PHOENIX (AP) — A judge presiding over a nearly 12-year-old lawsuit challenging the quality of health care in Arizona’s prisons is considering whether to launch a third contempt-of-court proceeding against the state for failing to improve prisoner care.

Arizona’s system for providing medical and mental health care for the nearly 25,000 people incarcerated in its state-run prisons remains “fundamentally lacking,” U.S. District Judge Roslyn Silver said, and prisoners are at risk.

Experts who monitor prison health care operations on behalf of Silver said at a court hearing Friday that Naphcare, the private company hired by the state to provide those services, doesn’t have enough workers and needs to increase salaries for new and existing employees.

Silver had previously said she expected to launch the third contempt proceeding against the state on Friday for violations of a court order requiring numerous improvements. But she ultimately held off on a decision and wants input from lawyers on both sides first.

“I still believe there are violations,” Silver said.

Previous contempt fines totaling $2.5 million have failed to motivate authorities to improve care, the judge has concluded in the past. Attorneys for prisoners are asking her to override or rescind a 2009 law requiring private companies to provide health care in state-run prisons.

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“It becomes apparent that the state law is a barrier to compliance with the court’s order,” said Corene Kendrick, one of the lawyers representing the prisoners.

Silver said she has concerns about overriding or rescinding the privatization law, though she said she hasn’t made a final decision. Still, she said, the state might be able to fix the problems by enforcing the terms of its contract with Naphcare. Naphcare, which has asked the court to let it join the civil case, didn’t immediately respond to a request for comment Friday afternoon.

The state has withheld more than $10 million from Naphcare in recent months due to understaffing.

Corrections Director Ryan Thornell told Silver that he and Gov. Katie Hobbs’ administration are committed to resolving the health care issues, saying, “We haven’t wavered from that.”

Arizona settled the case in 2014 but for years was dogged by complaints that it failed to follow through on its promises. The courts slapped the state with contempt fines of $1.4 million in 2018 and $1.1 million in 2021. The settlement was eventually thrown out due to Arizona’s noncompliance, and a trial was ordered.

In a blistering 2022 verdict, Silver ruled that the state was violating prisoners’ constitutional rights by providing them with inadequate care, knew about the problem for years and refused to correct it.

She also said the prison health care system’s deficiencies resulted in preventable deaths.

One key witness at the trial was prisoner Kendall Johnson, who testified tearfully about how she sought help for what started as numbness in her feet and legs in 2017 but it wasn’t until 2020 that she was diagnosed with multiple sclerosis.

She testified that she was unable to brush her teeth, had to wear diapers, paid fellow prisoners to feed her because of neglect prison staff and typically spent her days lying in bed counting the ceiling tiles.

Johnson wasn’t in court Friday, but an attorney read a statement in which she said, “I have not noticed a difference in medical care since I testified. I still have not seen a neurologist or MS specialist — can one come visit me?”

The lawsuit alleged that some prisoners complained that their cancer went undetected or they were told to pray to be cured after begging for treatment. The state denied allegations that it was providing inadequate care.

The complaint was filed on behalf of people in state-run prisons and does not cover the 9,000 people in private institutions.