Coleman v. Schwarzenegger

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

*886 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

*887 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”). 1 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 *888 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; 2 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 *889 and Rehabilitation 3 and a defendant here, recently put it, California “cannot at this time become further indebted for correctional healthcare.” 4 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 under *890 standing 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. 5

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). 6 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. 7

*891 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 . 8

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 *892 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. *893 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 *894 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. 9 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 *895 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 *896 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 meas *897 ure 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 *898 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. 10 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. 11 Nov. 14, 1991 Order at 4-5. *899 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). 12

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 *900 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 . 13

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. 14 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.

*901 Following the court’s provisional approval of the Program Guides, defendants continued to work with the Special Master to implement and revise the guides. 15 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. 16

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. 17 In addition, the court has issued several orders addressing deficiencies at specific *902 institutions. 18 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. 19

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”). 20

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

*903 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. 21 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, 22 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” 23 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. 24

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 *904 care, 25 as well as to provide adequate treatment space for all inmates with serious mental health disorders. 26 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. 27

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 *905 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. 28 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 beds, and DMH inpatient beds. See Coleman docket # 913 at 1-4, 4-13, 5-13, 6-4; Ex. D1148 at 12-1-16. 29 Unfortunately, the state remains unable to transfer inmates to required care in a timely fashion, and the Coleman court has issued numerous orders directed at expediting transfers and reducing delays. 30

c. Staffing

A final focus of the remedial effort in Coleman over the last decade has been the development and retention of sufficient numbers of competent mental health care clinicians. In June 1998, the Coleman court issued the first of numerous orders aimed at remedying the substantial under-staffing of the CDCR’s mental health care system, directing defendants to show improvement in the “quality and quantity of contracted psychiatric services and/or” the implementation of a “recruitment program sufficientn to fill vacancies in presently authorized positions.” June 16, 1998 Order at 1. In the same order, the court directed the Coleman Special Master to recommend the staffing ratios necessary to a constitutionally adequate mental health care delivery system. Id. at 2. 31 Since *906 then, the court has repeatedly ordered defendants to create the necessary positions and to hire staff to fill those positions. 32 In addition, the court has issued orders designed to assure the competence of staff, primarily by requiring the state to develop and implement a quality assurance and peer review process. 33

After two years of compliance monitoring, it became apparent that orders setting staffing ratios and requiring defendants to fill clinical positions would not be sufficient to remedy the constitutional violations. Accordingly, the Coleman court ordered defendants to develop a plan to retain CDCR psychiatrists. July 26, 1999 Order at 4. Over the next eight years, as part of its ongoing effort to ensure that California hires and retains sufficient clinical staff, the court issued several orders concerning recruitment and retention bonuses, as well as salary increases for mental health clinicians. 34

3. Special Master’s 2006 Monitoring Reports

By the end of the first decade of remedial work in Coleman , the state had made some progress but still had not met its constitutional obligation to provide Coleman class members with adequate mental health care. July 23, 2007 Order, 2007 WL 2122636 , at *3. Worse, two monitoring reports filed by the Coleman Special Master in 2006 reflected a troubling reversal in the progress of the remedial efforts of the preceding decade and demonstrated the profound impact of population growth on the state’s ability to meet its constitutional obligations to seriously mentally ill inmates.

On January 23, 2006, the Coleman Special Master filed his Fifteenth Monitoring Report, which included findings made at monitoring visits to all CDCR institutions between early August 2004 and late May 2005. Jan. 23, 2006 Fifteenth Monitoring Report at 2-3. The report was grim. The Special Master reported rising vacancy rates in staffing, as well as a “growing crisis in accessibility to a MHCB level of care and the continuing inadequacy of access to DMH programs highlighted by the unmet needs assessment that was conducted and concluded during the period.” Ex. D 1108 (compilation of summaries and recommendations from the Coleman Special Master’s twenty monitoring reports) at DEFS060221-DEFS060222. The Special Master also reported that “suicides in CDCR escalated significantly during the monitoring period for reasons that are just beginning to be subjected to analysis.” Id. at DEFS060222.

The Special Master further reported that “transfers to more intensive levels of mental health programming and treatment” had “deteriorated sharply and widely.” Id. at DEFS060252. The availability of MHCBs, “the department’s sole internal *907 resource for providing short-term crisis care for unstable and suicidal inmates,” had declined to the point that it “became by mid-2005 a critical issue with severe impact on CDCR’s most seriously mentally disordered inmates.” Id. In addition, “the waiting list for the admission to Psychiatric Service Units (PSUs) for EOPs with a SHU [Segregated Housing Unit] term, imposed on inmates who are viewed as a danger to themselves or others, expanded steadily, and mental health caseload inmates continued to spend long periods in reception awaiting transfer to EOP and 3CMS general population programs.” Id. at DEFS060252-DEFS060253.

Taken together, the expanding wait lists, critical shortage of beds, and identification of hundreds of inmates in need of clinical referrals “meant that a growing number of the most seriously mentally ill inmates in the CDCR were not receiving in a timely fashion the levels of care they needed.” Id. at DEFS060253. To explain this backward slide in the progress made under the Coleman court’s supervision, the Special Master pointed to the prison system’s expanding population. For example, “none of the [CDCR’s] planning documents ... addressed the department’s need to expand its capacity to provide acute inpatient DMH care to meet the expanding need being pushed, among other causes, by an inexorably rising MHSDS population commensurate with CDCR’s growing overall population.” Id. at DEFS060258. Likewise, progress in the timely transfer of mentally ill inmates from reception centers into general population programs had “been largely cancelled by the recently escalating growth in the overall CDCR population and the concomitantly increasing number of MHSDS inmates in reception.” Id. at DEFS060272-DEFS060273.

Defendants did not object to the Special Master’s Fifteenth Monitoring Report or the recommendations contained therein, including the Special Master’s finding as to the role played by the rapidly growing prison population and the resulting lack of space necessary to provide the requisite care to mentally ill inmates. Mar. 3, 2006 Order (Coleman docket # 1772) at 1.

As compliance work continued in 2006, the population pressures identified by the Special Master in his Fifteenth Monitoring Report were evident: Compliance became more difficult and the gains made by defendants in the first decade receded. On December 14, 2006, the Coleman Special Master filed his Sixteenth Monitoring Report. That report, which covered a monitoring period from the summer of 2005 until March 2006, Ex. D 1108 at DEFS060302, revealed that serious shortages in staffing and bed space, as well as substantial delays in transfers to necessary levels of care, continued unabated.

Among other findings, the Special Master reported that “the inexorably expanding demand for services resulting from the bulging population” had caused a “continuing deterioration of mental health staffing.” Id. at DEFS060303. According to the Special Master, “[tjwelve years after the determination that mental health treatment in CDCR was unconstitutional, the defendants still lacked clinical resources to meet the needs of some 25 to 30 percent of inmates identified as seriously mentally disordered.” Id. at DEFS060304.

Furthermore, the Special Master reported that

[t]he general breakdown in transfers was another transcendent issue in the 16th round of review. As the overall caseload population continued to increase, so too did the percentage of the caseload in need of program beds with intensive care and high security, including specifically DMH inpatient beds, MHCBs, PSU beds and EOP administrative segregation placements.

*908 id. at DEFS060306. “[AJecess to appropriate levels of care for seriously mentally ill inmates remained a problem in almost every CDCR institution.” Id. at DEFS060307.

Although Defendants filed a response to two recommendations contained in the Sixteenth Monitoring Report, they did not object to any of the above findings, once more including the Special Master’s determination that the “escalating growth in the overall CDCR population” was a major cause of the CDCR’s reversal of progress. Id. at DEFS060273; see Defs.’ Dec. 7, 2006 Response to Special Master’s Sixteenth Report.

C. Crowding in California’s Prison System,

1. The Increasing California Prison Population

Since the mid-1970s, California’s prison population has increased by over 750 percent, rising from approximately 20,000 inmates to an “all-time high” in October 2006 of over 170,000 inmates, with more than 160,000 housed in the state’s adult prison institutions. Ex. PI at 1 (Governor Schwarzenegger’s Oct. 4, 2006 Prison Overcrowding State of Emergency Declaration); Ex. P5 at 62 (May 2006 California Policy Research Center Report, “Understanding California Corrections”); Fact # 9, Nov. 17, 2008 Joint Statement of Undisputed Facts; Ex. D1259-1. Much of this population expansion occurred during the time in which the Plata and Coleman courts have monitored the medical and mental health care in California’s prisons. In 1991, when the Coleman plaintiffs filed their amended complaint, the state’s prison system housed approximately 100,000 inmates. Ex. P410 at 2 (CDCR Offender Information Services Branch Data Analysis Unit, Institution and Camp Design Bed Capacity and Population, June 30, 1987-June 30, 2007). As of August 27, 2008, 156,352 inmates were housed in in-state prison institutions. Fact # 10, Nov. 17, 2008 Joint Statement of Undisputed Facts. 35

The expansive growth of the prison population in California is due, in part, to the state’s adoption of determinate sentencing in the 1970s, Ex. P5 at 61-62, and the “countless increases in criminal sentences” enacted by the legislature or in initiative measures in succeeding years, Ex. P3 at 68 (Jan. 2007 Little Hoover Commission Report, “Solving California’s Corrections Crisis: Time Is Running Out”) (detailing increases in California sentencing since the Determinate Sentencing Act became effective in 1977). In addition, California’s prison population has increased because of its post-sentencing practices. “The state has [ ] been widely criticized for not doing a better job of preparing inmates to return to society.” Ex. P4 at, 121 (June 2004 Corrections Independent Review Panel Report, “Reforming Corrections”).

Approximately 90 percent of state prison inmates are eventually released on parole, and at present, more than half return to prison. A 2003 study by the Little Hoover Commission concluded that inmates are not prepared for their release from prison. Department of Corrections reports show that 43 percent of inmates released from prison in 1999 were sent back to prison within a year and that 56 percent returned within *909 two years. Many of those returned to prison are parolees who are sent back for violating the conditions of parole, rather than for committing new crimes, and many of those go back for relatively short periods of time — an average of &h months.

Id. The consequences of the state’s failure to prepare inmates for re-entry are significant: “The vast numbers of parolees returning to prison help drive both the size of the prison population and the cost of the system. In 2001 more than 74,000 (47 percent) of the average daily prison inmate population of 157,000 was made up of parole violators.” Id. Finally, also significant are the actions of the parole board and the Governor in declining to release prisoners serving terms of 15 or 25 years to life who have served their minimum sentence or more with unblemished records and are determined by prison officials not to constitute a risk to society.

