Extraction without reserve: The case of Arizona's penal care regime

Abstract

Prison healthcare reform and litigation have emerged as critical sites of social and political struggle in early twenty-first century punishment. In the case of Arizona, privatization of its prison healthcare system maintained commitments to cheap and mean punishment in the wake of economic crisis, which led to an ongoing class-action lawsuit over prisoners’ rights violations. By conducting a case study of Arizona's prison healthcare crisis, this article mobilizes important interventions in the theoretical accounts of late mass incarceration and the penal state. Not only did Arizona's brand of penal austerity anticipate the scaling back of social services across the state, but effectively subjected prisoners to a perpetual deferment of care. Drawing upon this sociopolitical context, I elaborate a theory of penal extraction whereby care capacity is not only removed from the prison, but the prisoner's life becomes like an exhaustible resource.

This article engages in a case study of Arizona's prison healthcare crisis in order to interrogate the extractive conditions of penal life. An extreme case of American punitiveness, Arizona continues to offer a counter-image to prison reform discourse. What emerged as a means to reduce rising correctional costs during a moment of extreme fiscal austerity, the privatization of Arizona's prison healthcare system in 2009 has led to an ongoing and costly legal battle over 8^th Amendment Constitutional rights violations. As the case of Arizona prompts us, how does the failed provision of prison healthcare open up new analytical insights to our understanding of punishment and penal change in the early twenty-first century?

Lynch's (2010) study of the modernization of the Arizona Department of Corrections (ADC) shows how a state located in the American southwest emerged as a national trend-setter in post-rehabilitative punishment. Not only did Arizona prove inhospitable to reformatory philosophies of correctional welfare for instance, but embodies the Sunbelt's political landscape of “post-New Deal governance” and a “post-Civil Rights fear of crime” (Lichtenstein, 2015: 124; Lynch, 2010). As an anti-welfare Sunbelt state, Arizona has historically pursued a no-frills penal regime in which structural contradictions between frugality and punitiveness drove its prison boom (Lynch, 2010). We see such dynamics repeating, but with a difference, through the state's prison healthcare crisis. Arizona has selected not to respond to the needs and vulnerabilities of its chronically ill prison population. The state has instead perpetually deferred care through privatization and legal noncompliance.

The devolution of Arizona's prison healthcare system tracks broader processes of social retrenchment whereby vulnerable populations are left to suffer without recourse (Soss et al., 2011; Wacquant, 2009). Understood as organized abandonment, as such processes persist into the twenty-first century, the provision of prison healthcare reflects a sort of relic of welfare now desecrated by neoliberal penality (Wacquant, 2009). In the case of Arizona, it is not that the state ever established an adequate standard of care in prisons or a robust welfare system, but that the abandonment of penal care has helped to shore up broader ideological commitments to privatization, austerity, and punitiveness more generally (Cate, 2021).

Debates on late mass incarceration have centered the prospects and pitfalls of cost-motivated reform measures (Cate and HoSang, 2018; Gilmore, 2015; Seeds, 2017). Whereas fiscal austerity has led many states to pursue some kind of decarceration reform, Arizona has remained staunchly punitive, focused primarily on cheapening its prison conditions. Not only has the state sustained dangerous levels of staffing shortages over the years and neglected to repair its dilapidated facilities, but the organization of its healthcare system, pre and post-privatization, has been especially dire. What we encounter in The Grand Canyon State are penal care regimes where bodies are left to deteriorate in abysmal conditions, where healthcare staff are overburdened by patient caseloads, and the modest of reforms are thwarted by a “failure of will” (Stern, 2019). As I aim to show, Arizona's penal care regime features acute conditions whereby the prisoner's life becomes a resource to degrade and exhaust without reserve. The decomposition and unraveling of prisoners’ bodies and minds constitute the scorched and despoiled by-products of extractive punishment, finding resonance with those destituted sites of capitalist accumulation, such as the razed forest, the waste lagoon, or the oil spill.

In 2012, the class-action lawsuit Parsons v. Ryan (currently Jensen v. Shinn) was filed in the Arizona district court, which documented egregious and systematic failures in ADC's provision of dental, mental, and medical care, as well as in its use of solitary confinement. The lawsuit was brought on by a coalition of legal organizations – Arizona Center for Disability Law, The Prison Law Office and The American Civil Liberties Union – less than a year after The Supreme Court's Plata decision. Parsons was settled in 2015 and its stipulation entailed over 100 compliance measures to be met at all publicly operated ADC prisons. Due to persistent noncompliance, however, the stipulation was vacated in 2021 and the case moved to trial. As of this writing, presiding Judge Rosalyn O. Silver has ruled that ADC is acting with deliberate indifference to prisoner's mental and medical health needs and therefore in violation of the 8^th Amendment ¹ .

By bringing together such penal artifacts as the Parsons litigation documents (motions, expert testimonies, and court orders) state contracts between Arizona and private prison healthcare providers, organizational publications written by ADC, prisoner advocacy groups, and private contractors, and, finally, journalistic investigations, I construct a case study that narrates the conditions and consequences of Arizona's prison healthcare crisis (Lynch, 2017). As I began with just general knowledge of the Parsons lawsuit, my approach was to craft a timeline of critical moments in Arizona's prison healthcare system. I would iteratively read my documents and then return to my narrative writing to add observational nuance, context, and relevancy. Taking this approach, I was able to identify internal mechanisms and machinations at issue in Parsons, which I analyze at length in the sections below. I liken my approach to what Lara-Millán et al. (2020: 356) describe as “positive contingency” in which archival documents are mined for when institutional actors make-meaning and take action in order to resolve institutional uncertainty. Although, as the Parsons case presents, ADC has not so much moved from crisis to certainty, but, rather, reproduced institutional unsettledness in various ways (Lara-Millán et al., 2020).

