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Delayed, Deficient or Denied: Medical Care in the Civil Commitment Gulag

by Barbara Koeppel

Dec 10, 2023 | Health


For the 6,000 men confined in compounds in the 20 states with civil commitment laws—which keep sex offenders behind bars and out of sight for decades after they complete their prison terms and often until they die—the mantra has got to be “don’t get sick.” (See “Sex Crimes and Criminal Justice”, The Washington Spectator, May, 2018).

If they’re sick, whether with kidney disease, Covid or cancer, medical care is delayed, deficient or denied. It doesn’t matter if the facility is in “blue” states, such as New York, Massachusetts and California, or “red” ones, such as Texas and Virginia. Also, it doesn’t matter if it is run by the state or a private corporation (such as the Management and Training Corporation—MTC).

I interviewed 15 men in Minnesota, Texas and California (one has since died) as well as nurses and therapists who work in these facilities. I’ve also corresponded with men in Massachusetts and New York. All agree the medical care is deplorable and far better in regular prisons—where the men completed their sentences before being sent, indefinitely, into civil commitment.

Coalinga, California

At Coalinga, California’s civil commitment compound, one resident (we’ll call him Robert to shield his identity) said he “had severe stomach pain, was wetting himself and urinated frequently.” Still, he had to wait over a month to get an appointment at the medical clinic where the nurse practitioner (NP) told him his PSA numbers were high and he should see a specialist. That was in October 2018. But since the men aren’t allowed to book their own appointments, Coalinga must make the referrals. So it wasn’t until February that Robert saw a urologist—whose tests showed he had Stage 3 prostate cancer and needed chemotherapy and radiation immediately. “Still, seven months passed before Coalinga arranged for my treatments, and then, only because the court intervened,” Robert said.

Fast forward to August 2022. Robert saw blood in his urine and the NP said he should see an oncologist; still, it took Coalinga’s clinic five months to write a referral and get him an appointment. “In January 2023, the oncologist said I needed a PET scan to see if the cancer returned—which took Coalinga another four months to arrange. Because the scan, which was in June 2023, showed a new spot on my kidney, the oncologist said to see a urologist right away. It’s now December, and Coalinga hasn’t made the appointment,” he says. His lawyer is seeking a court order to make it happen.

Another huge problem is that inmates in severe pain—whether from surgery, renal disease, or dying from cancer—don’t get the meds they need. Robert (who was a registered nurse before he was sent to prison and Coalinga) says “even when hospital doctors send an inmate back to Coalinga with a prescription for strong pain killers, Coalinga’s clinic won’t comply. Instead, they give meds like Tylenol, which usually doesn’t help. Or if they give morphine, it’s not nearly enough.”

A therapist who works at Coalinga (and asked to be anonymous) told me “I saw lots of agony in the medical unit. One patient was screaming in pain and the Coalinga doctor said I can’t give him more meds because the program won’t let me. Another man kept pressing the call button for help and no one came.” Why not? She says “the staff complained he was pressing it excessively. He died a few hours later.” She adds “last month, five men in the medical unit died, many with terrible pain.”

Yet another inmate who fared badly is Douglas Hopper. In April 2021, he had a haircut and the barber saw a tiny growth on his ear. Hopper, who had to wait until June to be seen at Coalinga’s clinic, told the nurse practitioner (NP) that he already had a malignant growth removed from his arm and cancer runs in his family. “By the time I was seen, the growth was bleeding continuously. When Coalinga finally referred me to a dermatologist, he told me I had Stage 2 skin cancer which had to be removed right away. The operation was in October (2021) and the surgeon said ‘The margins are clear.’ But I read about the cancer and learned that immunotherapy can keep it from spreading. Of course I wasn’t able to get it.

“By August 2022, I was very sick and an MRI showed a new lump above my collarbone and that I had chronic lymphocytic leukemia. The surgeon said ‘don’t worry. It won’t metastasize.’ But by late October, I felt another lump behind my jaw.” The clinic gave Hopper an antibiotic but didn’t refer him to a specialist. Finally, in February (2023), new tests showed the cancer had spread to his parotid gland—which is in the neck.

Hopper had another operation and was told to start immunotherapy immediately. But Coalinga didn’t arrange it. So Hopper’s cancer is now at Stage 3. Another surgery in June (2023) removed the parotid gland tumor and lymph nodes in his neck. “The doctor told me the cancer had spread to my jaw and I needed even more surgery. But if Coalinga had arranged for the immunotherapy two years ago, maybe it wouldn’t have spread,” he says. Now, part of Hopper’s neck is gone and he can’t open his jaw without a lot of pain. Immunotherapy still hasn’t begun.

