As 2025 draws to a close, how much closer/farther is the U.S. health system to/from the goal of providing primary care for all Americans? Much of the news isn't good. A recent analysis in the Annals of Family Medicine documented an 11% decrease in the number of family physicians practicing in rural areas from 2017 to 2023, with the Northeast suffering the largest proportional losses. As a faculty member at a Northeast residency program where many graduates have historically provided primary care to rural communities, this statistic hits home. Some of the "lost" physicians no doubt migrated to suburban or urban areas and continued to practice, but others developed burnout and left medicine altogether.
More and more clinicians, family physicians included, are participating in concierge or direct primary care practices, which collect an affordable up-front monthly fee per patient rather than rely on delayed insurance payments and provide relief from the burdensome paperwork that comes with third-party payers of health care. A study in Health Affairs used a national directory of direct primary care practices to create a longitudinal data set of clinicians from 2018 to 2023. During this five-year time frame, the number of practices and participating clinicians grew by 83 and 78 percent, respectively. Corporate-affiliated practices have made significant inroads into what was previously a clinician-owned model, with the percentage of independent practices shrinking from 84 to 60 percent. Although proponents tout its many advantages to clinicians and patients, the math is inescapable: every direct primary care physician who is caring for a panel of 500 patients rather than 1500 makes it more difficult for the other thousand to access traditional primary care.
With that context, what has PC4AA, the nonprofit group that I first highlighted in a blog post last year, been doing to improve primary care access? Rather than take a top-down approach like the National Academy of Medicine, they've chosen to tackle the problem from the ground up, community by community. One of those communities is New Bedford, Massachusetts, a multicultural, multilingual city of 101,000 people with just 36 practicing primary care clinicians, including 15 physicians. Of the 15 physicians, 10 are pediatricians and only 5 care for adults. An estimated 20 to 25 percent of the population does not have a relationship with a primary care clinician. Wait times for a new patient appointment range from two to nine months.
I've never been to New Bedford or spoken with anyone who provides health care there. So how do I know so much about this community and its ongoing primary care crisis? From the report released in October by PC4AA's New Bedford chapter, which contains an in-depth analysis of the state of primary care in New Bedford as well as a multi-pronged strategy to recruit more primary care clinicians to meet the needs of the population. The original working group is now convening task forces that will focus on enhancing the primary care training pipeline, making training more affordable through scholarships and loan repayment, encouraging the development of new residency programs, and supporting existing primary care practices financially to allow them to expand services to more patients in the future.
It's much too early to tell whether PC4AA will succeed in reinvigorating U.S. primary care where others have so conspicuously failed. But if, like me, you are looking for a reason to be optimistic about health care in 2026 - a year that is forecast to see the first increase in the percentage of the population that is uninsured since the Affordable Care Act's passage in 2010 - this is it. Community by community, rebuilding and remaking the system from the ground up.
