint a correctional expert pending the search for and appointment of a receiver. Id. at *34-35. On November 14, 2005, the Correctional Expert filed a report and recommendations on interim remedies concerning clinical staffing and death reviews. “[T]he Correctional Expert’s report powerfully underscore[d] the depth of the crisis in the delivery of health care services in the CDCR ....” Ex. D1065 at 1 (Dec. 1, 2005 Order). Over defendants’ objections, the court ordered a series of “discrete, urgently needed, remedial measures that could be undertaken immediately” to improve recruitment and retention of clinical staff. Id. at 1, 6-15. 7. Appointment of the Plata Receiver With the parties’ participation, the Plata court engaged in a national search for a receiver. On February 14, '2006, the court appointed Robert Sillen as Receiver, with an effective date of April 17, 2006. In its order of appointment, the court conferred broad authority on the Receiver to “provide leadership and executive management of the California prison medical health care delivery system with the goals of restructuring day-to-day operations and developing, implementing, and validating a new, sustainable system that provides constitutionally adequate medical care to all class members as soon as practicable.” Ex. P313 at 2 (Feb. 14, 2006 Order). The Receiver was assigned “the duty to control, oversee, supervise, and direct all administrative, personnel, financial, accounting, contractual, legal, and other operational functions of the medical delivery component of the CDCR,” id., and was granted “all powers vested by law in the Secretary of the CDCR as they relate to the administration, control, management, operation, and financing of the California prison medical health care system.” Id. at 4. On January 23, 2008, the Court appointed J. Clark Kelso to replace Sillen as Receiver, and he has served in that capacity to date. The Receivers have implemented substantial changes in the CDCR’s prison medical care system and have issued regular reports documenting their progress. For example, the Receiver has increased recruitment and retention of clinical staff, implemented a new pharmacy system, and instituted pilot programs to improve medical screening at reception centers and management of chronic care. Nonetheless, as we describe below, fundamental unconstitutional deficiencies, caused primarily by overcrowding, continue to exist and prevent the delivery of constitutionally adequate medical care to California’s inmates. B. Coleman (Mental Health Care) While the Plata court has struggled to bring the CDCR’s medical system into constitutional compliance for more than seven years, the Coleman action has lasted even longer — almost two decades. The first five years of litigation culminated in a finding that the CDCR was violating the Eighth Amendment by failing to provide constitutionally adequate mental health care to inmates with serious mental disorders. The past fourteen years have involved continual efforts to remedy the constitutional violations. At the time of the Coleman trial, the Eighth Amendment violations stemmed in large part from the state’s complete failure to identify with any accuracy the number of mentally ill inmates in the prison population, despite several expert reports addressing the issue. Early in Coleman’s remedial phase, the state developed a screening mechanism to identify mentally ill inmates and plans for a system that could deliver mental health care to the thousands of inmates suffering from serious mental disorders. There are currently over 34,000 inmates identified as seriously mentally ill in the state’s prisons. Ex. P243 at 900124 (collection of monthly CDCR mental health population placement reports, dated between December 2006 and August 2008). However, California remains unable to deliver constitutionally adequate mental health care for these inmates. After fourteen years of remedial efforts under the supervision of a special master and well over seventy orders by the Coleman court, the California prison system still cannot provide thousands of mentally ill inmates with constitutionally adequate mental health care, and “critically mentally ill inmates [are] languishing in horrific conditions without access to immediate necessary mental health care.” May 2, 2006 Order at 2. The relentless growth of the inmate population has prevented the state from meeting its obligations under the Eighth Amendment and has led, inexorably, to the proceeding before this court. 