While I believe that most would construct a narrative of events that is more or less similar to mine, my intervention lies in how I read these institutional developments alongside and against the extant literature and theoretical accounts of punishment (Lynch, 2017). As I put forth, Arizona's prison healthcare crisis complicates the decarceration narrative of late mass incarceration, problematizes the role of the law to correct and remedy constitutional rights violations, and illuminates the extractive features of punishment. We should consider the limitations of my analytical approach insofar as artifacts are the debris and detritus of the unrelenting trudge of social forces (Lara-Millán et al., 2020; Skarpelis, 2020). As secondary forms of data, the documents I gather together are inherently constrained in their communicative function, by being generated by social actors with various goals and motivations, and by largely excluding the voices of those who labor and live in the penal contexts in question (Lynch, 2017; Lara-Millán et al., 2020; Lara-Millán, 2021).

As Schoenfeld (2016) maintains, a state-level analysis provides nuance and variation within generalized narratives of punishment, as macro structural issues are mediated through localized institutions. While most state-level analyses have focused on the buildup towards mass incarceration of the late twentieth century, less attention has been given to specific penal practices (Seeds, 2018). Analyses of penal healthcare has been especially scarce save for Fleury-Steiner's (2009) Dying Inside, Simon's (2014) Mass Incarceration on Trial and Sufrin's (2017) Jailcare. This case study compliments and extends this research by demonstrating how contradictory imperatives in coercion, cost, and care has reproduced Arizona's cheap and mean penal regime (Lynch, 2010).

Arizona's prison healthcare crisis forefronts processes of abandonment with which we must contend in order to understand the relationship between an extractive logic of punishment and the administration of health in prisons. I conduct this inquiry across three parts: Part I situates the debates on late mass incarceration and austerity-driven decarceration reforms alongside issues in prison healthcare. Part II elaborates a theory of penal extraction which I use to analyze the crisis in Arizona's penal care regime. Part III narrates the conditions and consequences of Arizona's prison healthcare crisis. I make the argument that the delay, denial, and disavowal of care contours the features of penal extraction in Arizona. I end the paper by drawing insights from Arizona's extraction of penal life and how this might extend theoretical accounts of punishment and state violence.

Late Mass Incarceration

Late mass incarceration reflects a moment of reform efforts aimed at addressing the social ills of the penal state (Seeds, 2017). Key among such issues are the exorbitant costs of keeping people locked up, which has spurred policies to downsize prison populations as fiscally motivated measures (Aviram, 2016; Cate and HoSang, 2018). Also understood as decarceration, such reforms have come to reflect new terms, struggles, and orientations within the penal field that might be leveraged for more widescale progressive change (Goodman et al., 2017). At the same time, others remain pessimistic, or at least agnostic, towards the prospect of decarceration. In the American context, we have entered a sort of stasis in penal expansion, while still maintaining relatively strong punitive sentiments (Beckett 2018; Campbell et al., 2020).

The Great Recession of 2008 is particularly relevant to the sociopolitical context of late mass incarceration (Schoenfeld, 2016). Brought on by the collapse of the U.S. housing market and its overreliance on subprime mortgages, The Great Recession devastated the financial health of local governments, as well as global institutions. U.S. states suffered extraordinary revenue loss and incurred immense debt in order to stymie budget shortfall (Thompson and Smeeding, 2013). Austerity measures developed in the wake of the housing market crash motivated many state actors to reduce overcrowded prison populations as mass incarceration had become viewed as economically unsustainable (Brown, 2013; Clear and Frost, 2014). Not to say that economics drove prison reform, but in a much more complicated sense, the discourse of austerity was wielded by state actors to justify reform measures within new terrains of struggle and alliance (Beckett, 2018; Phelps and Pager, 2016). Cate's (2021) exceptional study of Mississippi shows how prison downsizing has translated into “mass incarceration on the cheap” (pg.1). Mississippi's brand of penal austerity has contributed to understaffing, dangerous prison conditions, weakened oversight, and the retrenchment of public services made reliant upon prison labor.

Late mass incarceration has also emerged alongside a prison healthcare crisis with the prospect of court-motivated reforms. The 2011 Supreme Court decision in Brown v. Plata ruled that California's overcrowded prisons impeded upon the delivery of constitutionally mandated healthcare. The healthcare conditions within California's prisons became so dire that at the height of its overcrowding crisis an average of one prisoner per week died a preventable death (Simon, 2014). As a result of the Plata decision, California would have to undergo a wide-scale decarceration experiment. Known as Realignment, California shifted jurisdictional responsibility from the state to the county for low-level, low-risk offenders and reclassified certain non-violent crimes as misdemeanors (Verma, 2016).

