!The future of primary care in Kentucky --- agk's diary 1 December 2025 @ 20:14 UTC --- written on GPD MicroPC in the kitchen --- It starts in some corner of Kentucky. Maybe Fulton in the southwest, maybe Paris in the northeast. A county fiscal court modestly subsidizes a primary care physician practice to retain the service for the community. It goes unnoticed til it's repeated by another fiscal court in another county, another practice. There's a letter to the editor, approving or complaining, a facebook thread or a lawsuit. Legislators in the Kentucky General Assembly will privately discuss counties sponsoring primary care providers. Then the Kentucky Senate or House will assign the issue to their Health Services committee. Hearings during recess session will investigate support for primary care physicians as a public service. The committee will discover big insurers don't object -- Blue Cross/Shield, United Healthcare, Cigna, Aetna, and Humana don't want primary care physicians! The work left for the committee involves concerns about preventing favoritism and corruption, problems they won't fully be able to solve. With the help of the Legislative Research Commiss- ion and Governor's office, the hearings result in a standard fee schedule for public service primary care physicians, deemed a ceiling. Primary care physicians who charge less may bid for public service contracts with counties or municipalities. The legislature's work will let counties and municipalities extend malpractice suit immunity to contracted public service PCPs, and let them use a state-administered defense fund. The program will be an extension of the one that immunizes state employees, and like the Federal Tort Claims Act Medical Malpractice Program. Not having to buy malpractice insurance will lower expenses for public service PCPs. Public service PCPs will be allowed to participate in the state employees' pension plan. Some counties will buy their student loan debt, and forgive it piecemeal as the PCP serves. Should either party end the public service agreement, the county will sell remaining debt to the previous loan servicer. Some municipalities and counties will provide county or city-owned commercial or residential property for contracted public service PCPs to use as a doctor's residence or office at no cost, or (more commonly) a discount below market rate. Some counties will provide an administrative assistant paid by the health department. Counties will not be allowed to gift or sell prop- erty to public service PCPs at a preferential rate, pay them, or provide them with financial incentives. Contract agreements will differ between counties. Most will prohibit taking patients from outside the county, prohibit discrimination against the poor or uninsured, prohibit billing uninsured residents more than fee ceiling rates, require generating reports to facilitate oversight, and require audit access to financial records. Some will expressly prohibit abortion care and gender-affirming care, others will expressly encourage palliative care over heroic measures. In Louisville, public service PCPs may be restricted to practice in a contracting district, not citywide. Over time, with the help of city councils and fiscal courts, some public service PCPs will get admitting privileges at nearby hospitals. Some public service primary care providers will take insurance. Some will run sliding-scale concierge practices, or concierge practices combined with charity programs funded by churches or rotary clubs. Some will write grants and run free clinics. Some will primarily serve Amish or Holiness who pool money in group medical savings accounts. Wealthier counties like Bourbon and Madison will have the most to offer, and benefit the most. The legislative committee will suggests one public service PCP per every 4,000 to 6,000 residents. But where will Kentucky find 700 to 1,000 primary care physicians? A few of the poorest southeastern mountain counties will be unable to attract public service PCPs their constituents desperately want. They will succeed in an audacious plan to work with their US Representat- ive to get work visas for five doctors from Cuba. Frontier Nursing University will license them as Nurse Practitioners. Because they are in fact phys- icians an exemption will be made, allowing counties to contract with them. Over the next decade southeast mountain counties and west Kentucky river counties will sponsor a handful of bright students to study at ELAM, the no-tuition Latin American School of Medicine in Cuba. Sponsor counties will try to organize US residencies. The program will be perennially controversial. Some students won't return to the US. Some won't find residencies. The ELAM sponsor program will face insurmountable obstacles and cease being possible after fifteen years. It will introduce a half-dozen primary care physicians with no student loan debt and with new ideas into public service primary care practice. A decade after the program starts there will be nowhere near enough primary care physicians. There will only be about 300 in contracted public service, 1 to every 13,000 Kentuckians. They won't be evenly distributed. Many Kentuckians will have no doctor, no nearby hospital, no ambulance service. A new idea will be auxiliary house call staff. County health departments, the state association of public service PCPs, and the University of Kentucky Center of Excellence in Rural Health will train community nurse aides, primary care techs, and community paramedics. These auxiliaries will work under supervision of RNs in public service PCP offices. The medics will do diabetes education, follow-up to ensure compliance, assess for barriers and resources, problem-solve, and provide urgent first-aid and mental health first aid. Like other medical and mental health techs, many will go on to nursing school or social work. Unlike other aides and techs, some will become new primary care physicians. The public service PCP program will never live up to its full promise. It will preserve the discipline of medicine in a patchwork of Kentucky counties as massive disruptions and widespread closures beset large segments of the former healthcare industry. Funding won't always be available. There will be favoritism and corruption. There will, however be some hundred outpatient internal medicine, family medicine, general surgery, pediatrics, OB/GYN, and psychiatry physicians with long careers serving the people of Kentucky from birth to death. The average office will consist of one physician, a nurse practitioner or physician's assistant, a registered nurse or two, one or two administrative staff, and a contracted cleaning service. After the healthcare industry deteriorates further, some offices will supervise four community aides. Pharmacy will be another matter.