Assessing the Effectiveness of Policies to Improve Access to Primary Care for Underserved Populations, Case Study Analysis: Detroit, Michigan

Focus Area:
Primary Care Transformation
Health Equity

Funding for this project was provided by the National Institute for Health Care Reform. Read a related report reviewing the evidence on the effectiveness of these policies.


This case study of Detroit, Michigan, the fourth in a series, assesses the effectiveness of various policy initiatives to expand access to primary care in the region, particularly for underserved populations. Several parts of the city are classified as primary care health professional shortage areas, and many policy initiatives have been implemented to make primary care more accessible, but barriers persist.

State and local governments have been proactive in increasing the number of graduate medical education spots in the city, and some of these residents have continued to practice in the area following completion of their training. At least one state workforce development program intended to recruit fully trained physicians in underserved areas like Detroit is showing promise. Despite these efforts, there is still a lack of primary care clinicians serving low-income populations in the city.

Though state and health insurer investment in primary care transformation has helped some local private primary care practices remain sustainable, not all of them accept Medicaid patients. Federally qualified health centers (FQHCs) and other safety net clinics trying to gain FQHC status remain a key source of primary care for low-income populations in the city. However, FQHCs in Michigan receive limited state funding, and outpatient clinics offering safety net services are facing barriers to converting to FQHCs. Consistent state funding of school based health centers (SBHCs), outpatient primary care clinics providing services in schools, and a recent boost in funding for SBHCs could create more points of access for primary care in the city.

Several interviewees specifically identified lack of access to transportation as a key barrier to accessing primary care in the city. An innovative local mobile health program is taking primary care directly to the communities most impacted by this lack of access to affordable and reliable transportation. Local providers have also taken advantage of federal flexibilities under the COVID-19 public health emergency period to build up their audio-only telehealth capabilities, allowing them to further connect with people in hard-to-reach communities.

While Medicaid expansion under the Affordable Care Act has helped improve affordability, local clinicians still find that low-income patients struggle to afford care because of high cost-sharing. Further, the inability of certain immigrant populations in the city to sign up for insurance has put primary care out of reach for many people.

Local providers serving vulnerable populations remain committed to providing culturally responsive care and building trust within the communities they serve. These goals are furthered by Michigan’s policies supporting the expansion of the community health workforce in the state and in Detroit.

Finally, though many providers and nonprofit groups are doing important work to improve access to primary care for underserved populations in Detroit, the catastrophic privatization of the local health department in 2012 has made it difficult for them to organize the various stakeholders and plan for the population health needs of Detroit. As the Detroit health department continues to rebuild, it will have the opportunity to leverage all these resources and expand its effectiveness.

Read the  Detroit case study


Read the Columbia County case study




Kona M. Houston M. Clark J. Walsh-Alker E. Torres Carillo Y. Assessing the Effectiveness of Policies to Improve Access to Primary Care for Underserved Populations, Case Study Analysis: Detroit, Michigan. The Milbank Memorial Fund. April 18, 2023.

 Case Study

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