Despite spending hundreds of millions of dollars to fill vacant medical and mental health positions at prisons and state hospitals, California has little to show for it, according to a new report from the state auditor.
Job vacancy rates have increased since 2019 at the three facilities examined in the audit, as has the state’s reliance on pricey temporary workers. Atascadero State Hospital, Porterville Developmental Center and Salinas Valley State Prison had health-related vacancy rates topping 30% during fiscal year 2023-24. At Salinas Valley State Prison more than 50% of health positions were unfilled.
Workers contend that the high vacancy rate leads to more on-the-job assaults, mandatory overtime and staff turnover.
“A high vacancy rate is a self-fulfilling prophecy,” said Dr. Stuart Bussey, president of the Union of American Physicians and Dentists, which represents about 1,300 state psychiatrists.
The vacancy rates persisted despite targeted bonuses and wage increases that prison health workers received in contracts and under court order during the Newsom administration. Those included $42,000 bonuses for prison psychiatrists in a 2023 contract and more recently $20,000 bonuses the state had to dole out to mental health workers through a long-running prisoner rights lawsuit.
At face value, some state health workers are comparatively well-compensated. All of the 55 prison employees who earned more than $500,000 in income last year were doctors, dentists, psychiatrists or medical executives, according to state controller data.
A board-certified psychiatrist at Atascadero State Hospital — some of the highest paid state employees — can earn more than $397,000 in base pay. They also retire with pensions through the California Public Employees’ Retirement System. In comparison, the mean wage for a psychiatrist in California is $328,560, according to the U.S. Bureau of Labor Statistics.
But in certain places, local hospitals are offering even more. In Monterey County, $90,000 hiring bonuses are common at private hospitals struggling to fill their own vacancies, staff told state auditors.
Despite the pay, vacancy rates were highest among psychiatrists at Atascadero State Hospital and second highest at Porterville Developmental Center and Salinas Valley State Prison, auditors found.
All three of the audited facilities house individuals who are either incarcerated or institutionalized because they were deemed by the courts to be dangerous or unfit to stand trial. Federal and state law as well as court rulings require the state to provide adequate medical and mental health care. As a result, most of the facilities are required to have vacancy rates less than 10%.
Over the past 30 years, California has consistently failed to meet that standard.
None of the state departments overseeing the facilities have taken necessary steps to ensure adequate staffing, auditors wrote.
The audit found:
- The facilities had a “significant number of vacant positions” that were not filled by temporary workers or staff overtime.
- Neither the Department of State Hospitals nor the Department of Developmental Services, which houses some people with developmental disabilities in Porterville, had procedures to adequately evaluate or budget for staffing needs annually.
- The state hospitals and developmental services departments as well as the Department of Corrections and Rehabilitation have no process to determine whether facilities are meeting staffing minimums during each shift.
In a letter to lawmakers, California State Auditor Grant Parks wrote that the state should conduct a statewide recruitment campaign to hire health care workers “because of the decades-long difficulties the facilities have had in filling vacant health care positions and a current and projected health care professional shortage.”
In response to the audit, the developmental services and state hospitals departments partially agreed with the findings in detailed comments.
The Department of State Hospitals, however, wrote that the vacancy rates covered during the audit period were significantly affected by the COVID-19 pandemic and that salary savings were overstated. “Our hospitals regularly meet or exceed mandated staffing minimums and have self-reported rare occurrences where they have not due to extraordinary circumstances,” department spokesperson Ralph Montano said, in an email to CalMatters. The department has agreed to implement many of the recommendations made in the report, Montano added.
In a statement, the corrections department said it was “committed to providing adequate health care for the incarcerated population, while ensuring fiscal responsibility.”
Workers claim state wastes money to fill vacancies
Coby Pizzotti, a lobbyist for the California Association of Psychiatric Technicians, which represents about 6,000 mental health clinicians, said the audit confirmed what many of the state worker unions had suspected: The state has continually refused to meaningfully improve wages, benefits and working conditions for employees, while spending money on temporary workers. This, the unions contend, makes the vacancy problem worse.
