September 2, 2025

Issue Brief

Implementing High-Quality Primary Care: A Policy Menu for States

Focus Area:
Primary Care Transformation
Topic:
Primary Care Investment
Contents A chevron icon

    Authors:

    Christopher F. Koller

    Christopher F. Koller 

    Diana Bianco 

    Katie Greene 

    Maddy Hraber 

    Sandra Wilkniss 

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      This report was developed in partnership with the National Academy for State Health Policy.

      With passage of One Big Beautiful Bill Act (H.R. 1), states are moving forward with implementing health-related provisions of the law and responding to its far-reaching implications for state budgets, health care delivery systems, and residents. Decreases in federal Medicaid expenditures will increase pressure on constrained state budgets, and projected losses in coverage within Medicaid and state-based health insurance marketplaces will pose new barriers to health care access and increase financial pressures on providers. As legislators and state leaders make decisions about how to account for funding reductions, prioritizing high-value investments with demonstrated impacts on health outcomes will be critical to sustain the health of our communities.

      Decades of research have established that primary care is the foundation of a well-performing health system that improves health for all  communities. Access to high-quality care is associated with increased life expectancy, reduced chronic disease burden, higher patient  satisfaction, fewer hospitalizations, and lower health care costs. Despite these benefits, the U.S. continues to invest just 5 to 7 cents of  every health care dollar on primary care — significantly less than other high-income counties. This underinvestment has contributed to declining numbers of clinicians serving in primary care fields and a growing primary care access crisis. Without further action, states will grapple with worsening wait times for appointments and declining numbers of individuals with a usual source of care, resulting in missed opportunities for preventing and managing costly chronic diseases and hospitalizations.

      Ensuring access to robust primary care is a pillar of a comprehensive approach for improving health outcomes while curbing the growth of overall health care costs. Over the last decade, many states have worked to rebalance health spending; advance payment and delivery models that incentivize high-quality, team-based care; attract and retain primary care clinicians; and address patient barriers to care. State executive and legislative leaders can explore these policy levers and successes as they seek to implement cost- effective strategies to strengthen primary care systems within their own states.

      A Primary Care Policy Menu for States

      Health policy leaders need a comprehensive approach to strengthening primary care. Implementing High-Quality Primary Care: A Policy Menu for States builds on the National Academy of Science and Medicine’s 2021 Implementing High-Quality Primary Care report by providing state leaders with a range of policy options states can use to strengthen primary care across geopolitically diverse contexts. Strategies in this menu are organized in five critical and complementary priority areas, with additional resources for each area in an appendix. These priority areas include:

      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 the Current and Future Primary Care Workforce
      5. Build Provider Capacity to Provide Patient-Centered, Whole-Person Care

      Priority Area 1: Make and Keep Primary Care a Top Policy Priority 

      Develop a statewide vision, convene key stakeholders, incorporate community voices, set goals, establish priorities and accountability, and measure progress. 

      Policy ActionsState Spotlights
      Establish a multistakeholder statewide primary care council, commission, task force, or practice level transformation group to assess and report on health of primary care and catalyze action. States that have launched primary care commissions through legislation, executive orders, and public-private partnerships include California, Colorado, Massachusetts, Maryland, Virginia, and Vermont.
      Define specific roles, scope, duties, deliverables, and a sustainability plan for the primary care commission through legislation or other means. Sample deliverables include: 

      • Identifying definitions and measurement approaches for primary care investment, workforce, and other key metrics 

      • Developing recommendations, goals, or strategies for primary care spending and other key priorities 

      • Creating workgroups or forums for collaboration across partners       		• Established by 2025 legislation, Arkansas’ Primary Care Payment Working Group will bring together state officials, primary care providers (PCPs), and payers to define, measure, and report primary care spending and recommend payment targets.

