BOISE - More than 25 years after a federal judge ordered Idaho to change the way it handled medical care, overcrowding and other issues at the Idaho State Correctional Institution, attorneys for inmates say problems in some areas of the prison near Boise are just as bad.

U.S. District Judge B. Lynn Winmill will hear arguments today on whether he should close the oldest portions of the lawsuit that's become known as the "Balla case" or allow regular monitoring by the inmates' attorneys to continue.

In a 65-page status report to the court, the inmates and their attorneys say the lawsuit should remain open. To back their claims, they offer testimony from an inmate who says he nearly bled to death and required surgery after he was forced to wait for hours for treatment of a perforated artery.

They've also provided a statement from a former doctor at ISCI who says the medical care process is downright obstructive and leaves many inmates without needed treatment and medications. Dr. Ralph Heckard wrote that psychiatric care is spotty at best and that medical procedures that should be done by physicians and nurses - like injections - are "delegated" to non-qualified workers.

It all shows that "prison officials still exhibit deliberate indifference to the serious medical needs of inmates," the inmates' attorneys wrote.

The case began in the early 1980s, when so many inmates at the prison began filing lawsuits that the cases threatened to clog Idaho's federal courts. A judge ultimately combined them into one big lawsuit, dubbed the "Balla case" after lead plaintiff Walter Balla.

In three major rulings over the next two decades, federal judges ordered the state to stop overcrowding at the prison, provide warm clothing to inmates, improve access to medical and psychiatric care and rehabilitation programs, and to take other measures to ensure that some units of the prison would no longer be "an extremely violent place to live."

In May, Winmill said he was inclined to close the oldest portion of the case, which specifically aimed to stop rampant violence, the near-routine brutal rapes of newly arrived young prisoners, limited access to psychiatric and medical care and other problems. At the time, Winmill said changing conditions and procedures at the prison make enforcing that part of the case difficult, and he said he would reduce the long-term monitoring requirements at the lockup as long as state officials continued to "tread cautiously and show good faith in maintaining compliance."

After Winmill's ruling, Idaho Department of Correction Director Brent Reinke said he was grateful the judge was acknowledging that times have changed. Reinke says the state has been "quite diligent" in its approach to dealing with the issues listed in the lawsuit.

But the inmates and their attorneys appear to be focusing in on the medical and psychiatric care at the prison, saying it's as bad or worse than it was when the lawsuit began. The doctor mentioned in the report, Heckard, said he started doing contract work with Correctional Medical Services - the private company that handles the state's prison medical care - for 2009. He chose to sever the contract after six months because he said he witnessed "rampant violations of plaintiffs' Eighth Amendment rights."

Inmates faced long delays for medical care, often having to fill out multiple requests for treatment before they were seen, Heckard wrote. He said there was only one doctor for roughly 1,500 inmates, and no pharmacists at the prison.

Heckard also said the medical care process at ISCI is "obstructionist," requiring physicians to fill out consultation application forms for every step in an inmate's care. For instance, he said, if an inmate with cancer needed a colonoscopy and biopsy, the physician would have to fill out an application for the procedure, then another one for the follow-up, and two more for visits with an oncologist and cancer surgeon.

If surgery was then needed, the physician would have to fill out an application for the surgery, one for the hospital where it would be performed, and sometimes even for the anesthesiologist. The same applications were required for any postoperative visits, to review the pathology report, and for each episode of chemotherapy or radiation.

Heckard says those applications weren't just paperwork - each one had to be authorized by the CMS regional medical director.

"This process was the source of multiple complaints by multiple providers specific to the cumbersome and obstructionist nature of the process," he wrote. "Often, even when requested and approved, the visitation or treatment was delayed further by 'scheduling' or 'transportation' issues."

Medical care is harder to access on weekends or after normal business hours, he said, because the on-call providers aren't physicians and were often unavailable by phone. Heckard said he was also routinely barred from ordering emergency medications for mentally ill inmates whose prescriptions had expired or run out, because he isn't a psychiatrist - even though for months the prison had no psychiatrist on staff.

Attorneys for the state didn't respond in court filings to the specific allegations made in the inmates' report, saying it would file a more detailed brief later.