2. Studies Commissioned by the State of California To Examine Prison . Crowding

The California legislature has recognized prison crowding as a serious problem since at least 1987, when it convened a Blue Ribbon Commission on Inmate Population Management. See Ex. P2 at 78. The commission issued its final report in 1990, with thirty-eight recommendations, including “alternative sanctions, and more programming [and] reentry programs.” Id. Between 1990 and 2006, more than a dozen commissions and other groups issued reports with proposals to solve the overcrowding problem in California’s prison system. Id. at 3, 10, 78-79. As Joan Petersilia, co-chair of the expert panel convened by the CDCR in 2007, noted, “all of the reports recommended essentially the same ten things,” including diverting nonviolent, non-serious offenders and technical parole violators from prison; using a risk and needs assessment tool to match inmates with resources and programming; expanding rehabilitative programs; reforming California’s determinate sentencing system; transferring low-risk prisoners in the later part of their sentences to community-based reintegration facilities; establishing a sentencing commission; reforming parole; creating partnerships between state and local corrections agencies; requiring that all programs be based on solid research evidence; and promoting public awareness regarding California’s prison system. Id. at 77.

One of the most exhaustive reports completed during this period was the June 2004 report of the Corrections Independent Review Panel, which was appointed by Governor Schwarzenegger; chaired by former California Governor and Attorney General George Deukmejian, who had a reputation as tough on crime; and composed of forty independent correctional consultants and representatives from state agencies. Ex. P4 at i. The Panel noted that California’s “correctional system has grown to become the largest in the nation, rivaling in size and numbers even those of most other countries,” and that “[n]ot surprisingly, this massive system shows the strains of both its age and its decades-long growth.” Id. at 199. The Panel found that “[a]dult prisons are severely overcrowded, imperiling the safety of both correctional employees and inmates.” Id. Consequently, a number of the Panel’s 237 recommendations, including the enhancement of earned credits, the expansion of rehabilitative programming, the identification of older inmates for early release, and the diversion of certain parole violators, were aimed at inmate population reduction. See id. at 122-61.

3. Defining the Capacity of California Prisons

In its report, the Corrections Independent Review Panel discussed three distinct measures of prison capacity: “design ca *910 pacity,” “operable capacity,” and “maximum safe and reasonable capacity.” Ex. P4 at 123-124. First:

“Design capacity” is the term used for the past 50 years to designate the number of inmates a prison is designed to accommodate according to standards developed by the Commission on Accreditation and the American Correctional Association. [Footnote omitted.] The number can be based on any combination of single-occupancy cells, double-occupancy cells, single- or double-bunked multiple occupancy rooms, or dormitories. The standards take into account the need for humane conditions, as well as the need to prevent violence and move inmates to and from programs, such as mental health care, education classes, and drug abuse treatment.

Id. at 123. “In California, design capacity is based on one inmate per cell, single bunks in dormitories, and no beds in space not designed for housing.” Id.

California has never limited its prison population to 100% design capacity, id. at 123 n. 1, and has in some respects planned for inmate population levels that exceed 100% design capacity. The “staffing packages” for California’s prison facilities have two parts: the “initial staffing package,” which is based on population at 100% design capacity, or one inmate per cell, and the “overcrowding package which, depending on the level of the facility being built, could be 150 percent, 175 percent, 190 percent or 200 percent.” Rep. Tr. at 540:24-541:4 (Raymond). The “overcrowding package” is “a staff enhancement of the design bed package.” Id. at 548:4-7. The combined staffing package shows the size of the staff necessary for a facility at 100% design capacity and the additional staff required as the facility becomes more crowded. Id. at 545:10-13.

Similarly, prisons built between 1985 and 1998, when the design capacity of the CDCR’s adult institutions and camps increased from 29,042 to near its present level of approximately 80,000 inmates, Ex. P212 at Table 10, “were designed and built to accommodate population growth” with respect to some infrastructure components — specifically the “ “water, wastewater, electrical and mechanical components, needed to meet anticipated overcrowding of as much as 190 percent in cells and 140 percent in dormitories.’ ” Dezember Trial Aff. ¶ 72 (quoting Ex. D 1292, Coleman Special Master’s May 31, 2007 Response to Court’s May 17, 2007 Request for Information, at 5). However, “these same prisons were not designed and made ‘no provision’ for any expansion of medical care space beyond the initial 100% of [design] capacity.” Id. (quoting Ex. D 1292 at 4-5). “Even worse, ‘none of the 19 CDCR institutions planned and built in the boom of the 80s and 90s gave any thought to the space that might be needed for mental health purposes.’ ” Id. (quoting Ex. D1292 at 5). 36 “A similar failure in design vision *911 occurred with the Department of Mental Health,” the sole provider of inpatient mental health care for CDCR inmates, “which discovered in 1998 that it had ‘no facilities of its own in which to provide the level of inpatient care needed by CDCR for high custody inmates with a history of violence or escape.’ ” Id. (quoting Ex. D1292 at 8). Thus, even though the infrastructure of California’s newer prisons was built to accommodate inmate populations greater than 100% design capacity, no similar accommodation was made for the provision of medical and mental health care in California’s prisons.

The second measure of prison capacity, “operable capacity,” refers to “the maximum capacity of the prisons to house inmates safely and securely while providing effective education, training, and treatment.” Ex. P4 at 122. “Operable capacity ... takes into account space needed for effective programming in addition to safety and security.” Id. at 124. Based on input from a “group of experienced California prison wardens,” the Corrections Independent Review Panel determined that the operable capacity of California’s prison system is 145% design capacity. Id. Notably, however, operable capacity does not take into account the space required to provide medical and mental health care. See id. at 161 n. 3; Nov. 9, 2007 Scott Report ¶ 46.

The third measure, “maximum ‘safe and reasonable’ capacity,” refers to “the maximum number of inmates who can safely and reasonably be housed in the prison system.” Ex. P4 at 124. This definition takes into account only “the ‘safe and reasonable’ capacity of individual housing units according to inmate custody levels, staffing levels, and the physical structure of the units.” Id. Units for inmates at higher custody levels have a lower maximum safe and reasonable capacity than units for inmates who present a lower security risk. Id. at 124.

The Department of Corrections has determined the maximum safe and reasonable capacity of the general population and reception center housing to be 190 percent of design capacity, while other housing can be filled only to between 100 and 160 percent of design capacity. Overall, the Department has determined that the maximum safe and reasonable capacity of the state’s male prisons is ... 179 percent of design capacity.

Id. “Maximum ‘safe and reasonable’ capacity” does not take into account “the need for humane conditions” incorporated into design capacity, or the need for programming space incorporated into both design and operable capacity. See id. at 123-124. More important for present purposes, that classification does not take into account the space or facilities required to provide medical or mental health care.

4. Crowding in Relation to Capacity

California’s inmate population has far exceeded the design capacity of the state’s prison system for over twenty-five years. See, e.g., Ex. P268 at 2 (Institution and Camp Design Bed Capacity and Population, June 30, 1983-June 30, 2003); Ex. P410 at 2; Ex. D1259-1. By October 2006, the state’s adult prisons, excluding camps, were operating at 200.2% design capacity with 162,792 inmates. 37 Ex. D1149 at 1 (CDCR weekly population report as of October 25, 2006). As of August 27, 2008, the population of these institutions was reduced to 195.9% design capacity with 156,352 inmates, largely as a result of shipping several thousand prisoners to *912 Mississippi and other contract states. Ex. P135 at 1 (CDCR weekly population report as of August 27, 2008). The current level of crowding far exceeds even the maximum safe and reasonable capacity of the California prison system, which, by CDCR’s own determination, is 179% design capacity for prisons holding male prisoners. Ex. P4 at 124.

D. Governor Schwarzenegger’s Emergency Proclamation

In response to the severity of the prison crowding problem, Governor Arnold Schwarzenegger, a primary defendant in both Plata and Coleman , declared a state of emergency on October 4, 2006. Ex. PI. In his Prison Overcrowding State of Emergency Proclamation, the Governor declared that “all 33 of CDCR’s prisons are now at or above maximum operational capacity, and 29 of the prisons are so overcrowded that the CDCR is required to house more than 15,000 inmates in conditions that pose substantial safety risks”; that “the severe overcrowding in 29 CDCR prisons has caused substantial risk to the health and safety of the men and women who work inside these prisons and the inmates housed in them”; that “the overcrowding crisis gets worse with each passing day, creating an emergency in the California prison system”; and that “immediate action is necessary to prevent death and harm caused by California’s severe prison overcrowding.” Id. at 1, 6, 8.

The risks enumerated by the Governor in his Proclamation include “increased, substantial risk for. transmission of infectious illness”; security risks caused by line-of-sight problems for correctional officers, particularly in areas where inmates are triple-bunked and in “tight quarters”; and “thousands of gallons of sewage spills and environmental contamination” from overloading the prisons’ sewage and waste-water systems. Id. at 2. Governor Schwarzenegger also declared that the suicide rate in the 29 severely overcrowded prisons “[was] approaching an average of one per week.” Id. at 6.

In addition, the Proclamation described three separate proposals by the Governor to address the overcrowding crisis, including a proposal for “two new prisons and space for 83,000 prisoners to address California’s current and future incarceration needs.” Id. at 7. The California Legislature rejected all of these proposals. Id. As a result, the Governor invoked his powers under the California Emergency Services Act to call for immediate efforts to transfer inmates to out-of-state correctional facilities, as well as the suspension of state contracting laws so that the CDCR could contract for all goods and services “needed to immediately mitigate the severe overcrowding and the resulting impacts within California.” Id. at 8-9.

The California Correctional Peace Officers’ Association (“CCPOA”), a plaintiffintervenor in this case, challenged the validity of the Proclamation in state court. On June 4, 2008, the California Court of Appeal upheld the Proclamation, finding that the Governor acted within his authority, in part because the declaration of emergency was based on conditions that presented extreme peril to the safety of persons and property. CCPOA v. Schwarzenegger, 163 Cal.App.4th 802 , 77 Cal. Rptr.3d 844 (2008). The Proclamation declaring a state of emergency remains in effect. Fact # 12, Nov. 17, 2008 Joint Statement of Undisputed Facts.

E. Motions To Convene Three-Judge Court and Subsequent Prison Studies by the State of California

1. Motions To Convene and Initial Proceedings

Following the Governor’s issuance of the State of Emergency Proclamation, the plaintiffs in Plata and Coleman filed mo *913 tions to convene a three-judge court to limit the prison population. 38 The Plata court continued the hearing on its motion to provide defendants with an opportunity to outline specific measures they were taking or planned to take to alleviate crowding, as well as to allow the Plata Receiver to analyze the effects of crowding on his remedial efforts. Feb. 15, 2007 Order in Plata at 4-5. Similarly, the Coleman court, after oral argument, continued the hearing for six months to permit defendants to demonstrate sufficient progress in their remedial efforts and in relieving prison overcrowding such that convening a three-judge court would not be necessary. Dec. 11, 2006 Rep. Tr. in Coleman, passim; Dec. 12, 2006 Order in Coleman at 1 .