      • Supported by investments from the Virginia Department of Health, the Virginia Center for Health Innovation (VCHI) launched the Virginia Task Force on Primary Care to promote the sustainability of primary care. Current recommendations from the task force include supporting integrated behavioral health models, setting a primary care spend target, and establishing a learning collaborative for incorporating technology and AI into primary care.
      Through the commission or other mechanism, publish a yearly primary care scorecard, report, or data dashboard to document ongoing progress toward spending targets, as well as other key indicators related to primary care workforce, access, and other priorities. States with primary care scorecards or data dashboards include Massachusetts, NewYork, and Virginia.

      To read more about this topic, see “Additional Resources”

      Priority Area 2: Pay Primary Care More and Differently 

      Increase the portion of health care spending going toward primary care and promote non fee-for-service reimbursement approaches that incentivize high-quality, team-based, whole-person care across all communities. 

      Policy ActionsState Spotlights
      • Establish primary care spending targets through legislation or executive orders that promote greater and sustainable financing of primary care. States can increase accountability for achieving spending targets through a range of options, including: 

      • Requiring commissions, payer collaboratives, Medicaid agencies, insurance regulators, or departments of health to issue annual public reports on primary care spending by payer that track progress toward spending targets 

      • Setting absolute and relative spending goals for primary care spending that include both fee-for-service (FFS) and non-FFS spending 

      • Requiring Medicaid and state insurance regulators to measure and increase the portion of health care dollars going into primary care across all payers, with penalties for noncompliance       		• California’s Office of Health Care Affordability set a goal of increasing primary care investment to 15% of overall medical spending by 2034, with an increase of .5-1% percentage points per year of overall spending for each payer.

      • Oklahoma requires its Medicaid managed care organization contractors to report on primary care spending and implementation plans for increasing spending.

      • Rhode Island and Oregon have processes in place to report on and enforce spending target goals across payers.
      • Update existing Medicaid reimbursement models for primary care to promote financial sustainability and high-quality care. Specific approaches include:

      • Increase Medicaid reimbursement rates to reflect true cost of team- based care delivery

      • Reimburse at 100%of the Medicare physician fee schedule (PFS) wherever possible (see here)

      • Leverage contractual requirements for Medicaid managed care organizations (MCOs) to offer additional payments to primary care or offer incentives to meet quality benchmarks      		• Effective January 1 2025, New Mexico raised Medicaid provider reimbursement rates for primary care services, with some increasing to 150% of the Medicare 2024 benchmarks.

      • In 2024, Medicaid physician fee schedules in Montana, Alaska, New Mexico, NorthDakota, Wyoming, Maryland, Indiana, and Vermont reimbursed primary care at or above 100% of Medicare rates.

      • Arizona uses state directed payments to increase primary care spend rates by 15% through MCO contracts.

      • Tennessee’s Patient Centered Medical Home model, supported by the state’s Health Care Innovation Initiative, serves approximately 40% of the Tennessee Medicaid population. Providers are eligible for a yearly payment based on performance, including outcomes, quality, and efficiency.
      In Medicaid and/or public employee plans, reduce use of fee-for-service payments and encourage, incentivize, or require adoption of innovative value-based payment models that encourage high-quality team-based care. Methods include:

      • Leverage Medicaid authorities (e.g., through Medicaid 1115 waivers, health homes, state plan amendments, or other authority) to incentivize primary care models that improve outcomes for patients

      • Develop advanced payment models(APMs) aligned with the HCP- LAN Framework to move toward value-based payment approaches

      • Incentivize team-based care by providing per capita bonuses for medical home certification by the National Committee for Quality Assurance (NCQA) or a state medical home certification      		• Maine’s Primary Care Plus program is a tiered payment model, with
      the highest tier providing population-based payments tied to cost- and quality-related outcomes, emphasizing whole-person focused primary care

      • North Carolina’s Advanced Medical Home program is a tiered medical home model with hybrid payment requirements established through Medicaid managed care contracts.

