The state of primary care: Falling funding and workforce decline

Primary healthcare is the backbone of a nation’s healthcare system. It positively affects the health of the population and helps to reduce health disparities. In the US, however, primary care is struggling. 

Trends in primary care

To gain a better understanding of the state of primary care in the US, the National Academies of Sciences, Engineering, and Medicine (NASEM) conducted a study to analyze the trends. They focused on five major areas: financing, workforce, access, training, and research. Their report yielded dismaying results.^[] The “scorecard,” the first of its kind, is a baseline for future evaluations—and a wake-up call to the nation to make a stronger investment in primary care.

Origin of the report

The NASEM scorecard study was a response to the call to action outlined in an earlier NASEM report, which advocated establishing high-quality primary care services in the US and a scorecard for measurement.^[] 

The authors commented on the need for these actions:

The NASEM describes high-quality primary care as "the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual's health and wellness needs across settings and through sustained relationships with patients, families, and communities."

The NASEM study was supported by the Physicians Foundation and the Milbank Memorial Fund, with study contributions from the Robert Graham Center, a research component of the American Academy of Family Physicians.

The primary care scorecard

The scorecard revealed the following:

• Funding: Primary care in the United States is consistently underfunded. Funding fell to 4.6% in 2020 from 6.2% in 2013—with a decline in Medicare, Medicaid, and commercial investments. To put this into perspective, the average investment in primary care is nearly 8% of total healthcare spending among the 38 industrialized nations of the Organization for Economic Co-operation and Development (OECD).

• Workforce: One-third of US doctors are primary care physicians, but only 21% of those who completed their residency between 2012 and 2020 were still practicing primary care 2 years later.

• Access: The number of adults who lack a regular source of care is on the rise. Over 27% of Americans didn't have a primary care provider in 2020, compared with 23.6% in 2010. 

• Training: Community-based training of physicians varies significantly between states. In some, all physicians are trained in rural or medically underserved areas, whereas in others, less than 6% of physician residents are trained in community settings—where most primary care takes place.

• Research: Funding for primary care research at the federal level is virtually nonexistent. Primary care only gets 0.2% of funding from the National Institutes of Health.

Real-life ramifications

The findings indicate a dearth of funding, a decreasing workforce, discrepancies in healthcare accessibility, and a significant lack of government funding for research in the primary care domain. 

President of the Milbank Memorial Fund, Christopher Koller, commented on the report in a press release:^[]

The NASEM report acknowledges that the US spends more per capita on healthcare than any other developed nation, yet has the worst health outcomes. 

Roadmap for reform

To improve high-quality primary care, the NASEM report suggests several measures:

• Ensure access: Require all covered individuals to name their usual source of primary care to their payers, and assign a source of care to those who don’t identify one. The report also calls for creating new health centers in underprivileged areas.

• Reform payment: Boost funding for primary care, and employ hybrid payment methods that combine elements of both fee-for-service and capitation.

• Train primary care teams: Expand and diversify the primary care workforce through initiatives developed with healthcare organizations and government agencies.

• Verify implementation: Establish a permanent Office of Primary Care Research under the National Institutes of Health, and a Secretary's Council on Primary Care, to foster research and enhance primary care access.

• Continue innovative educational programs: Continue the support of alternative training and funding models for graduate medical education, like the Teaching Health Center, which provides community-based training and encourages practice in underserved and rural areas.