First in a series
Despite Kaiser Permanente’s early emphasis on preventive health care, pervasive 20th century American attitudes about alcohol and drug abuse curbed Health Plan leaders’ willingness to tackle addiction as a bona fide treatable illness.
“Very few physicians or even psychiatrists are willing to treat the chronic alcoholic, just as few lawyers go into the specialty of bankruptcy law,” Paul Gliebe, MD, of the University of California medical school, told Kaiser Permanente physicians in 1953. “The chronic alcoholic is in most instances looked upon as a bankrupt personality.”
The American Medical Association (AMA) was also reluctant to empathize with alcoholics, stopping short of declaring alcoholism a disease in 1956, while encouraging hospitals to admit patients suffering from the symptoms.1
“Since the earliest era, (Kaiser) Permanente (KP) physicians had resisted the idea of comprehensive care for alcoholism, self-inflicted wounds, or other self-induced illness,” the late KP San Francisco pediatrician John Smillie, MD, wrote in his 1991 book, Can Physicians Manage the Quality and Costs of Health Care?
This resistance existed despite some early voices in Kaiser Permanente who pointed out what the Permanente organization accepts today — that social and behavioral imbalances lead to disease and the symptoms include addiction and depression, now being recognized as diseases in themselves.
One early KP psychiatrist, Bernard Kahn, MD, sounded an alarm at a Permanente Medical Group planning meeting in Monterey in 1960. From that vantage point, Kahn described the modern, ever-present pressures of managing technology, work and leisure:
“Our national consumption of tranquilizers and alcohol prove we are a nervous nation. Let’s face it: the internist, the surgeon, the general practitioner, our Drop-In (Clinic) physicians are treating this kind of illness — the intangible, aggravating, emotional upsets, day in and day out — regardless of what the Health Plan contract reads.”
Kahn asserted that the Health Plan needed to extend its preventive care to include alcoholics because they would surely develop chronic disease without treatment for their addiction. “(In this area) we’re already too late, and we are covering end-stage disease (caused by alcoholism).”
Dr. Kahn, a retired Navy psychiatrist, was helping to craft a cost-effective and practical psychiatric program, along with The Permanente Medical Group (TPMG) pioneer Morris Collen, MD, in the 1950s. Collen was concerned that traditional psychiatric appointments were too long at 50 minutes and would add unduly to Health Plan costs. He wanted Kahn to develop a program based on a 30-minute appointment. Unfortunately, Kahn died of a heart attack before he could accomplish the task, Dr. Collen said in his 1986 oral history.
In the late 1950s, Kahn and psychologist Nicholas Cummings had been successful in establishing a KP psychiatry program. But treatment for alcoholism and other addictions was kept at arm’s length until it was pushed by the federal government for its employees in 1969, physician leader Raymond Kay, MD, wrote in his 1979 book on the history of the KP Southern California medical group.2
The AMA also took its time to define alcoholism as a disease. It waited until 1967 to declare it a “disease that merits the serious concern of all members of the health professions." By then, President Lyndon Johnson had publicly called for more study and treatment for alcoholism, and health insurance plans had begun to respond.1
Richard Merrick, MD, then a young internist at KP’s Harbor City Medical Center in Southern California, said he was approached by the department chief in early 1971. “They needed at least one physician from each area to start an alcoholism program.
“There were 12 or 15 doctors in the department at the time and he came to me last because he had been turned down by everyone. There was zero interest at that time in having anything to do with ‘those people’. That was the common mentality at the time.”
There was little understanding of the functional alcoholic or socialite imbibing wine, he said, only of the “stinking drunk. There was hardly any concept of addictions being diseases. They were defects of character. It was a matter of choice. These people were ‘bad’ so how could you treat that?” he said.
Dr. Merrick hired a recovering alcoholic to help him organize a one-night-a-week outpatient clinic, which lasted for three-and-a-half years. But if a patient was going through withdrawal symptoms, he or she could not be admitted easily.
“They had to have a seizure to get admitted. That’s how crazy it was for a while,” he remembered. “Once in a while I would sneak somebody in, and I would take all kinds of heat from the Health Plan because they would tell me it wasn’t a covered benefit.”
But industry and the government were determined to extend addiction treatment to as many American workers and their families as possible. Recognizing the need, KP regions began instituting coverage in the late 1970s, usually offering outpatient treatment services through the psychiatry department with a copayment and yearly cap on the number of counseling appointments or group meetings a member could use.
By the early 1980s, alcoholics were no longer falling “through the cracks at Kaiser (Permanente),” according to Andrus Skuja, MD, then chief of the alcohol and drug abuse program in South San Francisco. His comments in an interview in the KP Reporter employee newsletter in December 1982 reflected Merrick’s early experience in Southern California:
During the 1980s as the nation recognized cocaine as a new addiction problem, KP saw the need to treat many other drug addictions. It was a little tough at first. Many alcohol counselors were not comfortable with “heroin addicts or pill users, and they didn’t seem to realize that the dynamics were all the same. Addiction is addiction,” Merrick recalled. “In the San Fernando Valley, one clinic treated alcoholics and another treated addicts other than alcoholics . . . that lasted for a while.”
Kaiser Permanente resisted the initial trend of sending people to 30-day inpatient treatment programs even though many large employers and well-off unions, such as the longshoremen, were pushing it. KP established inpatient detoxification programs at KP Fontana for Kaiser Steel Mill employees in 1978 and in Carson just south of Los Angeles in 1988.
Thirty days was the gold standard based on the Minnesota model of alcoholism treatment that health insurers recognized and were willing to pay for. It got a large push when Betty Ford, wife of President Gerald Ford, spoke of her alcoholism in 1978 and later lent her name to the Betty Ford Center for alcoholics and drug addicts.1
Merrick, who was never convinced of the need for the month-long inpatient stay, noted: “We never kept them in for 30 days . . . As it has shaken out, I was right.
“It was just common sense. If you are a functioning alcoholic and not going through detox, why on earth do you need to be in for 30 days when you can do equivalent work on an outpatient basis over a longer period of time, because treatment for alcoholism or any drug is a lifelong thing . . . There is nothing magical about the 30 days.”
This inpatient treatment model died off everywhere in the early 1990s and was replaced by less expensive residential treatment as an alternative for patients with special needs.
Next time: 1990s spawn research and refinement of addiction care
1 Slaying the Dragon: The History of Addiction Treatment and Recovery in America, William L. White, Chestnut Health Systems/Lighthouse Institute, 1998
2 Historical Review of the Southern California Permanente Medical Group, Raymond M. Kay, MD, 1978, publisher: the Southern California Permanente Medical Group.