For a clear-eyed view of the U.S. health system factors that have collectively conspired to cripple primary care, the five-part New England Journal of Medicine series "The Primary Care Puzzle" by cardiologist and medical reporter Dr. Lisa Rosenbaum is a worthwhile read. Although I would usually frown on a subspecialist writing a pessimistic view of the problems in my field of medicine (family medicine comprising the majority of primary care in Lancaster and elsewhere), Rosenbaum has interviewed all of the key informants and gets most of the story right.
Since it has become clear that primary care is a common good, like law enforcement and public libraries, it's fair to ask what state and federal governments have been doing to support high-quality primary care. A systematic review in JAMA Health Forum discussed 5 federally-supported programs in primary care "transformation" from 2011 to 2021: 4 demonstration projects in paying primary care practices prospectively and EvidenceNOW Advancing Heart Health, which focused on improving cardiovascular outcomes. The numbers of participating practices ranged from 500 to nearly 3000. None of these programs was a failure or an unqualified success (improving health outcomes, the patient and clinician experience, or saving the system money).
The Trump administration has shown little interest in supporting primary care beyond allowing persons to use health savings accounts to pay membership fees to direct primary care practices. This change will help some access primary care, but huge funding cuts to Medicaid and premium subsidies for health insurance marketplace plans will result in millions more losing access to their doctors. (Further damaging to primary care are the hostile takeover and suspension of activities of the Advisory Committee on Immunization Practices and the U.S. Preventive Services Task Force, respectively.)
States have taken different approaches to better resource primary care. Oregon, Delaware, Colorado, and California recently passed legislation aiming to gradually increase the proportion of all health care spending on primary care from 5-7% to 11.5% to 15% over the next decade. Delaware and Rhode Island have combined primary care spending targets with caps on overall health care spending increases.
In September, the Milbank Memorial Fund published a policy menu for states looking to strengthen primary care, organized by 5 priority areas and spotlighting examples of policy actions taken by states that are diverse geographically and ideologically:
1. Make and Keep Primary Care a Top Policy Priority
2. Pay Primary Care More and Differently
3. Make It Easier for People to Access Their Primary Care Clinician
4. Expand and Support and Current and Future Primary Care Workforce
5. Build Provider Capacity to Provide Patient-Centered, Whole-Person Care
These initiatives are a good start, but they are not nearly enough to close the gap between the inadequate primary care workforce we have and the one we need to make the lagging U.S. competitive internationally in health care spending and outcomes.