As Aviram (2016: 273) describes, California's enduring stance towards “savings-oriented correctional reform” was rearticulated post-Recession as financial concerns drove Plata compliance measures. Realignment was not only backed by threat of prison privatization, but was formulated through a cost-benefit framework that made counties bear more of the financial burden for their punitive appetites (see also Ball, 2014). Similar to what would come of the Mississippi model, “The California version of cost-centered reform offers very limited respite from several major current [healthcare] issues that can only be regarded as serious human rights crimes.” (Aviram, 2016: 274). Indeed, the discourse of penal austerity, as precipitated by The Great Recession and re-packaged under Realignment, can justify worsening prison conditions as much as it can decrease prison populations.

The Plata decision reasserted the legal mandate of the prison, to not only control and punish, but to provide care and protect against the needless suffering of prisoners. Yet, it is precisely the irresolvable tension of these imperatives that have manifested a prison healthcare crisis. Not only have prisons consistently fallen short in providing adequate and comprehensive care, but exposure to incarceration bears increased risk for morbidity and mortality in racially disparate ways (Reverby, 2019; Wildeman and Wang, 2017). However, the contradictory capacities of coercive care at issue under Plata and reiterated by Parsons are but contemporary instances of the prisoner's undecided position within the law, what Han (2015: 100) describes as the “vicissitudes of civil death.” Contradictions in costs, overcrowding, and constitutional deprivations only reformulate the structural displacement of prisoners’ right and social status.

Penal Extraction

The scandal exposed by the Plata decision was in the brutal routinization of death in California's prisons (Simon, 2014). Parsons (2012: 34) presents similar instances of dehumanizing treatment. As one horrifying account from the lawsuit reads:

“A prisoner who needed medical care for gastrointestinal bleeding and an untreated hernia tragically did not receive proper treatment even after Defendants were aware of his problems. His hernia ruptured his stomach lining and he was found dead after ‘vomiting up his insides,’ according to witnesses.”

Such abject suffering should be thought in relation to the broader organization and arrangement of penal life, what Friedman (2021a: 694) describes as “conditions where death is by institutional design and prison order is arranged so that people categorized as prisoners die socially, psychically, and physically.” Whereas punishment has been considered a means to administrate obedience and enforce docility, we might consider, at a different register, the ways in which it expends the body and mind of productive and disciplinary capabilities altogether (Foucault, 2012; Melossi and Pavarini, 2018).

As opposed to ensuring that the basic necessities of life, health, and well-being are met, what Gilmore (2007) calls the “antistate state” is based on the organized abandonment of social life. Organized abandonment finds its premier expression in the prison and through which, according to Gilmore (2007: 247), investments in land, people, capital, and state capacity are organized to “accelerate the mortality” of the most dispossessed populations. Indeed, it is through the notion of accelerated mortality that Gilmore (2007: 247) conceptualizes racism as the “state sanctioned and/or extralegal production and exploitation of group differentiated vulnerability to premature death.” Punishment makes destitute the potentials of being – not only in terms of the production of and exposure to precarity and vulnerability, but by carrying forward the racial categorization of groups of people and the places in which they live.

Whereas premature death is the material consequence of imprisonment, extraction is the process of accelerating penal life towards its demise (Gilmore, 2017). Prisons “enclose people in situations where they are expected, and in many ways compelled, to sicken and so die” (Gilmore, 2017: 236) As Gilmore (2017: 234) explains, prisoners are extracted of “the resource of life: time.” Extraction leaves a “hole in a life” through which carceral capacities, interests, and motivations are replenished and sustained (Gilmore, 2017: 234). Bodies with holes in them - the sick and dying - are the raw material and by-product of the penal state's ceaseless restructuring. Here, extraction should not be thought as a new formation of penal power, but a latent capacity made emergent by the health-based suffering of the prisoner.

Penal extraction also orients the burgeoning, critical scholarship on monetary sanctions. Wang (2018) argues that the carceral system is used to expropriate revenue from socially and racially marginalized populations for the budgetary health of governing municipalities. Page and Soss (2021: 291), focusing on what they term the predations of criminal justice, connect the financialization of punishment to “extractive projects that underwrite state development and capital accumulation.” Friedman's (2021b) analysis of pay-to-stay laws shows how the expansion of carceral power extracts from people money and time to the detriment of their well-being. Such forms of economic dispossession parallel and necessarily extend from the physiological and psychological degradations of premature death.

Penal extraction also shares resonance with Mbembe and Meintjes (2003: 14) theory of necropolitics, which maintains that sovereign power is expressed and defined by the “…material destruction of bodies and populations.” Writing in the context of postcolonial occupation and the modern warzone, Mbembe traces the power to kill and expose life to death to spectacular and exceptional forms of sovereign terror. Comparatively, penal extraction takes as its focus attritional forms of suffering, closer in scale to Berlant's (2007) slow death. That is to say, punishment exhausts life at dispersed and dilated, but no less brutal scales of state violence. As I will show in the case of Arizona, the delay, denial, and disavowal of care provide acute insights into how penal life is extracted towards death and without reserve.

Arizona's Careless Penal Regime

Throughout the mid to late twentieth century, Sunbelt states in the U.S. consolidated a national penal politics through which social problems had become interpreted as issues of crime and punishment (Campbell and Schoenfeld, 2013). Likewise, the expansion of penal power has also facilitated social ignorance and disregard towards the harsh realities of prisons (Schoenfeld, 2018). The political necessities of such carelessness is substantiated by the deplorable conditions of prison healthcare where life suffers without recourse in its own physiological and psychical deterioration. By analyzing the internal mechanisms and machinations at issue in the Parsons litigation, I elaborate the contours of penal extraction in the case of post-Recession Arizona. In particular, privatization and legal noncompliance reproduce exposure to premature death through what I identify as the perpetual deferment of care.