1. Findings of Eighth Amendment Violations The Coleman action was filed on April 23, 1990. On July 25, 1991, plaintiffs filed an amended complaint, Ex. D1036, raising claims under the Eighth and Fourteenth Amendments to the United States Constitution and the Rehabilitation Act, 29 U.S.C. § 794. These claims were based on serious inadequacies in the delivery of mental health care to inmates in the California adult prison system. Id. The Coleman court subsequently certified a class consisting of inmates with serious mental disorders. Nov. 14, 1991 Order at 4-5. The matter proceeded to trial before a United States Magistrate Judge, and in June 1994 the magistrate judge found that defendants’ delivery of mental health care to class members violated the Eighth Amendment. On September 13, 1995, the district court adopted the magistrate judge’s decision, with modifications. Coleman v. Wilson, 912 F.Supp. 1282 (E.D.Cal.1995). In adopting the magistrate’s findings, the Coleman court identified several significant deficiencies in the delivery of mental health care to California’s inmates. First, the court found delays in access to necessary mental health care “at each level of the mental health care delivery system as it exist[ed] in the CDC,” which “result[ed] in exacerbation of illness and patient suffering.” Id. at 1308, 1309. Evidence specifically noted by the Coleman court included “backlogs of 300^400 inmates awaiting transfer to enhanced outpatient programs at California Men’s Colony [ (‘CMC’) ] or California Medical Facility [ (‘CMF’) ]” and a defense exhibit describing “the problem of the backlog of male inmates awaiting transfer to CMF and CMC for mental health services” as “approaching the crisis level.” Id. at 1309 (internal quotations omitted). In addition, defendants did not have “a systematic program for screening and evaluating inmates for mental illness.” Id. at 1305. Instead, they relied on mechanisms that were “either used haphazardly, or depended] for efficacy on incomplete or non-existent medical records, self-reporting, or the observations of custodial staff inadequately trained in the signs and symptoms of mental illness.” Id. at 1305-06. As a result, “thousands of inmates suffering from mental illness [were] either undetected, untreated, or both.” Id. at 1306. Furthermore, the Coleman court found that “defendants’ supervision of the use of medication [was] completely inadequate; prescriptions [were] not timely refilled, there [was] no adequate system to prevent hoarding of medication, ... inmates on psychotropic medication [were] not adequately monitored, and it appeared] that some very useful medications [were] not available because there [was] not enough staff to do necessary post-medication monitoring.” Id. (internal quotations and citation omitted); see also id. at 1310. The court also found violations of a constitutional magnitude in the involuntary medication of inmates. Id. at 1313. In addition, the court found significant deficiencies in medical record keeping, “including disorganized, untimely and incomplete filing of medical records, insufficient charting, and incomplete or nonexistent treatment plans” at most prisons. Id. at 1314 (internal quotations and citation omitted); see also id. at 1315. The court found that “inmates [were] typically transferred between prisons without even such medical records as might exist.” Id. at 1314 (internal quotations and citation omitted); see also id. at 1315. The Coleman court also found that “the California Department of Corrections [was] significantly and chronically understaffed in the area of mental health care services.” Id. at 1307. Relying on the testimony of a defense expert, the Coleman court further found that “defendants [could not] provide adequate mental health care without some form of quality assurance” program to ensure the competence of their mental health care staff, but that the CDCR lacked any such program. Id. at 1308. These findings led the Coleman court to conclude that defendants lacked all of the “basic, essentially common sense, components of a minimally adequate prison mental health care delivery system,” id. at 1298 (citing Balla v. Idaho State Bd. of Corr., 595 F.Supp. 1558, 1577 (D.Idaho 1984) (citing Ruiz v. Estelle, 503 F.Supp. 1265, 1339 (S.D.Tex.1980))), including proper screening; timely access to appropriate levels of care; an adequate medical record system; proper administration of psychotropic medication; competent staff in sufficient numbers; and a basic suicide prevention program. Id. at 1298 n. 10. The Coleman court found that the CDCR was seriously deficient in each of the first five components and that the CDCR’s suicide prevention program was adequate in design but inadequately implemented due to severe and chronic understaffing throughout the CDCR. Id. at 1305-15. On the basis of its findings, the Coleman court entered an order for injunctive relief requiring defendants to develop plans to remedy the constitutional violations under the supervision of a special master. Id. at 1323-24; see also Fact # 5, Nov. 17, 2008 Joint Statement of Undisputed Facts. 