2. Intervening Reports on Prison Crowding

During the period in which the motions to convene a three-judge court were pending, two more reports concerning prison overcrowding were presented to the California Legislature. First, in January 2007, the Little Hoover Commission, a bipartisan and independent state body charged with conducting research and preparing recommendations to improve the economy, efficiency, and service of California state government, Cal. Gov’tCode §§ 8501, 8521-8522, echoed the concerns in the Governor’s State of Emergency Proclamation, stating that “California’s prisons are out of space and running out of time.” Ex. P3 at 1. In its report, entitled “Solving California’s Corrections Crisis: Time Is Running Out,” the Commission, which had previously issued a series of reports on California’s prisons, id. at 13, again offered “comprehensive recommendations” to reduce the prison population, improve public safety, and manage public dollars, id. at 1. Second, in June 2007, the Expert Panel on Adult Offender Recidivism Reduction Programming — a panel convened by the CDCR and consisting of the CDCR’s Chief Deputy Secretary for Adult Programs and a number of academic experts, consultants, and former and current secretaries of corrections in Pennsylvania, Arizona, Washington, Ohio, and Maine, 39 Ex. P2 at ii— issued a report recommending a course of action to reduce the prison population while at the same time reducing recidivism and generating savings. Ex. P2.

The first recommendation of both the Little Hoover Commission and the CDCR Expert Panel was to reduce prison overcrowding. Ex. P3 at iv; Ex. P2 at 10. Both panels noted that the state had received numerous reports over the past two decades containing recommendations for reducing the state’s prison population. Ex. P3 at iv; Ex. P2 at 10 & App. A. Although the Expert Panel was convened to make recommendations for reducing California’s high recidivism rate and “improving the programming in California’s prison and parole system,” Ex. P2 at vii, and not for “solving the overcrowding problem,” id. at 10, the panel nonetheless found that California’s prisons were “dangerously overcrowded” and that reducing overcrowding was a “ ‘pre-condition’ to [the] success” of its mission, id. at viii.

*914 3. Final Hearing and Rulings

On June 27, 2007, the Plata and Coleman courts jointly heard oral argument on plaintiffs’ motions to convene a three-judge court. Persuaded that the state had not adequately addressed its prison overcrowding crisis so as to make possible the remedying of the constitutional violations, and that consideration of a population reduction order was necessary in order to achieve that objective in both cases, both courts granted plaintiffs’ motions. July 23, 2007 Order in Plata, 2007 WL 2122657 ; July 23, 2007 Order in Coleman, 2007 WL 2122636 .

The Plata court found that although “the Receiver has made much progress since his appointment,” the establishment of the Plata Receivership did not require the court “to wait more time, potentially years, to see whether the Receiver’s plans will succeed or fail.” July 23, 2007 Order in Plata, 2007 WL 2122657 , at *3. It found that the unconstitutional conditions that led to the Receiver’s appointment continued to exist. The Plata court explained:

Had the Receiver reported to the Court that he did not view overcrowding to be a substantial impediment to implementing the reforms required in this case, the Court may well have reached a different conclusion regarding the appropriateness of convening a three-judge court to consider a prisoner release order. However, quite to the contrary, the Receiver’s reports indicate that overcrowding is a serious problem that impacts, for example, his ability to develop adequate reception centers and health facilities because of the high numbers of inmate transfers and the inadequate amount of available health care beds and other physical space. Receiver’s Report Re: Overcrowding [Ex. D1092] at 26-28. Overcrowding also negatively impacts the Receiver’s ability to hire and retain competent medical

and managerial staff. Id. at 24-26 . Beyond that, the Receiver reports that:

Every element of the Plan of Action faces crowding related obstacles. Furthermore, overcrowding does not only adversely impact the Receiver’s substantive plans, it also adversely impacts on the very process of implementing remedies because overcrowding, and the resulting day to day operational chaos of the CDCR, creates regular “crisis” situations which call for action on the part of the Receivership and take time, energy, and person power away from important remedial programs.

Id. at 28-29 ....

Tellingly, the Receiver’s concerns about the impacts of overcrowding on his ability to reform the medical health care delivery system became even stronger in the weeks following his initial report. In his supplemental report, filed just four weeks after his initial report, the Receiver concluded that: “Mission changes, yard flips, and prison-to-prison transfers, aggravated by the limited alternatives imposed by overcrowding, are now assuming a size, scope and frequency that will dearly extend the timeframes and costs of the receivership and may render adequate medical care impossible, especially for patients who require longer term chronic care.” Receiver s Sup 1. Report Re: Overcrowding [Ex. D1094] at 10 (emphases added). While the Court appreciates Defendants’ statements that greater coordination between the State and the Receiver will alleviate some of the Receiver’s concerns, such sentiments only underscore the Receiver’s expressed concerns that overcrowding presents serious problems not only because of the substantive ways in which it interferes with delivery of medical care, but also because of the amount of time and attention the Re *915 ceiver must devote to dealing with crowding-related issues. It is clear to the Court that the crowded conditions of California’s prisons, which are now packed well beyond their intended capacity, are having — and in the absence of any intervening remedial action, will continue to have — a serious impact on the Receiver’s ability to complete the job for which he was appointed: namely, to eliminate the unconstitutional conditions surrounding delivery of inmate medical health care.

Id. at *4 (last emphasis added).

The Coleman court found that between 1997 and 2005, defendants had made “slow but evident progress toward constitutional compliance,” but that, “[i]n spite of the commendable progress ..., defendants’ mental health care delivery system has not come into compliance with the Eighth Amendment at any point since this action began.” July 23, 2007 Order in Coleman, 2007 WL 2122636 , at *3. The Coleman court further found that:

Several prisons remain notable exceptions to the progress made at others, and delays in access to care at the highest level of need — mental health crisis beds, acute inpatient care, and intermediate inpatient care — have plagued the CDCR throughout the course of this litigation. Moreover, defendants’ efforts at long-range planning for the delivery of mental health care continues to be hampered by inadequacies in the capture and collection of data and the use of outdated methodologies to interpret that data.

... [0]n May 31, 2007, the Special Master reported that programming space, beds for mentally ill inmates, and staffing levels have all been “impacted seriously by overcrowding.” Special Master’s Response to Court’s May 17, 2007 Request for Information, filed May 31, 2007, at 4-14 (“Special Master’s May 31, 2007 Response”). The staffing shortages alone mean that the CDCR only has enough staff “to provide full mental health services to roughly two-thirds of its mental health caseload, or two-thirds of required services to its full caseload, or, probably more realistically, some combination of reduced services to some segments of the caseload that can be covered with a third less clinicians than required.” Id. at 11-12. While acknowledging the difficulties in quantifying precisely the scope of the unmet mental health needs, the Special Master reports that,

defendants cannot meet at least a substantial portion, amounting in some loose amalgam to about 33 percent, of acknowledged mental health needs with current staffing resources. Insufficient intensive mental health treatment beds and a chronic lack of programming space for mental health treatment contribute further to defendants’ inability to meet required mental health services. All three deficiencies are unquestionably exacerbated by overcrowding.

Id. at 14. With a mental health caseload of almost 33,000 inmates, id. at 2, this level of unmet needs is unconscionable.

Id. at *3-*4 (footnote omitted).

In their orders granting plaintiffs’ motions, the Plata and Coleman courts recommended that the cases be assigned to the same three-judge court “[f]or purposes of judicial economy and avoiding the risk of inconsistent judgments.” July 23, 2007 Order in Plata, 2007 WL 2122657 , at *6; see also July 23, 2007 Order in Coleman, 2007 WL 2122636 , at *8. The Chief Judge of the United States Court of Appeals for the Ninth Circuit agreed and, on July 26, 2007, convened the instant three-judge district court pursuant to 28 U.S.C. § 2284 .

*916 F. Proceedings Before this Three-Judge Court

In August and September 2007, this court granted motions to intervene on behalf of defendants filed by groups of district attorneys; sheriffs, police chiefs, and probation officers (collectively “law enforcement intervenors”); counties; and Republican state Senators and Republican Assembly Members. We note that the Republican state Senators and Republican Assembly Members constitute just over a third of the membership of each respective body. We also granted the CCPOA’s motion to intervene on behalf of plaintiffs.

On November 1, 2007, we appointed a settlement referee, former state Court of Appeal Justice Elwood Lui, and a settlement consultant, current state Court of Appeal Justice and former Legal Affairs Secretary to Governor Schwarzenegger, Peter Siggins, to aid the parties and intervenors in settlement discussions. Nov. 1, 2007 Order at 1-2. However, the settlement efforts ultimately proved unsuccessful, as Justices Lui and Siggins reported to the three-judge court on June 25, 2008.

On September 15, 2008, defendants filed a motion for summary judgment, which we denied by written order on November 3, 2008. Trial commenced on November 18, 2008, and concluded on December 19, 2008, after fourteen court days in which we heard testimony from nearly fifty witnesses, received written testimony from several additional witnesses, and received hundreds of exhibits into evidence. Following the close of evidence, we received proposed findings of fact and conclusions of law from the parties and intervenors and heard final argument on February 3 and 4, 2009.

To assist the parties in planning their further actions, we issued a tentative ruling on February 9, 2009, explaining that plaintiffs had met their burden of proof and that a population reduction order was necessary to remedy the constitutional violations concerning the provision of medical and mental health care in California’s prisons. We even gave the state an indication of the range within' which the population cap would fall. In our tentative ruling, we once again asked whether a court-appointed settlement referee would be of assistance. Plaintiffs and intervenors expressed a willingness to engage in further settlement discussions, but the state defendants responded that they did not believe such efforts would be fruitful.

After carefully reviewing all of the evidence and oral and written arguments presented in this proceeding, we make the following findings of fact and conclusions of law and issue the following order. This opinion and order supersedes the tentative ruling in its entirety.

III. LEGAL FRAMEWORK

Federal courts have long recognized that population reduction orders may sometimes be necessary to ensure constitutional prison conditions. For example, in Duran v. Elrod, 713 F.2d 292 (7th Cir. 1983), the Seventh Circuit upheld a district court’s order requiring a reduction in the population of the Cook County Department of Corrections, finding that the order was “sensitive to[ ] ... the principles of federalism,” id. at 297 , and that the district court “acted fairly and reasonably to ease a critical problem” of overcrowding in the face of “substantial noncompliance” by Cook County, id. at 298 . Likewise, in Newman v. Alabama, 683 F.2d 1312 (11th Cir.1982), the Eleventh Circuit found that, where Alabama’s county jails were unconstitutionally overcrowded, a cap on the state inmate population in the county jails “represented] the proper balance between the duty of the district court to remedy constitutional violations and the right of the State to administer its prison and parole systems,” id. at 1321 . There are other examples as well, including a continuing *917 cap on Los Angeles County’s jail population stipulated to by the parties in Rutherford v. Pitchess, No. CV 75-4111 (C.D.Cal.).