Leo Gutierrez, who’s 55, has battled kidney disease since 2016, when he started dialysis at the DaVita Kidney Care Center three times a week. He says the weekly bill is about $20,000—which doesn’t include the cost of the guards who accompany him for the six-hour trip. One inmate at Coalinga offered to donate a kidney so Gutierrez could have a transplant, but Coalinga staff said they weren’t allowed to approve this. However, Ralph Montano, the spokesman for California’s Department of State Hospitals, emailed me to confirm that transplants are allowed.

When the cost of dialysis and transplants are compared, the choice seems a no-brainer: according to Vimo.com, a health cost website, the average price for a kidney transplant is $143,500, although insurance companies negotiate the cost downwards (medications are extra). And that’s far less than the $2.5 million a year California pays for Gutierrez’s dialysis. He desperately wants the transplant because, as he told me, “I don’t want to die.”

Robert says the long delays are partly due to a shortage of social workers, psychologists, psychiatrists, doctors, nurses and psych techs; and, since September, even more staff have left and not been replaced. Thus, conditions can only deteriorate further—particularly as the men get older and have ever more ailments.

To make matters worse, during this past year, 15 Coalinga inmates tested positive for Hepatitis C and one for HIV. Before now, none of them had experienced infections or had a drug issue.
How could this happen? California’s Department of Public Health (DPH) checked the medical records and saw that all 16 men were treated at Coalinga’s pain clinic. Michael St. Martin, an inmate who collects data about the facility says the DPH thinks the infections were likely caused by cross-contamination at the pain clinic; it seems the staff re-used syringes (called pipettes) for a pain management procedure it performed instead of throwing them away after each use.

The men are furious because they weren’t informed about their infections even after Coalinga staff knew. St. Martin says “we only found out when we learned the pain clinic had closed. Now, 187 of the men are suing Coalinga and Dr. Francis Lagatutta, who ran the clinic, for malpractice.

Littlefield, Texas

At the Littlefield, Texas civil commitment facility, the medical clinic handled Covid in a way which ensured that many of the 390 inmates would get it. According to Mandi Brady, a security officer and medical assistant at Littlefield from 2018 to 2021, “Covid spread like wildfire every few days. It was the worst in 2021, when at least half the men had it and 12 died.”

Brady says those who tested positive weren’t quarantined from those who tested negative; the clinic didn’t sanitize the examining room between patients; the sick and non-sick were sent back to their rooms, which hold two, four or 14 men. “We passed food trays through their doors and the infected and uninfected ate together in their rooms. Also, they weren’t permitted to do their own laundry. Instead, staff threw their dirty clothes into the same sacks and washed them together,” she adds.

Further, the men weren’t given hand sanitizers, the staff weren’t given masks until October 2020, and the men weren’t given them until November. Wearing masks wasn’t mandatory until the end of December.

As for treating their pain, even if they had high fevers, they only got Tylenol, ibuprofen or aspirin,” Brady says.

Besides the Covid problem, Brady says one man (we’ll call him John) had serious stomach pain last spring. The sole full-time doctor at Littlefield’s clinic (who is retired from an OB-GYN practice in the town) gave him medicine ‘to settle his stomach.’ Since his pain persisted through July, he was referred to a doctor in Lubbock, TX. However, he couldn’t keep the appointment because the Management and Training Corporation (MTC), the company which runs Littlefield, wouldn’t approve it. The clinic re-scheduled a second appointment and MTC refused again. John’s wife contacted Marsha McLane, the executive director of the Texas Commitment Office, who called MTC headquarters to get the appointment approved. But MTC refused a third time. By early October, John was jaundiced and sent to an emergency room—which found he had a blocked bile duct. Surgery was performed to unblock the duct and the doctor also found Stage 2 pancreatic cancer. His chemotherapy began a week later. All told, it took him over a half year to get the diagnosis and start treatment.

Then there’s the bureaucratic boondoggle. Every year, Texas signs MTC’s contract—although the company has been caught in some messy maneuvers. According to a November 22, 2022 Texas Tribune article, “MTC billed Texas billions of dollars for inmate mental health programs it didn’t offer. And it forced prisoners to fill out false time sheets stating they received treatment from MTC counselors. If they didn’t, the inmates were warned they would be disciplined or lose their parole and be forced to return to prison.”

And Texas is not alone. The Tribune noted that “Mississippi…demanded MTC pay nearly $2 million for improperly billing the state for thousands of unmanned prison guard shifts,” based on an investigation by the Marshall Project.

