Building a Robust Primary Care Workforce: Diffusing Lessons Across States 

The United States spends $29 billion annually on graduate medical education (GME) yet the nation faces persistent shortages of primary care physicians (PCPs). Despite repeated calls to make GME spending more accountable and aligned with population health needs, PCPs comprise a shrinking proportion of the physician workforce. The result is longer wait times for appointments, worsening access to primary care in rural and underserved communities, and an increasing reliance on emergency rooms for care.

There is no “easy button” for solving PCP shortages, but we’ve let an important opportunity slip through our fingers. The Affordable Care Act authorized the creation of a national health workforce commission to provide strategic direction to Congress, the executive branch, states, and localities on workforce needs. The commission was never funded, leaving a gap in national workforce strategy, coordination, and oversight. Importantly, the commission was envisioned as a federal-state partnership, with states working with the federal government to identify and address pressing health workforce needs.

In the absence of a national health workforce strategy in the United States, individual states, including Missouri, North Carolina, and Wisconsin, have developed and implemented state-level graduate medical education (GME) strategies to “grow their own” primary care workforce. The challenge will be diffusing the lessons learned from their efforts across states.

State‑Level Innovation Is Showing How GME Redesign Is Possible, Incrementally

Charles Lindblom argued in The Science of Muddling Through that policymaking often advances through small, incremental adjustments rather than sweeping redesign. This is especially true in the US where pushback to attempts to create a more accountable, national GME system has impeded reform. Because Medicare, the largest federal source of GME funding, has remained largely unchanged, states are stepping in to incrementally reform GME. Through Medicaid, state appropriations, and targeted technical assistance, states are expanding GME in needed specialties and underserved communities, often with accountability measures built into funding decisions to ensure their investments produce residency graduates who remain in-state and practice in needed specialties, geographies, and settings.

John Kingdon’s seminal work on policy windows highlights why incremental gains matter. These incremental efforts are building evidence, capacity, and readiness for broader reform. When a policy window opens, triggered by a public health or financing crisis, political change, or heightened public awareness of the issue, the policy community will be armed with well‑developed, evidence‑informed GME models.

Next Steps: Diffusing the Lessons Learned Across States and to Federal Government

Arguably, the greatest opportunity for GME reform now lies in systematically capturing, evaluating, and diffusing state models and their outcomes. Horizontal diffusion across states can accelerate the adoption of effective GME and workforce strategies, while vertical diffusion — from states to federal policymakers — can inform national policy design, funding priorities, and accountability frameworks.

Theories of policy diffusion suggest several pathways through which this can occur: emulation (when states imitate other states despite limited evidence of a policy’s success), competition (when states perceive advantage — or fear disadvantage — relative to others), and learning (when one state adopts another’s policy based on demonstrated success).

Like US states, Sweden’s 21 regions collaborate with the federal government on the governing, financing and delivery of health care. Historically, regions acted independently without a coordinated and strategic plan to develop and sustain the primary care physician workforce needed to meet population health needs. That changed when Sweden’s National Board of Health and Welfare decided on a benchmark of 1 primary care physician for every 1100 residents in 2022. The benchmark provides a common and measurable goal for the regions while allowing them to tailor their workforce planning efforts to meet their region’s unique demands. Sweden’s approach blends competition and learning between regions; it is successfully building momentum and leading to progress toward the national benchmark. The Swedish model highlights the value of transparent workforce monitoring, shared benchmarks, and structured support for regional implementation in facilitating learning across jurisdictions.

US states are likewise showing what state-federal partnerships can do to increase primary care workforce capacity. State Medicaid spending on GME increased from $3.78 billion in 2009 to $7.39 billion in 2022.

What States Can Do Now:

• Use workforce data to drive GME investments. North Carolina’s GME Technical Assistance Center mapped existing training sites against health workforce needs to determine where to invest new GME funding.
• Build accountability into GME investments from the beginning. Missouri’s Graduate Medical Education Grant Program ties state GME investments to workforce goals by targeting funds based on factors such as the proportion of training in rural settings and whether residents train in rural clinics, federally qualified health centers, or area health education center-based clinics. Other considerations for funding include whether participating residents attended high school, college or medical school in Missouri and ultimately, the percent of graduates who are retained in Missouri and in rural areas.
• Track outcomes. Wisconsin ties GME expansion grants to a concrete accountability measure: funded residency programs must retain 50% of graduates in-state. As a result, the state has created 39 new and expanded programs that will produce more than 300 new GME positions at full complement. These programs are expected to retain 70% of their trainees instate, yielding roughly 100 physicians entering needed specialties of family medicine, surgery, psychiatry, OB/GYN and internal medicine.
• Disseminate lessons. By continuing to collect data, evaluate outcomes, and share lessons across states and with federal policymakers as they recently did at a National Academies of Science, Engineering and Medicine GME meeting, states can help translate incremental progress into scalable solutions and ensure that, when a national policy window opens, GME reform is grounded in the evidence needed to move the US toward a system in which the billions we invest are actually meeting the nation’s health needs. To foster dissemination across states, the Centers for Medicare and Medicaid Services and the Health Resources and Services Administration recently launched a State GME Community of Practice to support state officials and technical assistance center entities as part of the Rural Health Transformation Program.