Until 1996, federal courts relied upon general principles of equitable relief and federalism in deciding whether to enter a population reduction order to remedy constitutional violations. However, in 1996 Congress enacted the Prison Litigation Reform Act (“PLRA”), Pub. L. No. 104-134, 110 Stat. 1321 (codified in relevant part at 18 U.S.C. § 3626 ). The PLRA established “a comprehensive set of [statutory] standards to govern prospective relief in prison conditions cases.” Gilmore v. California, 220 F.3d 987, 998 (9th Cir. 2000). Because there is no dispute that both the Plata and Coleman lawsuits are “civil action[s] with respect to prison conditions,” the matter before us is governed by the statutory requirements of the PLRA. 18 U.S.C. § 3626 (a)(1).

The PLRA contains two sets of requirements that are relevant here: one applicable to all forms of “prospective relief’ in federal prison conditions lawsuits, see id., and another applicable only to “prisoner release orders,” see id. § 3626(a)(3). The PLRA defines a “prisoner release order” as “any order ... that has the purpose or effect of reducing or limiting the prison population, or that directs the release from or nonadmission of prisoners to a prison.” Id. § 3626(g)(4). Under this definition, a “prisoner release order” includes not only an order requiring the release of presently incarcerated inmates, but also an order requiring the diversion of convicted persons from prison, changing the treatment of parole violators in order to prevent their return to overcrowded prisons, or imposing a cap on the prison population or any part of it. See, e.g., Tyler v. Murphy, 135 F.3d 594, 595-96 (8th Cir.1998) (finding a cap on the number of technical probation violators who could be admitted to a particular facility to be a “prisoner release order”). There is no dispute that the population reduction order requested by the plaintiffs falls within the PLRA’s definition of “prisoner release order” because the order would have the “purpose” of “limiting the prison population.” 18 U.S.C. § 3626 (g)(4). Accordingly, this court can grant the plaintiffs’ request for a population reduction order only if the proposed order meets both the PLRA’s specific standard for prisoner release orders and its general standard for prospective relief in prison conditions cases.

A. The PLRA Standard for Prisoner Release Orders: Primary Cause and No Other Relief

The PLRA does not prohibit courts from entering an order requiring a reduction in the population of a prison or prison system. To the contrary, in enacting the PLRA, Congress was clear to state that “a court still retains the power to order [a population reduction order]” when such an order “is truly necessary to prevent an actual violation of a prisoner’s federal rights.” H.R. Rep. No. 104-21, at 25 (1995); cf. 141 Cong. Rec. S14419 (daily ed. Sept. 27, 1995) (statement of Sen. Abraham) (noting that the PLRA permits “narrowly tailored order[s] to correct” constitutional violations and that the PLRA “allows the courts to step in where they are needed”). 40 Rather than barring *918 “prisoner release orders” altogether, the PLRA simply makes such orders, including population caps and other population reduction orders, “the remedy of last resort.” H.R. Rep. No. 104-21, at 25.

It does so by imposing a number of restrictions on the entry of prisoner release orders. First, a court considering such an order must find that “a court has previously entered an order for less intrusive relief that has failed to remedy the deprivation of the Federal right sought to be remedied through the prisoner release order,” and that “the defendant has had a reasonable amount of time to comply with the previous court orders.” 18 U.S.C. § 3626 (a)(3)(A). If both of these requirements are met, the court must request that a three-judge district court be convened to consider the propriety of the proposed order. Id. § 3626(a)(3)(B). Finally, the three-judge court must find by clear and convincing evidence (1) that “crowding is the primary cause of the violation of the Federal right,” and (2) that “no other relief will remedy the violation of the Federal right.” Id. § 3626(a)(3)(E).

Before convening the present three-judge court, the Plata and Coleman courts found that their prior orders for less intrusive relief had failed to remedy the unconstitutional denial of adequate medical and mental health care to prisoners in California’s prisons, and that the defendants have had a more than reasonable amount of time to comply with those prior orders. See July 23, 2007 Order in Plata, 2007 WL 2122657 , at *3; July 23, 2007 Order in Coleman, 2007 WL 2122636 , at *2. Accordingly, the findings required by § 3626(a)(3)(A) have been made. The procedural history described above clearly establishes that the Plata and Coleman courts have previously entered orders for less intrusive relief that have failed to remedy the constitutional deprivations at issue in each case despite the reasonable time given to defendants to comply with those orders. In this opinion and order, we primarily consider the requirements of § 3626(a)(3)(E) — whether crowding is the “primary cause” of the unconstitutional denial of adequate medical and mental health care to California’s prisoners, see infra Section IV, and whether any other form of relief could remedy those constitutional violations, see infra Section V.

B. The PLRA Standard for All Prospective Relief: Need-Narrowness-Intrusiveness and Consideration of Public Safety

In addition to these specific limitations on the entrance of prisoner release orders, the PLRA establishes a standard applicable to all forms of prospective relief in prison conditions lawsuits. First, the PLRA requires that such relief “[be] narrowly drawn, extend[] no further than necessary to correct the violation of the Federal right, and [be] the least intrusive means necessary to correct the violation of the Federal right.” 18 U.S.C. § 3626 (a)(1)(A). Rather than imposing any new limitations on federal authority, this provision codifies the common-law standard for injunctive relief, generally referred to as the “need-narrowness-intrusiveness” standard. See H.R. Rep. 104-21, at 24 n.2 (1995) (explaining that the “dictates of [ 18 U.S.C. § 3626 (a)(1) ] are not a departure from current jurisprudence concerning injunctive relief’); see also Armstrong v. Davis, 275 F.3d 849, 872 (9th Cir.2001); Smith v. Ark. Dep’t of Corr., 103 F.3d 637 , 647 (8th Cir.1996); Williams v. Edwards, 87 F.3d 126 , 133 n. 21 (5th Cir.1996). 41 Likewise, the PLRA requires *919 that any prospective relief “extend no further than necessary to correct the violation of the Federal right of a particular plaintiff or plaintiffs.” 18 U.S.C. § 3626 (a)(1)(A); cf. Lewis v. Casey, 518 U.S. 343, 357-360 , 116 S.Ct. 2174 , 135 L.Ed.2d 606 (1996) (holding that the remedy in a prison conditions case must remedy actual injuries that have been identified by the court and suffered by the plaintiffs). In class action lawsuits such as Plata and Coleman, the PLRA requires that the remedy be tailored to the actual injuries suffered by class members. See Armstrong, 275 F.3d at 870-73 .

Second, the PLRA requires that any court considering the entry of prospective relief give “substantial weight” to any adverse impact the order might have on public safety or the operation of the criminal justice system. 18 U.S.C. § 3626 (a)(1)(A); see also H.R. Rep. No. 104-21, at 24 (1995) (stating that courts must give “appropriate consideration” to “any potential impact on public safety or the criminal justice system”). This requirement codifies the longstanding common law requirement that federal courts “pay particular regard for [] public consequences in employing the extraordinary remedy of injunction.” Weinberger v. Romero-Barcelo, 456 U.S. 305, 312 , 102 S.Ct. 1798 , 72 L.Ed.2d 91 (1982); see also Yakus v. United States, 321 U.S. 414, 440 , 64 S.Ct. 660 , 88 L.Ed. 834 (1944).

We address the “need-narrowness-intrusiveness” standard in Section VI and consider the impact of the order we adopt on public safety and the operation of the criminal justice system in Section VII.

C. The Remedial Nature of the Three-Judge Court Proceeding

The question before this three-judge court is whether the remedy requested by the plaintiffs is proper as a matter of federal law. The Plata and Coleman courts years ago identified the constitutional deficiencies underlying this proceeding. Since that time, both cases have been in their remedial phase. After prior remedial efforts failed, the Plata and Coleman courts both faced the question whether an order requiring a reduction in the population of California’s prisons was necessary to remedy the previously identified constitutional violations, and both concluded that such an order should be considered by a three-judge court.

We need not yet again evaluate the state’s continuing constitutional violations. In requesting that this three-judge court be convened, the Plata and Coleman courts both found, without objection from defendants, that the constitutional violations were ongoing. See July 23, 2007 Order in Plata, 2007 WL 2122657 , at *3; July 23, 2007 Order in Coleman, 2007 WL 2122636 , at *4. That is sufficient under the PLRA. In addition, defendants have never filed a motion to terminate under § 3626(b), the proper means for any challenge to the existence of “current and ongoing” constitutional violations relating to the provision of medical and mental health care in the California prisons. Moreover, even if we were required to find independently that the requirements of § 3626(a)(3)(A) — including its requirement that prior orders have “failed to remedy the deprivation of the Federal right”— have been met, we did so in denying defendants’ motion for summary judgment, Nov. *920 3, 2008 Order at 6-7, 2008 WL 4813371 . Accordingly, the question we must answer in this opinion and order is entirely remedial, i.e., whether the plaintiffs’ proposed remedy meets the imposing standards established by the PLRA. 42

IY. CROWDING AS PRIMARY CAUSE

The extent of overcrowding in the California prison system, approximately 190% of systemwide design capacity, is “extraordinary” and “almost unheard of.” Rep. Tr. at 297:1-17, 298:19-20 (Haney). The problem is “widespread” and “not restricted to just a few institutions. It’s occurred throughout the system.” Id. at 297:23-25 . There would seem to be no dispute about the egregious nature of the overcrowding in this case. Under the PLRA, however, the question is whether clear and convincing evidence establishes that the overcrowding is the primary cause of the unconstitutional denial of adequate medical and mental health care to California’s prisoners. 18 U.S.C. § 3626 (a)(3)(E)®. Only if it is may the court — a three-judge court — enter a population reduction order. Defendants do not contest that prison crowding impedes the delivery of constitutionally adequate medical and mental health care in the California prison system. They claim only that crowding is not the primary cause of the violations of plaintiffs’ constitutional rights. E.g., Rep. Tr. at 2953:6-11 (closing argument by defendants’ counsel).