Penal austerity

In the years leading up to the Parsons lawsuit, Arizona was reeling from the economic impacts of The Great Recession and the state's political terrain had become seeded by the nativist and anti-government Tea Party movement (Berman and Borns, 2012). Arizona was one of the worse hit by the housing collapse, which induced an additional crisis in the state's structural deficit (Murry et al., 2011). The election of Governor Jan Brewer in 2009 would entail an especially conservative agenda and myopic budgetary quick-fixes in the face of a $3 billion shortfall (Berman and Borns, 2012). Brewer entered the national spotlight as the foil to the Obama Administration, having infamously wagged her finger in the face of the President and had joined the 26 Republican states who brought suit over the Affordable Care Act. Most notoriously, Brewer signed into law SB 1070 – the “show me your papers” bill – which targeted Latino communities by making it a crime for any undocumented person to live in the state and allowed public employees to deny services to anyone suspected of being undocumented.

One of Brewer's first acts as Governor was the appointment of Charles Ryan as director of the Arizona Department of Corrections. Ryan had a long 23-year career in ADC prior to his appointment and had already served as interim director in 2002 after the retirement of his predecessor, Terry Stewart. At the time, Ryan had gone on to join Stewart's private consulting firm, which had been awarded a Federal contract to rebuild the Iraqi prison system and advise on the management of Abu Ghraib - the scandalized prison where photographs surfaced of U.S. military personnel abusing and sexually humiliating naked detainees. Ryan's appointment as director of ADC and his connections to the international prison industry should not be overlooked as the Parsons lawsuit centers the degrading treatment of prisoners under privatized healthcare.

Between 2000–2008, Arizona's prison growth outpaced all western states, which incurred considerable operations and daily-living costs. By 2009, corrections was the third most expensive item in the state budget, behind K-12 education and healthcare appropriations. Financial anxieties would collate onto prison healthcare expenditures. As Ryan (2009: 2) primes in his first five-year strategic plan submitted to Governor Brewer, the aging prisoner population and the affliction of chronic disease would become an increasingly expensive problem for the state:

“Many of these inmates suffer from the nine chronic high-cost illnesses that contribute to nine out of ten deaths in the United States, including congestive heart failure, chronic lung disease, cancer, diabetes, chronic liver disease, and dementia. As these chronic diseases progress, the amount of care needed and cost of care delivered increase markedly.”

The medical concerns of a sick prison population would not be met with an expansion of healthcare services or the decreasing of the prisoner population, but instead, constitute a financial problem in the context of an economic recession. Deficits in healthcare capacity would ultimately motivate privatization, which overlaid with ADC's long ideological reliance upon the private prison service industry to offset correctional expenditures (Lynch, 2009).

As Lynch (2009: 130) has described, the harshening of Arizona's penal regime has culminated in prisoners being treated as “transferable expenses whose costs can and should be reduced through whatever modes available to the state.” On September 30^th 2009, HB 2010 (Arizona House of Representatives, 2009) was passed which privatized ADC's healthcare system. The bill placed significant cost restrictions on vendor contracts. Healthcare expenditures could not surpass the department's 2008 fiscal costs and referrals to outside providers could not exceed rates under the state's Medicaid program, Arizona Health Care Cost Containment System (AHCCCS). However, the rise in healthcare costs nationwide and Arizona's growing and increasingly ill prison population would make the cost-reduction stipulations of HB 2010 untenable (Isaacs, 2013).

Prison healthcare privatization also anticipated broader austerity measures in Arizona's Medicaid system. In 2010, the state had decided to deny coverage for certain organ transplants - such as lung, pancreas, and some heart procedures - as they were considered costly and ineffective at extending patients’ lives (Berman and Borns, 2012). Two people died directly as a result of defunding and another 98 would be left without recourse. As one New York Times op-ed put it, “…[N]o other state in recent memory has made such a numbers-driven calculation pitting the potential loss of life against modest savings” (Sack, 2010). The policy to deny organ transplants would be reversed no more than a year later. Cuts were also made in Medicaid services deemed optional by Federal policy, such as wellness exams, dental care, and cochlear implants.

In 2011, Brewer eventually approved $1.1 billion in spending cuts, which fell predominately on K-12 education, state universities and healthcare relief for the poor. The most egregious cuts were made to AHCCCS, which was considered by Brewer to be the primary cause of the state's financial deficit. A direct result of the recession, costs of and enrollment in AHCCCS continued to rise and the state lacked revenue for increased expenditures (Berman and Borns, 2012). In terms of qualification requirements, Arizona had actually operated one of the more generous state Medicaid systems (Sommers et al., 2012). In 2000, Arizona voters passed Proposition 204, which extended AHCCCS to childless, low-income adults. Funded by a big-tobacco lawsuit settlement, Medicaid expansion had particular financial benefits for southern and rural hospital systems, which served some of the most vulnerable populations in Arizona (Adler, 2018; Langellier et al., 2014; Sommers et al., 2012). In 2011, however, the state cut over $500 million from AHCCCS, which translated into increased co-pays, penalties, and the freezing of 140,000 childless adults from coverage. Eligibility would eventually be restored and expanded in 2014 once Brewer reversed her opposition to the Affordable Care Act. A coalition of hospital systems and the Arizona Chamber of Commerce had convincingly lobbied the governor's office that uncompensated care would be more costly for the state compared to Medicaid expansion (Adler, 2018).

