I Was There at Citicare:  The Second Health care Reform and Its Fallout

 

Most people think health care reform was achieved only lately, here in the twenty-first century, after more than a half century of failed attempts, and is called Obamacare after the administration that finally achieved the nearly-impossible.

 

Not so. There remain alive a few who still remember that this nation’s first health care reform was the Kaiser-Permanente model.  Implemented in California in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield, Kaiser-Permanente introduced Americans to the concept of managed health care that spends small bucks up front for primary care that can prevent the spending of big bucks later on for costly hospital care. In the words of the late Carlos Hernandez, a dearly remembered Kentucky Commissioner of Public Health:  preventive health care is having the good sense to build a fence at the top of a cliff instead of a hospital at the bottom to treat all the broken bones of people who fall off the cliff. So yes, Kaiser was first, a fact mostly unremembered today.

 

But fewer still remember that the nation’s second health care reform initiative took place right here in Kentucky, in Louisville/Jefferson County during the years 1981-83, well over two decades ahead of Obamacare. I remember this well because, by serendipitous chance, I happened to be one of the lucky few who participated in implementing it. We called it Citicare.

 

Designing this innovative health care system, building its data systems and getting up its ducks in a row would take more than two years. My staff and I had been brought together over the preceding year as the new “Primary Care Branch”—a quite novel innovation, for the time, in a state government. We became the work crew who staffed the Citicare project.

 

I remember endless planning and design meetings. Some of them involved arising at 3:00 AM to drive from Frankfort to Louisville where we’d meet with physician consultants whose only available consultation time was at the crack of dawn before their hospital rounds. In the final weeks leading to startup, long overtime hours were applied to the endless lists and new computer programs that would be needed to systematically track the managed care of Citicare’s patients.

 

Those patients, the Citicare clientele, would be the Medicaid welfare eligibles of Louisville and Jefferson County—the poorest of the poor, whose frequent and costly medical bills were paid by federal and state tax dollars. The core of their new “managed care” would be prevention—quite a new thing at the time, in Kentucky or anywhere else (except California). The idea was to schedule each person for regular checkups by a primary care physician, so that anything found to be going wrong could be identified—and fixed—early on, when results were most likely to be good, and most certainly at much reduced cost.

 

Medicaid patients had always mostly depended on hospital emergency rooms—the costliest portal in the entire health care system. Many had never heard of primary care or “preventive” care, and typically put off seeking any medical care they knew they couldn’t afford, with the inevitable result that by the time they showed up at the ER they were in truly serious condition. Conversely, many of the poor used the costly ER for minor ailments such as their children’s sniffles and cut fingers. The waste of tax dollars in inappropriate use of highly technical emergency rooms was enormous.

 

Citicare Day 1 finally arrived. All Medicaid patients in this trailblazing pilot project were scheduled for checkup assessments by their newly assigned primary care docs, who were paid so much per head for their services. Patients found to need minor treatment received it immediately. More serious conditions discovered by the checkups were scheduled for followup. All the new managed care patients began receiving preventive health education for the first time in their lives. For the first time in their lives these citizens—poor enough to qualify for Medicaid—were receiving health care as good as that routinely received by all other citizens.

 

Dramatic success stories began making headlines immediately. Data were daily collected and added up to assess the program’s results—and those results were spectacular from the first month. I will never forget some of the key results, because so many of them hovered around fifty percent:

• The number of Medicaid patients receiving managed primary care screening went from zero to 100%;
• Persons receiving needed primary care treatment increased by about 50%;
• Inappropriate use of emergency rooms decreased by more than 50%;
• and the corollary—inappropriate spending of tax dollars for primary care treatment that didn’t need to be delivered in an emergency room went down by over 50%.

 

Throughout its first year of operation, Citicare was an astounding success in every aspect. From a humanitarian standpoint, several thousand poor peoples’ lives were made immeasurably better through the first decent health care most of them had ever known, simply because they couldn’t afford the medical costs that were a normal part of life for everybody else who had health insurance. From a budgetary standpoint, the program’s elimination of vast unnecessary expenditures in costly emergency rooms exceeded the cost of administering the program itself. In my little bureaucratic branch, we all felt justifiably proud of these stupendous accomplishments on behalf of both poor people and taxpayers.