2. Remedial Orders On December 11, 1995, the Coleman court appointed a special master to oversee the remedial phase of the action. Dec. 11, 1995 Order Appointing a Special Master at 2. The specific duties of the Special Master included working with defendants to develop a remedial plan to address the constitutional violations identified by the court, monitoring defendants’ implementation of and compliance with the remedial plan, and submitting interim reports on the progress of the remedial plan and defendants’ compliance. Dec. 11, 1995 Order of Reference at 3-4. Eighteen months later, the Special Master submitted a report to the court accompanied by remedial plans, policies, procedures, and forms collectively identified as the Mental Health Services Delivery System Program Guides (hereafter “Program Guides”). June 6, 1997 Special Master’s Report on Plans, at 1-2. The court accepted the Special Master’s report, ordered two specific modifications recommended by the Special Master, gave provisional approval to the Program Guides, and directed the Special Master to “forthwith commence monitoring defendants’ implementation of and compliance with” the delivery of mental health care services as set forth in the Program Guides. June 27, 1997 Order at 2-3. Following the court’s provisional approval of the Program Guides, defendants continued to work with the Special Master to implement and revise the guides. In early 2006, the Special Master submitted a report and recommendations regarding a Revised Program Guide that defendants concurrently submitted for final approval. See Jan. 2006 Revised Program Guide (■Coleman docket # 1753). On March 3, 2006, the Coleman court gave final approval to all undisputed provisions of the Revised Program Guide and ordered their immediate implementation. Mar. 3, 2006 Order at 1-2. Operating under the framework established by the Program Guides, the Coleman court has engaged in extensive efforts to address the identified constitutional violations through means other than a prisoner release order. Since June 1997, the Coleman Special Master has filed twenty monitoring reports and fifty-six other reports. During the same period, the Coleman court has issued well over seventy orders concerning the matters at the core of the remedial process. As discussed in detail below, the vast majority of the orders by the Coleman court have been directed at accurately projecting short-, medium-, and long-range bed needs; creating a sufficient number of beds at the higher levels of the mental health care delivery system; reducing delays in transfers to necessary levels of care; and ensuring adequate staffing. In addition, the court has issued several orders addressing deficiencies at specific institutions. Finally, the court has issued several orders concerning suicide prevention efforts, including, in the last five years, orders addressing a rising number of inmate suicides, particularly in administrative segregation units. a. Mental Health Care Beds and Treatment Space As the remedial phase of Coleman began and thousands of inmates with serious mental disorders were identified, the need for additional treatment space at every level of the mental health care delivery system became manifest. See Ex. D1292 (Special Master’s Response to Court’s May 17, 2007 Request for Information) at 5 (noting emergence in mid- and late-1990s of a “need for much expanded mental health care and the space needed to provide it”). At the time of the Coleman trial, mental health care delivery to inmates in California’s prison system was “limited to a few institutions and involved some 3,200 designated mental health care beds,” Defs.’ Proposed Finding of Fact #45 (citing Ex. D1273 at 43-44; Dezember Trial Aff. ¶ 70), including beds for inpatient hospital care provided by the Department of Mental Health (“DMH”) at CMF and Atascadero State Hospital. Dezember Trial Aff. ¶ 70. After the Coleman trial, defendants undertook to implement plans for the delivery of a continuum of mental health services, including long-term inpatient care (provided through the department’s contract with the California Department of Mental Health), short-term inpatient care (the department’s Mental Health Crisis Bed program), intensive outpatient care (the Enhanced Outpatient Program) and routine outpatient care (the Correctional Clinical Case Management program). Mar. 12, 1996 First Report of the Special Master on the Remedial Plan at 2-3. Defendants