The emergence of Sunbelt penology has reflected broader political economic shifts in the retrenchment of state responsibilities and ideological investment in the free-market (Lichtenstein, 2015). As Arizona experimented with the austerity of public life, prisoners would constitute the threshold of abandonment whose care would be viewed strictly as expenditures to reduce. Similar to post-Recession Florida, cost-cutting and penal commitments would only exacerbate dehumanizing prison conditions (Schoenfeld, 2018). The brutal economization of prison life would anticipate broader state austerity measures and legitimize free-market principles and anti-government sentiment in the wake of ideological crisis (Wang, 2018).

Liminal care

Transitioning to a private vendor worsened longstanding issues in ADC's healthcare system. Staffing became difficult to maintain as healthcare providers began to vacate their positions out of concern that they would lose their jobs once a vendor had been selected (Ortega, 2012). Medical staff vacancies had been an ongoing issue for the department and, along with the push toward privatization, the department's medical infrastructure became increasingly disorganized. By 2011, 22% of all healthcare positions were vacant and a vendor had yet to be awarded a contract (Ortega, 2012). Prisoners also faced lengthy delays and barriers to care as providers became overburdened with caseloads and lacked a system to effectively track and monitor patient treatment. The department would also delay referrals to outside specialists so as to pass these costs along to the eventual vendor (Isaacs, 2013).

Staffing shortages, delays in healthcare services, and infrastructural dilapidation effectively placed prisoners in a liminal position between state and private provided care. “In the fiscal year ending [in 2010], Corrections spent $111.3 million, or an average of $3258 per inmate, on health care, down 27 percent from $140.5 million, or an average of $4482 per inmate, two years earlier” (Ortega, 2012). An instance of scaling back carceral capacity, the delay and denial of services seemed to offer an immediate cost-saving strategy beyond that of contracting with a private vendor.

Difficulties in securing a vendor illustrated the overall underfunding of ADC's healthcare system. The 2007–2008 fiscal year cost-restrictions were not operationally feasible and it remains unclear why spending limits would be set so low when it was projected that both the prison population and state healthcare expenditures would increase. Due to a lack of proposals, however, the cost-provision of HB 2010 was removed in 2011 and the language of the bill was amended to securing “the most qualified provider.” The bill would retain the provision that payments to outside specialists could not exceed AHCCCS rates, which would later prove problematic in securing community-based referrals. It would still take another year before a vendor would assume operations. For two full years ADC had functionally operated a hollowed out healthcare system.

Exodus of staff, delays and denials in care, and failing medical infrastructure proved especially devasting to the lives of prisoners. Between 2011 and 2012 there were 37 deaths in ADC of which 19 were by suicide. The complete neglect and disarray of ADC's healthcare system gave it the name of Arizona's “second death-row” (Isaacs, 2013). The catastrophic conditions set during this period of liminality would disrupt any smooth transition to a private vendor. It was also during this transitionary phase that the Parsons’ (2012) lawsuit was officially filed, which further documented systemic barriers to accessing care, chronic understaffing, and unsanitary conditions of confinement. The declaration's harrowing description of psychotic decompensation, untreated diseases, and unhealed and debilitating injuries reflect the physical and psychical realities of exposure to premature death.

Vendor troubles

In the context of expanding systems of control and surveillance, third parties have been granted increased power to meet the needs of incarcerated and supervised populations (Miller and Stuart, 2017). Prison healthcare vendors are examples of such third parties, which heightens an already tenuousness relationship between care and vulnerability (Phelps and Ruhland, 2021). ADC's vendor contract would be structured by what is referred to as a “capitation”. Here, ADC pays the vendor a per diem rate for each prisoner, which is based on an estimate of total healthcare expenditures for the year. In order to be competitive for procurement, vendors often engage in a race to the bottom as states are likely to pursue the cheapest of proposals (Gelman, 2020). For the state, capitation allows for a fixed and determinate budget of healthcare expenditures, while the vendor is incentivized to reduce the actual cost of care in order to increase profit margins.

There are two primary ways to reduce prison healthcare expenditures: 1. staff reduction and 2. care denial. In Arizona, both strategies would be pursued. “Privatization is usually embarked upon to reduce prison expenses, with efficiencies induced by financially stressing the service function. For medical care, the most direct way to reduce expenses is to deny, delay, or dilute care” (Zullo, 2017: 96). Not only does capitation further induce the abandonment of care in prisons, but prisoners’ lives become like an extractable resource; health becomes an exhausted remainder of economic gain.

Wexford Health Sources would assume operations in July 2012 as the lowest bidder in ADC's request for proposals. Wexford's three-year contract totaled $349 million, $5 million more per year than what ADC was spending on healthcare at the time. However, the department claimed these costs would be off-set by the employee pensions they would no longer have to pay. ADC collapsed its healthcare division and instituted a minimally staffed Health Care Service Monitoring Bureau. The bureau would be tasked with ensuring contract compliance, quality of care, and assisting Wexford with any other related issues, all of which became matters of contract dispute and grounds for termination no less than a year later (Wexford, 2011).