A closer look at MTC’s record shows that Texas may also be in on the take. The Tribune noted that the advocacy group, LatinaJustice, suggests that the Texas Department of Criminal Justice knew about the “the fraud that MTC was committing” and still renewed its contracts.

Moose Lake and St. Peter, Minnesota

As in Texas and California, the men in Minnesota’s sex offender program (MSOP) at its two facilities in Moose Lake and St. Peter wait months for medical care; nine months is the norm to see an outside doctor. This happens because Moose Lake doesn’t have a full-time in-house doctor. Daniel Wilson, who has a para-legal certificate and has been an inmate for six years, says “besides the long wait, clinic staff don’t tell us the truth about our diagnoses. We can submit something like a FOIA request to see our test results and doctors’ notes, but you have to know how to do it and most of the men don’t.”

Wilson says “one man had abdominal pain and was examined at Essentia (a nearby hospital) in July 2022. The hospital sent his medical records to Moose Lake where the nurse who read them told the inmate ‘nothing was wrong.’ As his pain worsened, he asked Essentia to send him the records directly: they showed he had Stage 5 kidney disease (end-stage renal failure).”

Another inmate hurt his ankle and asked for an x-ray. The clinic finally arranged one four months later. The Moose Lake nurse who read the results told him his ankle was sprained and gave him a brace. But as this made his pain worse, he sent a formal request to obtain his results—which showed his ankle was broken in three places. Surgery wasn’t approved, the bones healed badly, he’s in constant pain, and he walks with a limp.

The MSOP is also required to provide sex offender counseling, which theoretically leads to an inmate’s release into the community—if he can prove he reached the program’s top level. According to Ruby Brewer, a behavioral therapist who worked in Moose Lake from 2016 until 2019, they get no useful therapy; and the way the program is designed, they can’t progress.

In fact, most inmates will be in the MSOP until they die. As Minnesota Federal Judge Donovan Frank observed “the program is clearly broken.” Judge Frank compared it to the children’s game, Chutes and Ladders: whenever an inmate reaches the program’s top tier, the staff find a bogus reason to knock him to a lower level.

Thus, since 1994 when the law passed, 946 men have been committed to MSOP but only 21 have been fully discharged. Another 92 were “provisionally” discharged—and then only because the court intervened. Of these, only 52 live in the community; the rest still live at Moose Lake.

Brewer, who has a master’s degree in mental health counseling, says the MSOP’s goal is to keep the men forever. Because she fought this, she was put on “paid administrative leave”; she was guilty of “employee misconduct” because she blew the whistle on MSOP abuses. “Two supervisors told me to lower the men’s progress scores. If I didn’t, they said ‘their scores would look too good, we’d have to move them to the next level, and ultimately release them.’ I was warned that if I didn’t comply I’d be fired or put on leave.” She says most of the therapists did as they were asked “because they didn’t want to lose their jobs.” Also, she says “many have the mind-set to keep the men locked up indefinitely.”

Moose Lake’s executive director, Nancy Johnston, was interviewed on a local television news show this past November 1. She insisted that “any claim that MSOP supervisors would direct therapists to lower assessment scores so clients could not progress through treatment is false.” But Dr. Nicole Elsen, a clinical supervisor at St Peter admitted in sworn testimony in a 2015 court case (Karsjens v. Jesson) that she did direct the clinicians to lower the men’s scores.

Brewer says “so many men are old and disabled and in wheelchairs, on walkers or on oxygen. Some are amputees, some have Alzheimer’s, and lots are on dialysis. Since 1994, 101 men have died there.”

Because so few inmates are ever released, at least 300 are over 65 and one is even 89. At Moose Lake, 138 men have been held for over 20 years, and 62 men for over 26 years. Wilson says “there’s one death every 60 days. And life expectancy in the MSOP is 20 years less than in the general population.”

Brewer says that if Minnesota legislators cared about costs, the MSOP would close today: each inmate costs taxpayers $171,000 a year, while prison inmates cost $41,366 (in 2015); nursing home patients cost $90,000, assisted living patients cost $48,000 and those getting 44 hours a week of home health care cost $60,000.

A 2019 Bureau of Justice Statistics (BJS) report found that sex offenders are much less likely than people convicted of other offenses to be re-arrested: BJS data show that people who served time for sex offenses had much lower recidivism rates than almost any other group.

Brewer insists “it’s beyond insane to keep them so long. Maybe 10 or 15 of the younger men are dangerous and need to be in a secure facility, but the elderly should be released or placed in geriatric facilities.”


Barbara Koeppel is a Washington, D.C.-based investigative reporter who covers social, economic, political, and foreign policy issues.

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