We accept defendants’ proposed definition of “primary cause” as the cause that is “first or highest in rank or importance; chief; principal.” Random House Webster’s Unabridged Dictionary 1537 (2d ed. 1998) (defining “primary”). 43 We note, however, that the PLRA does not require that crowding be the only cause of the constitutional violations at issue. “Probably it cannot be said of any event that it has a single causal antecedent; usually there are many.” 4 Harper, James and Gray on Torts § 20.2 (3d ed. 2007). The PLRA’s “primary cause” standard incorporates this basic aspect of causation. By requiring only that crowding be the primary cause of the constitutional violations at issue, the PLRA’s language explicitly contemplates that secondary causes may exist. Had Congress intended to require that crowding be the only cause, it would have used language to that effect — for example, “exclusive” or “only” instead of “primary.”

As all of the parties to this proceeding have recognized, in the context of prison conditions litigation “crowding” refers to the presence in a facility or prison system of a prisoner population exceeding that facility or system’s capacity. See, e.g., Doty v. County of Lassen, 37 F.3d 540, 543 (9th Cir.1994) (finding overcrowding where a jail’s actual population exceeded its design capacity by an average of approximately fifty percent); Hoptowit v. Ray, 682 F.2d 1237 , 1248-49 (9th Cir.1982) (finding a penitentiary overcrowded where its population exceeded its design capacity); see also Lareau v. Manson, 651 F.2d 96 , 99-100 (2d Cir.1981); cf. Random House Webster’s Unabridged Dictionary 482 (2d ed. 1998) (defining “crowded” as “filled to excess”). In other contexts, the term “overcrowding” would ordinarily be used. Here, the words crowding and over *921 crowding have the same meaning, and we use them interchangeably.

A prison system’s capacity is not defined by square footage alone; it is also determined by the system’s resources and its ability to provide inmates with essential services such as food, air, and temperature and noise control. Following the parties’ lead, we will discuss the capacity of the California prison system primarily in terms of design capacity. As the Corrections Independent Review Panel explained, design capacity “designate^ the number of inmates a prison is designed to accommodate according to standards developed by the Commission on Accreditation and the American Correctional Association.” Ex. P4 at 123. These standards “take into account the need for humane conditions, as well as the need to prevent violence and move inmates to and from programs, such as mental health care, education classes, and drug abuse treatment.” Id.

Taking into account the meaning of “primary cause” and the criteria governing “crowding,” we must determine whether the presence in California’s prison system of a prison population almost double the system’s design capacity is the principal cause of the failure to provide constitutionally adequate medical and mental health care to the members of the Plata and Coleman classes.

As we discuss below, the evidence presented at trial, including testimony from defendants’ experts, admissions by defendants and their agents, and data maintained by defendants, overwhelmingly establishes not only that crowding adversely affects every aspect of prison administration, forcing a constant state of crisis management, but also that crowding creates numerous barriers to the provision of medical and mental health care that result in the constitutional violations we consider here. These barriers include severe space and other shortages that prevent inmates from receiving the care they require. Crowding also renders the state incapable of maintaining an adequate staff and an adequate medical records system. In addition, crowding causes prisons to rely on lockdowns, which further restrict inmates’ access to care, and it forces prisons to house inmates in non-traditional settings, such as triple-bunks in gyms and day-rooms not designed for housing, that contribute to the lack of care and the spread of infectious disease and that increase the incidence and severity of mental illness among prisoners.

Multiple experts testified that crowding is the primary cause of the constitutional violations at issue in Plata and Coleman. Most impressive, four current or former prison administrators so testified. These four correctional experts had, collectively, administered the correctional systems of five different states, including California. 44 Three had never before testified on behalf of a prisoner, and two were not paid for their time as experts. A number of medical and mental health experts also testified that crowding is the primary cause of the constitutional violations, and even defendants’ own mental health expert testified that crowding is the primary cause of defendants’ inability to provide adequate care to the Coleman class at reception centers. Dec. 10, 2007 Packer Report at 20. As the Secretary of the Pennsylvania Department of Corrections testified, “the biggest inhibiting factor right now in California being able to deliver appropriate mental health *922 and medical care is the severe overcrowding of [the] system.” Rep. Tr. at 219:7-10 (Beard). We agree. For the reasons we discuss below, we conclude that clear and convincing evidence establishes that crowding is the primary cause of the unconstitutional denial of medical and mental health care to California’s prisoners.

A. General Problems in the Delivery of Medical and Mental Health Care Caused by Crowdiny

Correctional experts agree that crowding “affects virtually every aspect of a prison’s operation.” Aug. 15, 2008 Lehman Report ¶ 10 (expert report from former head of corrections in Pennsylvania, Washington, and Maine). Jeanne Wood-ford, the former head of corrections in California, testified that, under crowded conditions, there “are simply too many issues that arise from such a large number of prisoners and staff. One result of this is that management spends virtually all of its time fighting fires instead of engaging in thoughtful decision-making and planning. This results in short-sighted decisions that create even more crises.” Nov. 9, 2007 Woodford Report ¶ 12. Doyle Wayne Scott, a thirty-year employee of the Texas Department of Criminal Justice who served as its Executive Director for five years, explained:

Overcrowding has burdened CDCR’s inadequate management systems that underlie health care delivery. The excessive population leads to management failures in two ways. First, overcrowding engenders a state of perpetual crisis that causes management failures. Administrators spend their time doing damage control, rather than making sure the prison is operating properly and prisoners are getting the services that they need.... A population of 7,000 or more, as is found in some California prisons, is not manageable at all. The sheer size and complexities of managing a prison that size would be overwhelming for one manager especially with the limited resources in the areas of staffing and inadequate space for services to the offenders that I observed at all of the prisons I toured in California. One warden simply cannot know what he/she needs to know on a daily basis to make good informed management decisions.

Second, overcrowding overwhelms management infrastructure. As I have read in numerous reports of the Receiver, the CDCR lacks the management information systems needed to adequately organize and track prisoner transfers for specialized medical and mental health care and public health related needs (for example, people with compromised immune systems not going to Valley Fever risk areas) in the severely overcrowded conditions.

Nov. 9, 2007 Scott Report ¶¶ 1, 76-77. Secretary Woodford concluded that crowding makes it “virtually impossible for the organization to develop, much less implement, a plan to provide prisoners with adequate care”; “[i]n [her] opinion, it is all but impossible to safely and humanely incarcerate this many prisoners within the existing facilities.” Nov. 9, 2007 Woodford Report ¶¶ 10,12.

As put in the most simple terms by Secretary Woodford, who recently administered the California prison system and who shortly before that was the warden at San Quentin, “[o]vercrowding in the CDCR is extreme, its effects are pervasive and it is preventing the Department from providing adequate mental and medical health care to prisoners.” Aug. 15, 2008 Woodford Supp. Report ¶ 31. While defendants dispute that crowding is the primary cause of the ongoing constitutional violations in Plata and Coleman, they do not dispute that crowding makes the delivery of adequate medical and mental health *923 care in the California prison system extremely difficult. Matthew Cate, the current head of the CDCR and a defendant in this proceeding, stated that “overpopulation makes everything we do more difficult,” Rep. Tr. at 1688:19-20, and further agreed that crowding continues to “severely hamper[ ]” the Department’s ability “to provide inmates with adequate medical care in a fiscally sound manner,” id. at 1683:8-19 (testimony that statements in the Office of the Inspector General’s 2006 audit of the CDCR, issued when Cate was the Inspector General, continue to be true today); Ex. P46 at ES-1 (April 2006 Office of the Inspector General Accountability Audit, Review of Audits of the California Department of Corrections and Rehabilitation Adult Operations and Adult Programs, 2000-2004). James Tilton, Cate’s predecessor as Secretary of the CDCR, likewise explained that it “was clear” to him that crowding, and the resulting lack of space, adversely affected the delivery of medical and mental health care. Sept. 3, 2008 Tilton Dep. at 80:5-25. Similarly, John Dovey, a former CDCR official, testified before a state Senate committee in August 2006 that “the risk of catastrophic failure in a system strained from severe overcrowding is a constant threat. As the Director of the Division of Adult Institutions [for the CDCR], it is my professional opinion this level of overcrowding is unsafe and we are operating on borrowed time.” Ex. P72 at 15 (Aug. 15, 2006 CDCR Presentation to Senate Select Committee on Prison Population Management and Capacity). Before this court, Robin Dezember, then the Chief Deputy Secretary of the Correctional Healthcare Services Division of the CDCR, stated his “belief that we are terribly overcrowded in our prison system,” and that crowding adversely affects the delivery of mental health care services. Rep. Tr. at 853:13-15, 21-24. Even defendants’ expert Dr. Ira Packer opined that “the overcrowding in CDCR significantly contributes to the difficulties in providing adequate mental health services.” Dec. 10, 2007 Packer Report at 8.

B. Space Issues Affecting the Delivery of Care

The evidence before us demonstrates that crowding causes a number of specific problems central to the ongoing violation of California inmates’ constitutional right to adequate medical and mental health care. One of the clearest effects of crowding is that the current prison system lacks the physical space necessary to deliver minimally adequate care to inmates. This manifests itself in a variety of areas, each of which we discuss below.

1. Reception Centers

The medical and mental-health related problems caused by crowding are immediately apparent at the state’s reception centers. Each year, California admits approximately 140,000 inmates into the state prison system. Rep. Tr. at 224:17-18 (Beard); see also Aug. 15, 2008 Austin Report ¶¶ 45-46 & Table 3; Ex. P18 at 3; Ex. P19 at 2; Ex. P75 at 3. 45 The CDCR’s reception centers are the locus of the intake and classification functions for all of these inmates. See Nov. 9, 2007 Austin Report ¶¶ 27-28; Aug. 15, 2008 Austin Report ¶ 97. The CDCR has reception centers at twelve prisons, nine at male institutions and one at each of the state’s three *924 female prison institutions. Ex. P135 at 3-4. As of August 2008, all but one of these reception centers were near or over 200% design capacity, and two were over 300% design capacity. Id. This severe crowding at the reception centers makes it impossible to provide adequate medical and mental health services to inmates entering the California prison system. In addition, severe crowding throughout the system forces prisons to house inmates in these reception centers without adequate care for extended periods of time.

As the Plata Receiver explained, reception centers “must be staffed and have the appropriate clinical space to provide a level of medical care and clinical evaluations above that of the general population institutions.” Ex. D1092 at 19 (Plata Receiver’s May 15, 2007 Report Re: Overcrowding). 46 Each time an individual is admitted to the CDCR, whether for the first time, by re-offending, or on a parole violation:

he or she returns to the CDCR through a reception center where a medical/mental health/dental health care appraisal must be performed. Once that appraisal is completed the newly received prisoner is transferred to an open bed at a prison which has been designated for his or her classification. However, none of the CDCR’s designated reception centers were designed or constructed with adequate clinical space [to perform these functions].