planned regional mental health care service areas, with “[i]nitial entry to the service continuum ... provided primarily through a uniform screening process” at each of the CDCR’s reception centers. Id. at 3. Defendants’ remedial plans were built around the Mental Health Services Delivery System (“MHSDS”) set forth in the original Program Guides and the Revised Program Guide. The MHSDS is designed to provide mental health care to all inmates with current symptoms of any of the Axis I serious mental disorders identified in the current Diagnostic and Statistical Manual, inmates who need mental health treatment “to protect life and/or treat significant disability/dysfunction” resulting from a diagnosed or suspected mental disorder, and inmates with a diagnosis or recent episode of exhibitionism. Ex. D1148 at 12-1-6. The MHSDS has the same basic structure as the “embryonic” system first reported by the Coleman Special Master in March 1996. The system is designed around four levels of care: the Correctional Clinical Case Management Services program (“CCCMS” or “3CMS”), the Enhanced Outpatient Program (“EOP”), Mental Health Crisis Bed (“MHCB”) Placement, and DMH Inpatient Hospital Care. Ex. D1148 at 12-1-7 to 12-1-9. A significant amount of remedial effort in Coleman has been spent on the as yet unsuccessful endeavor to develop a sufficient number of mental health care beds at the EOP, MHCB, and inpatient levels of care, as well as to provide adequate treatment space for all inmates with serious mental health disorders. The Coleman court has issued numerous orders addressing the need for mental health care beds and treatment space, including orders directing defendants to assess the need for beds and treatment space throughout the mental health care delivery system and to plan for and develop the necessary number of beds as well as sufficient space at each level of care. When the state’s growing prison population reached a record of more than 160,000 in 2006, the shortage of beds and space reached a crisis level. In March 2006, defendants were ordered to submit a plan to meet both the immediate and long-term need for mental health care beds. Mar. 3, 2006 Order at 3-4. During a subsequent hearing on the adequacy of defendants’ proposed plan, the CDCR’s then-Director of Health Care Services reported a shortage of 75 MHCBs and 125 intermediate inpatient beds and “repeatedly referred to the shortage as a ‘crisis.’ ” May 2, 2006 Order at 2. The Coleman court found that defendants’ plan entirely failed to address the CDCR’s immediate bed needs: The special master reports, the record reflects, and defendants admit, that the plan presented to the court in no way adequately responds to the severe shortage of intermediate care facility beds and mental health crisis beds that currently exists in the CDCR. It is undisputed that the shortage is leaving critically mentally ill inmates languishing in horrific conditions without access to immediately necessary mental health care. Id. The court further found that defendants’ long-range plan for the provision of acute and intermediate care beds and mental health crisis beds appeared “sound in principle,” but required revision because it was based on population figures that were “already out of date.” Id. Defendants’ plan for EOP beds was not approved because it “describe[d] a shortfall of over 1000 such beds in the year 2011.” Id. at 4. Following the hearing, the court ordered defendants to file an amended long-term plan and to include with that plan a list of any projects that could be accelerated; to file a plan for the interim provision of intermediate inpatient beds and mental health crisis beds; and to maintain, open, or create intermediate inpatient and mental health crisis beds at specific prison locations. Id. at 4-6. The Coleman court has subsequently issued several orders concerning the provision of EOP, MHCB, and inpatient beds, all of which are in critically short supply, including an extensive order concerning defendants’ long-range and interim plans for the provision of these beds. However, providing the beds is obviously infeasible without the necessary space in which to locate them, especially in light of the constantly increasing need for such beds as a result of the substantial, if unanticipated, growth in the prison population. b. Transfers to Appropriate Level of Care Throughout Coleman’s remedial phase, the state’s delivery of mental health care to its inmates has been plagued by delays in the transfer of inmates to higher levels of care. Both the original Program Guides and the Revised Program Guide include timelines for post-referral transfers to EOP programs, mental health care crisis bed