 

Citicare Day 365 rolled around…  …and the program was abolished immediately after Kentucky’s newly elected governor took office. It seems that the Kentucky Medical Association didn’t like the idea of the government meddling in “their” territory, so their recent political donations had been strategically placed, with promises. Citicare was killed summarily at the end of its colossally successful first year. Its like would not be seen again until the run-up to so-called Obamacare—the Affordable Care Act (ACA)—which was patterned after a chinchy Republican-designed program, then operating in Massachusetts, in hope that a Congress half full of Republicans just might help adopt it. (Instead, they went into a frenzy of trying to kill it a’borning.)

 

So don’t let anyone tell you health care reform or responsible government initiatives for the medically indigent were dormant before Obamacare. We Kentuckians were all over it in 1983, and we did it well.

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The Rest of the Story

Well, after all that, there arose the question of what to do with my Primary Care Branch, which had been created a’foresight expressly to provide a staff for the Citicare project. The new crowd in town decided our physician placement program (recruiting primary care docs for medically underserved areas) and other health care reform-oriented activities could be politically useful, so they kept us together and busy doing good works. But our successes after Citicare were a mixed bag.

 

To make a long story short, a short, self-serving state senator from deep eastern Kentucky tried four times to abolish my branch through the state budget process. Each time, the department- and cabinet-level leaders above me made end runs around the tactic by renaming my branch and slightly revising its mission in modified language directing that we keep on doing what we were trying to do—establish some health care reforms that would help Kentucky citizens so poor they couldn’t afford health insurance but not quite poor enough to qualify for the tax-paid welfare known as Medicaid. Thus my original Primary Care Branch became the “Primary Care Development Branch,” then the “Community Health Development Branch”, then something else…I forget the name, it’s been so long ago now…

 

Given that over the decade following Citicare my branch got three new names and re-stated missions in defiance of three abolition attempts, I conclude that the leaders above me surely must have felt the branch’s existence and mission counted for something valuable. It is patently unusual for such backbone to arise in the Executive Branch in any act of defiance against the Legislative Branch. I recall one instance in which the officially published state budget contained language directing that an amount of money exactly equal to my personal salary must be eliminated from our budget—yet I kept my job in my same old branch with new name and slightly revised mission.

 

None too subtle, that, but the short-person state senator didn’t get his way until the fourth try when Kentucky’s only governmental unit exclusively dedicated to health care reform in service to the poor was finally done in. A temporarily appointed political hack with zero commitment to the public good reassigned my branch’s remaining employees to other jobs and gave our furniture away to other units.  I poignantly recall one lonely day standing in the empty room that had been my job and personal mission for fifteen years—no employees, no furniture, no phones—just me and the rug on the floor, with no assignment, not even a boss to report to. So after all those action-filled years of working at the leading edge of public health that truly matters, I went off somewhere else and did a few more years of nondescript semi-useful government work until my comfortable retirement rolled around at age 65.

 

But—By God my Primary care Branch colleagues and I were there when it counted. And then we kept on trying—under duress—for another twelve years. During those years we did a lot of good works on behalf of primary health care for Kentucky’s poorest citizens. These works included, significantly, a two-year pilot project in four of Kentucky’s poorest counties—we set a new precedent by paying county health departments to contract with local primary care docs to provide basic medical care for the medically indigent. It worked exceedingly well, almost as well as Citicare—so it also of course got abolished, not without some acrimony, and the short-person state senator finally got his way. But all that’s another story for another time.

 

With Citicare we successfully implemented the nation’s second-ever genuine health care reform—decades ahead of Obamacare—on behalf of desperately poor Kentuckians who benefitted hugely from state government’s meddling interference in the greed-driven health care marketplace. At least for one single, glorious, year.

 

And to this day I am glad, glad, glad.

 

Sincerely,

William D. Coffey, January 2023.