In August of 2012, no more than a month into their contract with ADC, a series of issues brought department scrutiny over Wexford. Problems ranged from medication delays, insufficient staffing levels, inappropriate incident reporting, and improper emergency response. The very same problems that plagued the department prior to Wexford's tenure. Reports surfaced that a nurse had a prisoner lick powdered medication from their hand after running out of cups and another detailed an outbreak of whooping cough at the women's Perryville prison. The most egregious issue was a Hepatitis C exposure that occurred at the Lewis prison complex. A subcontracted nurse had reused a syringe for a Hepatitis C positive prisoner, which contaminated a multi-dose insulin vial, exposing over 100 prisoners to the virus (Isaacs, 2013).

ADC assessed Wexford as being in noncompliance with their contract and issued a $10,000 sanction. Wexford did not just refute the allegations, but pointed the finger back at ADC. According to Wexford, uncooperative correctional staff impeded upon their ability to adequately investigate the Hepatitis C exposure. Wexford also identified several questionable health staff practices well-established before they took over for ADC. These included removal of patient's medication records from storage locations, as well as inconsistencies in updating chronic care data in ADC's inmate health monitoring system (Wexford, 2012).

Wexford also confronted ADC in not being forthwith concerning the overall conditions of its healthcare system, which were assessed by the vendor as failing to meet basic professional standards. As noted by Wexford, “the ADC system is broken and does not provide a constitutional level of care” (Wexford, 2012: 3). Indeed, Wexford characterized ADC's healthcare system as utterly dysfunctional: having failed to test prisoners for infectious disease, to properly train correctional and health staff, to process thousands of backlogged cases for specialty care, to correctly dispense proper medications and to correct a work culture of unaccountably, hostility, and medical malpractice (Wexford, 2012). Wexford even went as far to state that everything alleged in the Parsons lawsuit was true.

The disputes between ADC and Wexford could not be amended and contract termination was finalized on January 30^th, 2013. Wexford would continue to operate healthcare services until March whereupon Corizon Correctional Healthcare would takeover. As the process of termination illustrates, privatization not only consolidates the delay and denial of care, but also its disavowal. Despite being the very cause of contractual dispute, either Wexford or ADC would address or take responsibility for the suffering of prisoners. ADC's catastrophic healthcare system would remain in place and simply passed on to the next vendor.

Failed transitions

Corizon Correctional Healthcare would transition as ADC's healthcare provider on March 4^th 2013, right at the beginning of the Parsons legal proceedings. Corizon had submitted a proposal for services back in 2012 – along with Wexford and Centurion – as the second lowest bidder. Given the urgency of the situation, Corizon appeared poised to lead transition efforts. At the time of its contract with ADC, Corizon was the largest prison healthcare provider in the country and had experiences transitioning healthcare services from Wexford in New Mexico, Pennsylvania, and Wyoming (Corizon, 2012).

The frequency of provider-to-provider transitions, as undergone in Arizona, demonstrate how the prison healthcare industry fails on its own free-market principles. Mechanisms of competition are basically absent as there are too few providers and governments ultimately become dependent upon the industry for service provision (Gelman, 2020). Not only is provider turnover frequent and disruptive to healthcare continuity, but quality of service only ever fluctuates between being very bad to mediocre (Zullo, 2017). Vendors are often marred in some kind of controversy or litigation, but this has no real impact on contract procurement. Just as mass incarceration regulated and concealed the unemployed labor market in the U.S, it has created other opportunities to effectively subsidize failed industries (Western and Beckett, 1999).

In its correspondence to ADC, Corizon emphasized their ability to facilitate a seamless transition of services within 30 days, noting the staff and operational concerns they would inherit. What was described as a special situation was going to require revamped personnel training, communication and documentation practices, as well as vast infrastructural improvements. In an effort to retain staff Corizon dispatched transition teams tasked with persuading healthcare workers to remain in their positions (Corizon, 2012). Despite Corizon's transition strategy, fundamental issues persisted. The company struggled to retain and hire staff and actually reduced and eliminated certain positions. By June of 2013, staffing dropped to a deplorable 53% (Wilcox, 2013).

The legal proceedings during this time would reveal the troubling state of ADC's healthcare system. Dr Robert Cohen (2013: 11), who provided expert testimony on behalf of the plaintiffs, described what he characterized as a “failed medical care system.” Along with staffing shortages, Dr Cohen identified outstanding issues in access to care, unkept medical infrastructure, and insufficient oversight and monitoring:

Corizon, like Wexford and the Arizona Department of Corrections before it, has proved again that where corners are cut in providing medical care by having too few professional staff and an inadequate budget, patients will suffer, and sometimes die, because of systemic neglect. Prisoners are getting lost in the medical care system; their serious chronic diseases are not being followed as closely as they should be; and requests for necessary outside medical consultation are going unfilled.

Through the brutal reduction of cost and capacity, privatization intensifies mechanisms of penal extraction. Not only are prisoners subjected to preventable forms of suffering and death, but the prison becomes reproduced as an organized disaster (Friedman, 2021a).