Id.; see also, e.g., Aug. 15, 2008 Haney Report ¶¶ 246-247 (describing space shortages at the California Correctional Institution reception center, including a holding room containing three holding cells that “were originally intended to hold disciplinary cases but now have been converted to mental health use”). “To make matters worse, as the original prisons designated for reception became overwhelmed by the influx of parole violators, the CDCR was forced to ‘convert’ general population prisons into reception centers. These ‘conversions,’ however, were not accompanied by adequate additions to clinical staff or clinical space.” Ex. D1092 at 19; see also, e.g., Nov. 9, 2007 Stewart Report ¶ 48 (because reception center at DVI “was not designed as a reception center, it has been difficult to find space for various reception center functions”).

Without sufficient space, reception centers are unable to screen or treat inmates adequately. For instance, as plaintiffs’ medical expert Dr. Ronald Shansky explained, the number of prisoners who must be processed at the reception center at CIM “exceeds the number of patients that can be adequately treated,” thereby forcing the prison to “squeeze[ ] too many prisoners and too many providers into the available treatment area.” Nov. 9, 2007 Shansky Report ¶ 12. Exams are conducted in areas separated only by “a thin white fabric folding screen that is approximately five to six feet tall” and conversations between physicians and inmates can be overheard on the other side of the screen. Id. Similarly, at North Kern State Prison, inmate health interviews are conducted in a small office, “with prisoners sitting back to back, separated only by a shoulder-high divider.” Sept. 10, 2008 Shansky 2d Supp. Report ¶ 23. Such conditions do not allow for appropriate confidentiality, causing prisoners to be “less likely to provide accurate information about sensitive medical and psychiatric conditions.” Id. ¶ 24 ; see also Aug. 15, 2008 Haney Report ¶ 280 (psychiatrist and psychologist who work in the North Kern reception center “must share a converted cell that serves as their office”); Nov. 9, 2007 Stewart Report ¶ 48 (describing observations of small classroom at DVI reception center “where at any *925 time six psychologists simultaneously conduct reception center mental health assessments for new arrivals”); id. ¶ 82 (noting that the “[l]ack of adequate and appropriate space for reception center psychological screening was also apparent at DVT). -

Moreover, at North Kern, follow-up physical examinations are conducted in rooms that “are so small that it would be very difficult if not impossible to perform an actual physical examination in them,” so that the “‘exams’ that take place are in fact simply medical interviews, primarily for the purpose of determining what type of housing is appropriate for the prisoner.” Sept. 10, 2008 Shansky 2d Supp. Report ¶25. This violates the “basic principle that incoming prisoners must undergo a comprehensive exam upon arrival so that an adequate treatment plan may be developed and implemented. A physical exam, as opposed to a medical interview, is necessary because some conditions can be identified and confirmed only through physical examination of the patient.” Id. ¶ 26 ; see also Rep. Tr. at 224:10-225:15 (Beard) (testifying that the number of people coming in through reception centers may cause prisons to “miss people who have certain needs and certain care needs that aren’t being dealt with”). The medical facilities at North Kern are also so “inadequate” that defendants cannot comply with the Plata policies and procedures they agreed to implement, which provide for a complete history and physical examination of inmates within fourteen days of arrival at a reception center. Sept. 10, 2008 Shansky 2d Supp. Report ¶ 22.

The consequences of the state’s inability to screen inmates properly at the reception centers are obvious: If an inmate’s health needs are not identified, they cannot be treated. In addition, inmates whose needs are not identified may be placed in a setting that will exacerbate existing but unidentified health problems. Likewise, if the lack of confidentiality in the screening centers prevents inmates from reporting infectious diseases, the failure to diagnose them at the reception center may result in their being spread throughout the prison population.

In addition to preventing the reception centers from properly screening newly admitted inmates, crowding at the reception centers prevents the provision of adequate care to the inmates housed there. As numerous experts, including defendants’ own mental health expert, testified, the number and types of inmates in the centers overwhelms their capacity to provide adequate medical or mental health care services. Rep. Tr. at 1121:16-19 (Packer); Rep. Tr. at 368:12-369:4 (Woodford) (mentally ill inmates did not receive “really any treatment” at San Quentin reception center beyond identification as CCCMS or EOP and certainly not anything “to prevent further deterioration of people’s mental illness”); Aug. 15, 2008 Stewart Supp. Report ¶ 136 (“CDCR’s Reception Centers are dangerously overcrowded and do not and cannot provide appropriate mental health care for anyone”); Sept. 10, 2008 Shansky 2d Supp. Report ¶ 79 (“acute staffing shortage, coupled with the lack of clinical exam space” prevents North Kern State Prison from providing incoming inmates with comprehensive physical examination or follow-up appointments with primary care providers); Rep Tr. at 368:12-22 (Woodford) (at San Quentin reception center, due to vacancies and “just the sheer numbers and lack of space,” medical staff “were unable to keep up with physicals or providing any kind of chronic care follow-up”).

If California’s inmates spent only a brief time at the reception centers before being placed in other facilities, the centers’ inability to provide adequate medical and *926 mental health care to the inmates housed there would constitute ■ a less substantial aspect of the constitutional violations at issue in this proceeding. However, inmates in California are “tend[ing] to spend significantly longer periods of time in reception centers.” Nov. 9, 2007 Stewart Report ¶ 24; see also Nov. 9, 2007 Austin Report ¶ 27 (reporting that the CDCR routinely fails to meet its mandate to transfer inmates from reception centers to mainline institutions within sixty days). As one of plaintiffs’ experts Dr. James Gilligan explained, “The dramatic levels of prison overcrowding through the state mean that individuals coming into prison are housed in ‘Reception Centers’ for extended periods of time, far longer than intended.” Aug. 15, 2008 Gilligan Report ¶26 (footnotes omitted).

The consequences of the increased lengths of stay at the reception centers along with the lack of space in those centers are particularly grave for Coleman class members. Dr. Packer, defendants’ mental health expert, reported that mentally ill individuals “often enter[ ] the prison system with a more acute mental health presentation, not having received adequate treatment in the community and/or having abused substances there.” Dec. 10, 2007 Packer Report at 20. These inmates are “disproportionately represented” among the parole violators returning to custody for short sentences, id., and are thus likely to spend their entire sentence at the reception center. Id. Because their sentences are so short, they are frequently discharged before receiving treatment and fall into “a vicious cycle, as they decompensate in the community and quickly return Id.; see also Aug. 15, 2008 Haney Report ¶¶ 358-59. (“[M]entally ill parolees often do not receive meaningful mental health treatment when they are on parole.... Frequently as a result of their decompensation, many are returned to prison, often for technical or minor violations. Thus, many of the parole violations that return them to prison are directly related to their unmet mental health needs. When they return to prison, these vulnerable prisoners are then packed into overcrowded reception centers.”).

The absence of adequate mental health care at reception centers also has significant adverse consequences for mentally ill inmates admitted to serve longer sentences in state prison. The shortage of mental health care beds throughout the prison system — which we discuss in more detail below — means that these inmates often spend months in a reception center with little or no access to necessary mental health care while waiting for a bed to open up. See, e.g., Nov. 9, 2007 Stewart Report ¶ 166 (discussing impact of delays in transfer of mentally ill inmates from reception centers to necessary level of care); Aug. 15, 2008 Haney Report ¶ 105 (discussing delays in transfer of EOP inmates out of CIM reception center); id. ¶ 129 (discussing prolonged reception center stays and minimal treatment provided for EOP and CCCMS inmates at CIM reported by Coleman Special Master). For example, the number of inmates in reception centers needing an EOP level of care 47 continues to grow, see Ex. P243 at 900004-06, 900121-23, but the EOP program provided to these inmates falls far below the care mandated by the Program Guide for EOP patients. Aug. 15, 2008 Haney Report ¶ 29 (citing September 2006 Program Guide, Ex. P9 at 12-4-1); see also Nov. 9, 2007 Stewart Report ¶ 167. This is not surprising, given that the conditions in these reception centers have been described as “toxic, noxious, psychologically and medically unhealthy,” Rep. Tr. at 953:13-14 (Haney), and that a lack of *927 treatment space severely impedes efforts to provide even the most rudimentary forms of mental health care in reception centers. E.g., Nov. 9, 2007 Stewart Report ¶ 80; Aug. 15, 2008 Haney Report ¶¶ 246, 247.

2. Treatment Space

The severe shortage of treatment space evident at CDCR reception centers affects the provision of medical and mental health care throughout the state prison system. Dr. Stewart reported that the “problem of adequate office and treatment space is endemic in the CDCR,” Nov. 9, 2007 Stewart Report ¶ 190, and the Plata Receiver noted in his Turnaround Plan of Action that “investments in health care facilities have significantly lagged behind growing inmate populations, so much so that available clinical space is less than half of what is necessary for daily operations.” Ex. D1133 at 25. In part, this is due to the CDCR’s policy and practice of anticipating that prisons will be filled beyond their design capacity, but not including sufficient health care space to serve the anticipated population. Ex. D 1092 at 20 (Plata Receiver’s May 15, 2007 Report Re: Overcrowding). Compounding problems caused by the lack of space, the space that does exist to provide health care services is often “woefully inadequate. Through years of neglect, the facilities have long since passed the time when modest investments could remedy the problem. We are dealing not with deferred maintenance, but with some facilities that are literally falling apart.” Ex. D1133 at 25.

The court received evidence of inadequate treatment space at a variety of prisons statewide. At Avenal State Prison, staff must attempt to provide care for 7,525 inmates in space designed for less than one-third of that number. Ex. D1233 at 25 (Plata Receiver’s Nov. 3, 2008 Analysis of Year 2007 Death Reviews). 48 At Mule Creek State Prison, a Plata Receivership team found that “[a]ll of the Facility Clinics are undersized for the quantity of inmate/patients seen on a daily basis and laek[] appropriate holding/waiting space for inmate/patients ducated [scheduled] to be seen by health care providers.” Ex. P101 at 7 (Plata Receiver’s Custody/Security Assessment for Health Care Access at Mule Creek State Prison).

One expert who testified at trial explained that crowding has so “over-taxed” the clinical facilities at California Institution for Men that, as with the reception center at the same prison, “fundamental medical confidentiality rights are routinely ignored” in the space used to provide care to inmates housed at the prison:

In the West facility clinic at CIM, two PCPs [primary care physicians] share one room and simultaneously see patients for sick call and other encounters. A thin fabric folding screen separates the area in which the doctors see patients from a single exam table which the PCPs must share, as the room is not large enough to accommodate a second table. In the same clinic, the registered nurse conducts face-to-face triage appointments with patients in a large room that is shared by another nurse (who may be seeing patients) and an office technician. These arrangements cannot provide for minimally adequate patient-provider privacy. Moreover, the medical treatment area is so small that there is no medically appropriate waiting area, so sick patients must wait for appointments on a small bleacher outside the clinic, exposed to the elements.