“Effectively, it’s a shadow state employee workforce. They’re just not called civil servants,” Pizzotti said.
The departments saved $592 million in payroll over six years by carrying the vacancies, the auditors wrote. But, auditors criticized the state departments for their inability to specifically track how they later spent that money. The departments counter that, generally, the money can be used to offset other costs or it can be given back to the state.
But they have also poured money into temporary positions to meet court-mandated minimums. During the six-year audit period, the state spent $239 million on contract workers to fill staff vacancies. The departments were authorized to spend more than $1 billion on temporary workers during that time period, though they used only a fraction of the money, according to the audit.
Contract workers, while making up less than 10% of the health care workforce, are paid so much that they cost more per hour than state workers even after accounting for benefits, auditors also found.
State workers’ unions say that’s more evidence toward their argument that these arrangements don’t save the state money.
“Contracting out is not a great way to do business. It’s expensive,” said Doug Chiappetta, executive director of the psychiatrists union.
Instead, state health worker unions want the state to increase salaries and benefits, to make permanent positions more attractive to candidates rather than spending it on highly paid contract workers.
The psychiatric technicians union, psychiatrists union and the state nurses union said that contract workers get paid two to three times more per hour than state employees, according to job advertisements from contracting agencies they have collected. Those companies are also able to offer generous benefits and scheduling flexibility that state jobs don’t have.
“It’s been a slap to our faces to see how the state doesn’t care for our nurses,” said Vanessa Seastrong, chair of Bargaining Unit 17 for SEIU Local 1000, which represents about 5,100 registered nurses. “You’re standing next to a nurse that is doing less work than you and getting paid more than you. How does that bring up morale?”
Bigger problems for recruitment
Even relying on temporary contract workers, the state has in many cases still failed to maintain staffing minimums for health care positions.
Vacancy rates increased significantly between 2019 and 2024. Salinas Valley State Prison saw vacancies jump 62% during the audit period, and more than half of mental health and medical positions were unfilled during fiscal year 2023-24.
Atascadero State Hospital’s vacancy rate rose 39% over the audit period for a total vacancy rate of about 30%. During the last three years of the audit period, Atascadero also lost 90% of its staff to attrition.
Porterville Developmental Center’s vacancy rate increased by just 6% over the audit period, but more than a third of its positions remained unfilled in the final year of the audit.
In interviews with auditors, administrators at the facilities said that the COVID-19 pandemic caused higher staff turnover as well as an increased reliance on contract workers to fill gaps.
All three facilities, which are located along the Central Coast or in the Central Valley, face additional barriers to recruitment.
These areas suffer from health care professional shortages. The area along the coast where Atascadero State Hospital and Salinas Valley State Prison are located faces a medium shortage of behavioral health workers, while Porterville Developmental Center is in an area with a severe shortage, according to the Department of Health Care Access and Information.
“Places like the Central Valley have substantially fewer mental health professionals per population than compared to the rest of the state,” said Janet Coffman, a professor at UCSF’s Institute for Health Policy Studies who studies workforce issues. “Particularly for Porterville, that’s a big part of the issue.”
At the same time, demand for mental health services has increased in the general population, Coffman said.
Combined, that makes it more difficult for the state to compete with the private sector, which is also struggling to hire health care workers.
Other barriers are difficult to address with money alone. The patient population can make the work dangerous. Staff are frequently verbally or physically assaulted. Unsafe conditions make it harder to recruit new workers and sometimes cause long-time workers to retire early.
“There were 2,700 assaults on staff last year. It’s not a matter of if, it’s when,” Pizzoti said.
The audit recommended that the state conduct a market analysis of all health care positions to determine whether payment was competitive, streamline the hiring process, and conduct a statewide recruitment campaign.
Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.