Transition, whether that be from public to private or vendor to vendor, would simply be a repetition in failed and catastrophic healthcare. While such inefficiencies might be reason to reject the very terms of privatization, we should consider the extent to which such failure reiterates the prison as a form of civil death. What Han (2015: 96) describes as the prison's legal architecture only ever “establishes the prisoner's precarious if not absent security in bodily and psychical integrity.” The failure of privatization in the Arizona case maps onto and extends the repetitions of civil rights violations of prison conditions more generally (Dayan, 2014). Insofar as the prisoner's right is always subject to despoilment, privatization simply inflects civil death with the ideology of capitalist accumulation and brutal forms of extraction. Market failures find their correspondence with the structural failure of the law in what is otherwise the prisoner's perpetual deferment of care.

Noncompliance

Throughout the Parsons litigation, ADC would be assessed as lacking the basic components of a bureaucratically managed healthcare system. Issues in medical care spanned problems in mental health treatment, dental care, and the use of solitary confinement. All of which were similarly mismanaged, degrading in treatment, and cause of serious harm and injury to prisoners. While litigation seemingly provided an opportunity for reform, it has been routinely undercut by ADC through acts of willed failure and bad faith efforts.

ADC settled Parsons just days before the case would go to trial. A stipulation was approved in 2015, which constructed 103 performance measures (PMs) to be implemented at 10 state prison complexes (Parsons, 2014). The PMs were designed to align Arizona's prison healthcare system with basic constitutional and medical standards, which included things like sufficient staffing levels, timely care and treatment regiments, intake screenings, and prompt scheduling of specialty care appointments. PMs would be set at incremental thresholds where in the first year ADC agreed to be in 75% compliance, 80% by the second year, and remain at 85% thereafter. All PMs would be subject to review by the prisoners’ legal team and fines would be assessed by the court if performance measures were not met or fell out of compliance. As a condition of entering the settlement, ADC was able to deny responsibility for its failed healthcare system (Rothschild, 2019).

By 2016, prisoners and their attorneys filed a motion to enforce compliance after ADC failed to reach or maintain critical PMs, which detailed shocking accounts of suffering and death (Parsons, 2016). It appears that ADC's strategy was, in bad faith, to prolong legal proceedings through discovery disputes, scheduling extensions, and faulty remediation plans (Rothschild, 2019). The department would effectively leverage the law in order to repeat the delay and denial of care the stipulation was designed to resolve. Despite the court's frustrations, its ascription to judicial deference would nonetheless benefit ADC's evasion of oversight and regulation (Dolovich, 2022). It had also come to light that not only did ADC approve an increase in Corizon's capitation rate, but had devised various sanction and incentive schemes to financially induce PM compliance.

ADC was officially held in contempt of court for noncompliance in 2018. In his order, then presiding Judge Duncan (2018: 20) admonished ADC's lackadaisical efforts and their unwillingness to compel Corizon to resolve fundamental issues. “[ADC's] repeated failed attempts and too-late efforts, to take their obligation seriously demonstrate a half-hearted commitment that must be braced. The evidence suggests that the State's recalcitrance flows from its fear of losing its contracted healthcare.” At a rate of $1000 per non-compliant PM, Judge Duncan imposed upon ADC a $1,445,000 fine. However, when ADC renewed its contract with Corizon in 2015, it included an indemnification clause. Not only did this require Corizon to pay all of ADC's legal fees (and those of the plaintiffs’ attorneys), but should ADC ever be found in contempt of court, Corizon, would be the one responsible for payment. Indemnification had removed all material incentive on the part of the state to improve its prison healthcare system. Writing on the privatization of prison healthcare in Florida, Schoenfeld (2018) notes that political conflict over rising costs had made these ventures untenable for both governmental leaders and private businesses. In Arizona, however, the state has essentially economized its tolerance for prisoner rights violations.

Compliance continued to prove futile, prompting the court to appoint an expert – Dr. Marc Stern – to review the auditing of PMs and the quality of care provided. While Dr. Marc Stern's report provided the most comprehensive assessment of ADC's healthcare system at the time, it would repeat the array of issues that had endured over the previous decade such as understaffing, delays in care, and insufficient case monitoring. Not only were critical PMs found to be in non-compliance, but Dr. Stern calculated that ADC's healthcare system was underfunded by a conservative estimate of $84 million, which consisted of gaps in healthcare costs and vendor profit margins. Not only did the Stern report capture the austerity of ADC's penal care regime, but also the crude economic value extracted from prisoners’ exposure to premature death (Wang, 2018).

While in the midst of Dr Stern conducting his report, ADC's healthcare vendor would again be dredged in scandal. A whistleblower investigation revealed that Corizon instructed employees to mislead ADC's audits of PMs. A leaked email described overworked medical staff crying while trying to perform impossible duties for sick and in-need prisoners. “We are all burning out and in desperate need of sufficient staff. We are asking for help not only for us but for our patients” (Jenkins, 2019). The story broke after former healthcare workers testified on PM violations. One health provider stated she was instructed by a doctor to keep a prisoner suffering from a heart attack comfortable and “let him die” after falsely claiming that all the arteries in his heart were inoperable (Jenkins, 2019). In light of these controversies, ADC did not renew its contract with Corizon and instead selected the company Centurion to resume operations on July 1^st 2019. Within the span of seven years, ADC would transition through three different health service vendors. The repetition of disruption would prove the most enduring feature of privatization. ²