Nov. 9, 2007 Shansky Report ¶24. Dr. Shansky also testified about the shortage of clinical space he observed at several other prisons. Id. ¶¶ 16-23 (Valley State *928 Prison for Women, Avenal State Prison, and San Quentin); Sept. 10, 2008 Shansky 2d Supp. Report ¶¶ 31-46 (North Kern State Prison, Substance Abuse and Treatment Facility, Pleasant Valley State Prison, and California State Prison-Solano); see also Rep. Tr. at 663:22-665:10 (Rowlett) (testifying about clinical space shortage at California State Prison-Solano). Similarly, Secretary Woodford testified that “space represents a serious obstacle to the delivery of health care.” Aug. 15, 2008 Woodford Supp. Report ¶ 27; see also id. ¶¶ 27-29 (discussing space issues encountered on tours of the Correctional Training Facility (“CTF”) and California State Prison-Los Angeles County (Lancaster)).

As the Plata Receiver concluded in his supplemental report on overcrowding, “[t]here is a dire need for additional clinical space ... in the prisons because the existing capacity has been swamped by the number of inmates in the system.” Ex. D 1094 at 2 (Plata Receiver’s June 11, 2007 Supp. Report Re: Overcrowding). On the basis of all of the evidence received at trial, there is no doubt that crowding renders the existing clinical space in California’s prisons grossly inadequate.

3. Inability To House Inmates by Classification

Crowding also negatively impacts the state’s ability to house inmates according to their proper classification, which in turn creates inadequacies in the medical and mental health care that the system is capable of providing to inmates.

A prison classification system is “an objective tool” that allows correctional staff to consider individual factors, including “age, criminal history, educational levels or deficiencies, mental health issues, [and] medical issues” so that inmates can be placed “in the appropriate custody housing level.” Rep. Tr. at 149:18-24 (Scott). Prisoners in California are assigned to one of four levels of classification “based on the length of their sentence, their disciplinary history and other objective factors.” Nov. 9, 2007 Woodford Report ¶ 13.

In an overcrowded system, this classification system breaks down. A “well-functioning” system of classification should have no more than 10% of prisoners housed outside their classification level. Nov. 9, 2007 Scott Report ¶ 69. In California, population pressures have forced the CDCR to house an estimated 25% of inmates outside their classification levels. Id. This failure to house inmates within such levels “mak[es] it harder to provide for their medical and mental health care needs,” id. ¶ 68 , and deprives the overcrowded system of “the flexibility needed to respond to inevitable crises.” Id. As Director Scott explained, this “widespread rejection of CDCR’s classification system has a significant impact on medical and mental health care”:

[I]t is harder to get health care appointments within the prison as well as out-of-prison specialty appointments, and more limited staff contact means that staff are less responsive to emergencies due to distrust, lack of understanding and compassion, and simple logistics: it is harder to get staff attention in a high-pressure, high-security unit. In addition, prisoners are subject to increased degrees of danger and potential for violence because they are placed with more dangerous and violent prisoners than their classification scores would warrant.

Id. ¶ 71 . Similarly, Secretary Woodford testified that crowding makes it “impossible to move inmates where they need[ ] to be” to address inmates’ medical and mental health needs. Rep. Tr. at 375:4-6; see also id. at 227:4-13 (Beard) (“[H]uge overcrowding creates a problem, because you have an individual who needs to go to Institution A, and Institution A is full. So *929 where do you put him.... [Y]ou end up having to put them somewhere that maybe is not the most appropriate for that individual.”). Dr. Shansky likewise agreed “that the CDCR is currently unable to accommodate the housing needs of medical patients requiring specialized placement.” Nov. 9, 2007 Shansky Report ¶ 126.

4. Beds for Mentally III Inmates 49

Crowding has also created severe bed shortages at every level of the CDCR’s mental health care system, causing inmates in need of higher levels of care to languish in clinically inappropriate settings. It is not simply the beds themselves that the state does not possess, but the space in which to place them. The need for such space is rapidly growing. From December 2006 to August 2008, for example, the shortage of EOP beds more than tripled to almost 1,000. Ex. P243 at 900007, 900124. Likewise, between June and September 2008, the CDCR’s severe shortage of mental health crisis beds prevented more than two-thirds of the inmates referred to such beds from actually being transferred. 50 See Exs. P555, P586, P587, P585 (mental health crisis bed referral data from June 2008 through September 2008 showing 391 transfers out of a total of 1,424 referrals). At the level of care reserved for the most mentally ill, inmates sometimes wait as much as a year before being transferred to inpatient beds. Aug. 15, 2008 Stewart Supp. Report ¶ 20.

The shortage of mental health beds throughout the system means that large numbers of inmates in need of care cannot be transferred and do not receive the treatment their mental illness requires. See, e.g., Aug. 15, 2008 Haney Report ¶ 216. Inmates requiring an EOP placement often remain in general population yards receiving only “limited mental health treatment.” Id. Many of them decompensate and require one or more admissions to a mental health crisis bed for stabilization. Id. Because of the severe shortage of available mental health crisis beds, however, inmates in need of such care are frequently placed “in a variety of temporary housing alternatives” ranging from infirmaries to “telephone-booth-sized interview stalls typically placed in corridors.” Ex. D 1292 at 3. “Most of these alternative placements lack suitable staffing and/or the physical configuration needed for the continuous monitoring or intensive treatment provided in a MHCB unit.” Id. at 3-4 . Suicidal inmates referred to mental health crisis beds have spent “from Thursday evening to ... Monday morning” being transferred between so-called “dry cells,” which are “tiny, freestanding upright cages with mesh wiring surrounding them (and no toilet),” during the day and so-called “wet cells,” which are holding cells that have toilets, at night. Aug. 15, 2008 Haney Report ¶ 156. In several instances, inmates referred to mental health crisis beds have committed suicide while awaiting transfer. E.g., Nov. 9, 2007 Stewart Report ¶¶ 173-75 (inmate referred to crisis bed hanged himself after several *930 days on a “suicide precaution protocol” in a mental health outpatient housing unit); Aug. 15, 2008 Stewart Supp. Report ¶ 100 (after determination that neither restraint room nor crisis beds were available, an inmate referred to mental health crisis bed and for possible involuntary medication returned to administrative segregation cell where he hanged himself); id. ¶ 109 (inmate identified as “high suicide risk” and referred to crisis bed hanged himself two days later in unlicensed infirmary at CTF).

These shortages at every level, which are caused by the lack of space resulting from overcrowding, have created a destructive feedback loop that is now endemic to the CDCR’s mental health care delivery system. Inmates denied necessary mental health placements “are decompensating and are ending up in mental health conditions far more acute than necessary .... creating] a cycle of sicker people being admitted, with greater resources necessary to treat them, which then creates even further backlog in an already overwhelmed system.” Aug. 15, 2008 Stewart Supp. Report ¶ 92; see also Nov. 9, 2007 Stewart Report ¶¶ 31, 32; Ex. D1292 at 9-10; Dec. 10, 2007 Packer Report at 11. Because overcrowding has led to a significant, unaddressed demand for mental health services that only becomes more acute over time, new mental health beds cannot be added quickly enough to address the system’s problems. “[D]ue to the effects of overcrowding on the delivery of mental health care, any reduction in the waitlists for higher levels of care will be temporary due to the pentup demands in the system.” Aug. 15, 2008 Haney Report ¶ 33.

C. Conditions of Conñnement

The severe overcrowding in California’s prisons has also affected the conditions under which members of the Plata and Coleman classes are confined. One consequence of the growing gap between the size of the CDCR population and the capacity of its prisons has been a significant increase in the use of “non-traditional” or so-called “ugly” or “bad” beds. Ex. P4 at 200; Rep. Tr. at 1912:8-14 (Kernan) (CDCR Undersecretary of Operations). These include triple bunks, housing two inmates in cells designed for one inmate, and “beds for both low — and medium-risk inmates ... crammed into gyms and day-rooms that were never meant to be used for housing.” Ex. P4 at 200; see also Rep. Tr. at 1912:15-17 (Kernan). The court heard testimony and saw photographic and videographic evidence of these beds. See, e.g., Rep. Tr. at 148:9-149:1 (Scott); id. at 269:11-25 (Lehman); Exs. P336, P339, P348, P363. Director Scott, the former head of corrections in Texas, described some of the ugly beds he saw on his tours of California prisons as “truly appalling” and reported that, “[i]n more than 35 years of prison work experience, I have never seen anything like it.” Nov. 9, 2007 Scott Report ¶ 11. In the October 2006 Prison Overcrowding State of Emergency Proclamation, Governor Schwarzenegger found that the CDCR was housing “more than 15,000 inmates” in these beds. Ex. PI at 1. By August 2007, the number of inmates housed in non-traditional beds had increased to approximately 19,600. Rep. Tr. at 1893:11-19 (Kernan); see also Ex. D 1252-2 at 2. At the time of trial, the department was using approximately 14,000 such beds. Rep. Tr. at 1911:9-14 (Kernan).

The use of non-traditional housing raises serious safety concerns, contributes to the spread of infectious disease, and exacerbates mental illness. First, as Secretary Woodford, former head of the CDCR, testified, the number of custodial staff is often “grossly inadequate” to meet “basic needs” with “often only two officers to supervise 200 prisoners in a gym or a dorm. This is extremely dangerous for *931 both the prisoners and the staff because line of sight supervision is impossible under these circumstances and it does not permit the staff the time to recognize that prisoners are in trouble from, any number of causes, including medical or mental illnesses.” 51 Nov. 9,-2007 Woodford Report ¶ 17. One of her successors, Secretary Tilton, similarly reported that because of overcrowded conditions, including the high use of non-traditional beds, “the risk of catastrophic failure in a system strained from severe overcrowding is a constant threat.” Ex. P104 at 15.