Despite ADC's bad faith enforcement and Corizon's scandalous dealings, the issue of noncompliance would also feature the limitations of the law to achieve institutional change. Not only would ADC utilize legal proceedings to prolong healthcare reforms, but effectively neutralized mechanisms of enforcement. Civil contempt would all but be absorbed into an extractive matrix of capitation rates, profits, and performance incentives; streams of revenue that circulate by virtue of the prisoner's destitution. As Schoenfeld (2010, 2018) has shown in the case of Florida, prisoner rights litigation has often necessitated the expansion of carceral capacity. Through Parsons, however, state capacity has not so much been increased, but kept in a constant state of flux. Prolonged proceedings, repeated vendor transitions, and tenuous PMs demonstrate the ways in which care is only ever yet to arrive, continuously disrupted and perpetually deferred. The diffusion of various interests – the state, the court, and private vendors – features competing motivations and investments that ultimately maintain the vicissitudes of civil death, as well as the extraction of penal life (Han, 2015).

Conclusion

Sunbelt penology set the tone for the U.S. penal order, marked by mass incarceration and the harshening of prison living-conditions. (Campbell and Schoenfeld, 2013). The early twenty-first century now confronts us with the social wreckage of such unprecedented incarceration, which is presented, in its most visceral forms, by the illness, injury, and death of prisoners (Simon, 2014; Sufrin, 2017). Arizona is a notable case as the state anticipated and intensified much of the U.S. punitive imperative. Whereas the state was a pack-leader in the era of post-rehabilitative punishment, Arizona now demonstrates the limits of current prison reform discourse driven by cost-centered and court-motivated appeals (Lynch, 2010; Schoenfeld, 2018). The state has only further consolidated its cheap and mean regime through increased reliance upon private industry and continued disregard for prisoners’ rights (Lynch, 2010). In this way, Arizona situates the mutability of penal extraction. Not only is penal life being hastened towards death, but the constitutional provision of care becomes a means to expropriate state revenue for capital accumulation.

As Sufrin (2017: 8) notes, “the health status of incarcerated persons is a case study in structural violence.” The Parsons lawsuit might be thought in this way as the return of the repressed of the penal order and which demands confrontation with and contemplation of the general destitution of social life. Arizona, however, has repudiated the existence of such suffering through organized forms of failure and extractive punishment. What Campbell and Schoenfeld (2013) describe as the carceral rationale of governance seems to have given way to the anti-governance of penality. Perkinson (2010: 10), writing on the failure of rehabilitation and reformist ideals in Texas prisons, notes that punishment has excelled in other ways, such as “fortifying social hierarchies, enacting public vengeance, and symbolizing government resolve.” Parsons centers not so much state vengeance or resolve, but institutionalized incompetence that exacts tremendous suffering on prisoners. As Judge Silver (2021: 32) laments in the order to vacate the settlement:

Defendants’ failures have led to preventable deaths, possibly including suicides. Defendants’ failures have also led to untold suffering by individuals unable to obtain medical treatment…It is impossible to quantify, monetarily, the harms suffered by prisoners because of a lack of adequate health care.

What Barder (2020: 35) calls unsuitable governance refers to the infliction of slow forms of violence through the organization of “extraordinary ignorance or carelessness.” Arizona is quite literally a careless penal regime whose prison population has been abandoned to their own biological and psychological deterioration. Here, Arizona's prison healthcare crisis can be extended to thinking about general issues in state violence and the power to kill and expose life to death (Mbembe and Meintjes, 2003) Specifically, penal extraction helps us to consider the everyday modes of death-making that may or may not irrupt into spectacular displays of sovereign power and brutality. The dispersed and dilated suffering of prisoners in Arizona is therefore implicated within broader, global arrangements of precarious living, where “dying and the ordinary reproduction of life are coextensive” and inscribed by indifference, incompetence, and inaction (Berlant, 2007 : 762; see also Alphin and Debrix, 2020; Davies et al., 2017).

Defunding the penal state is not the same as dismantling it (Cate, 2021). Here, Arizona problematizes the reformist discourse that characterizes early twenty-first century punishment. Not only does Arizona's penal care regime illustrate the corruptibility of cost-conscious and court-motivated penal change, it has facilitated a perverse form of decarceration through the wearing down and exhaustion of prisoners’ lives. That is, the state is effectively reducing its prison population via attrition, as opposed to release (Friedman, 2021a). As an extreme case, Arizona is not an outlier, but a condensed version of the regulatory failure of the penal state (Dolovich, 2022). Given its particular and historical significance within the U.S. penal field, Arizona's staunch refusal to provide care to prisoners, despite considerable and costly litigation, preserves strategies of indifference that can be replicated by other states and with dire consequences, as already highlighted by the disaster of COVID-19 in carceral institutions (Friedman, 2021a; see also Reiter, 2021).

The unquantifiable and untold harm caused by ADC's healthcare system situates the prisoner whose body and mind are only valued as surpluses to be expended without reserve. To the extent that an austere prison is always desired, privatized or not, the existence of penal life will inevitably frustrate such pursuits. The prisoner's demand for remedy and relief, premised upon an assumed right to care, is therefore always in excess of what the interests in the prison can or will provide. And it is precisely this antagonism between the austerity of punishment and the excess of life that structures the conditions of possibility for extraction. The fantasy of the optimized administration of provision and deprivation, of cost and care, will only repeat the realities of such harm. Rather, the very logic of austerity, in all its forms, iterations, and fantasies must be refused. Where life is priceless, life is priceless ³ .