Second, crowding generates unsanitary conditions, overwhelms the infrastructure of existing prisons, and increases the risk that infectious diseases will spread. See, e.g., Nov. 9, 2007 Scott Report ¶¶ 17-24. The Governor recognized such dangers when he issued his emergency proclamation on crowding, declaring that “current severe overcrowding in 29 CDCR prisons” has caused “substantial risk to the health and safety of CDCR staff, inmates, and the public.” Ex. PI at 1-2. Similarly, Scott Kernan, then the Chief Deputy Secretary of the Division of Adult Institutions for the CDCR, declared that overcrowding “has led to increased numbers of infectious disease outbreaks and riots and disturbances system-wide.” Ex. Pll ¶ 3 (May 16, 2007 Deck of Scott Kernan filed in Plata) (noting eleven different outbreaks, possible outbreaks, or exposure to tuberculosis at seven prisons). As plaintiffs’ medical expert testified, “the overcrowded housing conditions, and in particular, the conditions in the non-traditional beds, including the converted gyms, create potential breeding grounds for disease.” Sept. 10, 2008 Shansky 2d Supp. Report ¶ 118; see also -Rep. Tr. at 270:7-12 (Lehman) (crowding “contributes to the difficulties of healthcare delivery by virtue of the fact that it increases the incidence of illnesses, [and] infectious disease”); id. at 257:15-22 (Beard) (while prisons may not always be incubators for disease, “they could be if your population densities get so intense,” like “if you have a gymnasium that you triple bunk and put hundreds and hundreds of people in a closed dense area”); id. at 88:25-89:3 (Stewart) (interviewed two Coleman class members who “were suffering from staph infections that they got while living in these unhealthy conditions”); Ex. P4 at 200 (non-traditional beds “create difficult, unsanitary living conditions where ventilation is poor, toilet access is limited, and as many as 200 people might share six showers”). “Until CDCR reduces its population, it will remain highly vulnerable to outbreaks of communicable diseases, including staph infections, tuberculosis and influenza.” Nov. 9, 2007 Shansky Report ¶ 135.

Third, plaintiffs’ mental health experts also reported on the toxicity of non-traditional housing for members of the Coleman class and other inmates. As Dr. Stewart explained, “[placing inmates in overcrowded gym and dorm settings is often inappropriate for people with mental health issues and can either exacerbate existing symptoms or, in some cases, trigger symptoms in people who would not otherwise display them.” Aug. 15, 2008 Stewart Supp. Report ¶ 66; see also id. ¶ 52 (crowded dorm “settings also may exacerbate mental health conditions such as paranoia and create stressful environments for people who are otherwise vulnerable due to mental health issues, including cognitive impairment”); Aug. 15, 2008 Haney Report ¶ 291 (reporting on “extensive use of ‘non-traditional’ or ‘bad’ beds” at North *932 Kern State Prison, which was operating at 200% design capacity, and describing housing conditions as “especially inappropriate for the confinement of mentally ill prisoners”).

Finally, non-traditional beds are frequently created by “converting activity space into inmate housing areas,” which adversely impacts all inmates by reducing the amount of space available for programs. Ex. P4 at 124. As the Coleman Special Master has explained:

The inevitable result of severe overcrowding is that everyone also spends more and more time in their cells. General yards are more crowded, less well supervised and increasingly dangerous. There are not nearly enough walk-alone yards to provide statutorily required amounts of exercise for those who by choice or need require them. Gyms are no longer an option for time out of one’s cell. Dayrooms share many of the same problems. Work or vocational opportunities shrink in the expanding population. Disturbances occur more frequently, with resulting increases in the number and duration of lockdowns. All inmates must spend increasingly larger chunks of their days in their cells, or much more dangerously, in one of those triple-bunked “non-traditional” spaces. None of this is conducive to the health and well-being of any inmate, much less a seriously mentally disordered inmate/patient ....

Ex. D1292 at 7-8. Instead, these conditions “inevitably escalate[ ] the incidence of mental illness and exacerbate[ ] the condition of those already mentally fragile and vulnerable.” Id. at 8.

D. Other Access to Care Issues

Beyond the issues arising from critical space shortages, crowding has other severe impacts on access to medical and mental health care.

1. Staffing

The level of crowding has rendered current staffing levels insufficient to handle the health care needs of the overpopulated system:

Many CDCR prisons are unable to sustain the basic delivery of medical, mental health, and dental services because of limited staffing (clinical and custody) and an overwhelming number of prisoner/patients who require care. Every day, many California prison wardens and health care managers make the difficult decision as to which of the class actions, Coleman, Perez, Armstrong or Plata they will fail to comply with because of staff shortages and patient loads.

Ex. D1092 at 30 (Plata Receiver’s May 15, 2007 Report Re: Overcrowding). 52 Crowding also makes it impossible for the CDCR to hire the additional staff necessary to provide constitutionally adequate medical and mental health care to the current population.

a. Medical Staff

Defendants’ own data demonstrates significant vacancy rates for medical staff. As of August 2008, 20 percent of chief physician and surgeon positions, 25 percent of physician positions, 19 percent of physician assistant positions, 39 percent of nurse practitioner positions, 10 percent of registered nurse positions, and 18 percent of licensed vocational nurse positions re *933 mained vacant. Ex. D1235-2 (charts summarizing staffing trends and indicating number of positions and number of positions filled by full-time employees). The statewide vacancy rate for primary care provider positions, which include physicians and surgeons, nurse practitioners, and physician assistants, was 27 percent. Id.; Nov. 9, 2007 Shansky Report ¶37 (explaining positions that are considered primary care providers). Some prisons have attempted to fill these vacancies with registry (contract) physicians, but this practice is insufficient as a long-term solution. “Because registry physicians tend to turn over quickly, the prisons end up spending time doing extensive on-the-job training repeatedly, which is time-consuming and detracts from patient care delivery.” Sept. 10, 2008 Shansky 2d Supp. Report ¶ 66; see also Nov. 9, 2007 Shansky Report ¶ 45.

“In any system, inadequate medical staffing, whether due to unfillable vacancies or insufficient allocation of positions, •will result in delayed care. In a dramatically overcrowded system like the CDCR’s the treatment delays become more acute.” Nov. 9, 2007 Shansky Report ¶ 46. In overcrowded systems, prisoners experience “significant appointment delays,” id., both in terms of seeing a primary care physician and even in being triaged by a nurse to determine whether an appointment with a physician is necessary. E.g., id. ¶¶ 46^19; Sept. 10, 2008 Shansky 2d Supp. Report ¶¶ 67-77. In addition, “[w]ith too few primary care providers to meet the most immediate needs of the current population, some prisons are unable to develop required medical programs,” including the chronic and preventive care programs required by the Plata policies and procedures to which defendants have committed themselves. Nov. 9, 2007 Shansky Report ¶¶ 51-53. “Even the remedies the state uses to alleviate crowding cause problems for an already overburdened staff. For example, at CTF the medical department was swamped with work because they had been ordered to review 1,500 medical files to determine which prisoners were eligible for transfer to out-of-state prisons.” Aug. 15, 2008 Woodford Supp. Report ¶ 6.

In addition to rendering current medical staffing levels seriously inadequate, crowding makes it impossible for the CDCR to increase the number of clinical positions to the level needed to provide adequate care to inmates. Staffing and space issues are inextricably intertwined such that, given the overcrowding, hiring staff alone could not solve the problem. As Secretary Lehman asked, “[W]here are the providers going to work and how”? Rep. Tr. at 272:1-13. A number of chief medical officers expressed the opinion that they would not have sufficient space for clinical staff if all of the clinical positions currently budgeted were filled, id. at 501:3-7 (Shansky), let alone if new positions were created and filled.

Moreover, crowding negatively impacts the recruitment and retention of clinical staff. See, e.g., Nov. 9, 2007 Shansky Report ¶¶ 16, 20. Dr. Shansky explained that “[t]he clinical space allocated at San Quentin is so substandard and creates such a stressful environment that ... the prison’s capacity to retain physicians is seriously jeopardized by both the physicians’ perception of personal safety issues and the unprofessional conditions.” Nov. 9, 2007 Shansky Report ¶ 23. More, broadly, Dr. Shansky testified:

I believe that the hiring gains for clinicians made in the past year will be lost if these systemic issues [concerning overcrowding] are not addressed, because many newly-hired clinicians will be unwilling to risk their professional credentials and reputations by practicing in an environment where their patients are at *934 risk of harm because among other things adequate clinical space is scarce, appointments are not scheduled, complete medical records are unavailable, and medications are not delivered.

Id. ¶ 136 . The Plata Receiver likewise reported that crowding interferes with the “ability to recruit, hire and retain competent medical personnel. The overwhelming number of prisoners needing care at the prisons, existing .staffing shortages and inadequate clinical space are just a few of the consequences that make developing a competent medical staff a daunting challenge.” Ex. D1094 at 2 (Plata Receiver’s June 11, 2007 Supp. Report Re: Overcrowding);

b. Mental Health Staff

There are also staffing shortages “at all clinical levels” of the CDCR’s mental health care delivery system, and overcrowding in California’s prisons has “a profound impact” on mental health staffing levels. Rep. Tr. at 309:3-22 (Haney). Between March 2008 and August 2008, for example, the total vacancy rate among existing mental health care positions ranged from 22 percent to 36.1 percent, while the vacancy rate in psychiatrist positions was particularly high, ranging from 30.6 percent to 54.1 percent. Ex. P245 at 1. Moreover, CDCR “significantly underestimated the staffing needed to implement critical portions of the Coleman Program Guide requirements” in its 2008-09 staffing requests. Aug. 15, 2008 Haney Report ¶ 336 (citing Ex. P485, July 12, 2008 letter from Coleman Special Master to Robin Dezember and Coleman defense counsel reporting review of CDCR workload study). -Accordingly, these high vacancy rates understate the actual level of mental health understaffing. Dr. Haney reported on the “significant staff shortages” at the eight facilities he visited, all of which he described as “[sjeverely [o]vercrowded.” Aug. 15, 2008 Haney Report at 56 & ¶ 335.

As Dr. Haney explained, these shortages have a serious adverse effect upon the mental health care provided to inmates.

[Sjerious staffing shortages all translate into inadequacies in the mental health delivery system and, in some instances, an outright denial of needed and mandated mental health services. In many of the units this means that professional staff are doubling up on duties, performing more tasks than they should be called upon to handle, and managing far larger caseloads than is appropriate or effective. One psychologist at CIM told me “I can t keep up with everything. I’ve been doing too much. We hired new staff, but that hasn’t helped.” He also told me “in my opinion, we are doing about 50% of what we should be doing.”

Id. ¶ 335.

Although defendants need additional clinical staffing to implement necessary mental health programs, the CDCR “ha[s] been unable to recruit and retain staff even to meet the budgeted levels.” Id. ¶ 336. This inability is directly related to the overcrowding in California’s prisons. “[T]he serious deficiencies in office and treatment spaces I observed throughout the system are themselves an obstacle to ever achieving appropriate clinical staffing. The working conditions are terrible and there is no space, in any event, for more clinicians.” Id. Dr. Stewart explained that “it is extremely difficult to recruit and retain good clinical staff in a correctional environment in the best of times,” but that, “[i]n overcrowded systems, with the attended violence, high acuity, [and] short

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