      • Massachusetts’ Primary Care Sub-Capitation program has three tiers of payments to providers based on increasing levels of comprehensiveness with supplemental fee for service payments, implemented through its Accountable Care Organization.
      • Encourage multi-payer alignment across Medicaid, Medicare, and commercial markets on primary care spending thresholds, quality measures, and payment approaches. Strategies include:

      • Convene interagency or multi-payer collaborative groups to align on quality measures, payment approaches, and multi-payer targets

      • Participate in multi-payer Center for Medicare and Medicaid Innovation (CMMI) demonstration projects, such as the All-Payer Health Equity Approaches and Development (AHEAD) Model

      • Support the development of common sets of quality metrics across payers to ease reporting burdens on providers and encourage adoption of APMs

      • Encourage common care delivery and billing requirements and processes among payers (e.g., comparative coding tables)      		• Colorado HB 22-1325 gives the Colorado Division of Insurance the authority to develop aligned alternative payment model parameters for primary care services in partnership with state agencies, insurers, providers, and consumers. The aligned APM parameters address quality measures, core competencies for the delivery of advanced primary care, risk adjustment, and patient attribution, and are reviewed annually through a stakeholder process.

      • Maryland’s primary care program assists practices in transforming health care delivery to put more of an emphasis on preventive care and chronic disease management

      • California’s Medicaid program (Medi-Cal), health insurance marketplace (Covered California), and public employee and retiree program (CalPERS) developed nearly identical contract provisions to require health plans to report on primary care spend, primary care payment models, and increase adoption of value-based purchasing (VBP) models for primary care.

      • Maryland, Connecticut, Hawaii, Vermont, Rhode Island, and five counties in New York are participating in CMMI’s model. AHEAD is a state total cost of care model that seeks to reduce cost growth while improving population health. Increasing investment in primary care across all payers and aligning primary care transformation with innovations in Medicaid are core components of the model.

      To read more about this topic, see “Additional Resources”

      Priority Area 3: Make it Easier for People to Access Their Primary Care Clinician

      Incentivize primary care providers operating in shortage areas or serving underserved patient populations to expand services through capital grants or loans.

      Policy ActionsState Spotlights

      Incentivize primary care providers operating in shortage areas or serving underserved patient populations to expand services through capital grants or loans.
      • Colorado’s Primary Care Fund, supported by state tobacco taxes, provides funding for community health centers and safety net clinics based on the number of medically indigent patients served. 

      • Rhode Island’s Executive Office of Health and Human Services announced $5 million in grant funding to support recruitment and retention of PCPs. Practices can receive up to $375,000 for expanding patient panels, accepting Medicaid patients, and recruiting new clinicians or mid-level clinicians. 

      • New York’s Community Health Care Revolving Capital Fund is a public-private financing partnership that provides affordable loan capital for eligible community-based primary care and behavioral health providers.
      Update Community Health Center (CHC) and Rural Health Center (RHC) reimbursement models to support sustainability for medically underserved areas. Strategies may include: 

      • Adopt CHC and RHC APMs that reflect the cost of care 

      • Align CHC change-in-scope requirements with federal standards 

      • Allow CHCs to bill for multiple encounters in the same day visits      		• Through a state plan amendment, Louisiana provides additional reimbursement through APMs to federally qualified health centers (FQHCs) to assist with costs incurred from operating in underserved areas. 

      • Effective 2023, North Carolina adopted an APM that allows for FQHC Medicaid reimbursement rate to be rebased triennially based on Medicaid cost reports. Between rebasing years, FQHCs can request an adjustment to their encounter rate for a change in scope of services such as adding a new service or service delivery site or adding a new target population. 

      • Oklahoma allows billing for multiple visits at a FQHC within the same category of service on the same day if each visit addresses a distinct and unrelated diagnosis. Florida’s same-day billing policies allows for Medicaid reimbursement of services provided through the fee-for-service delivery system at an encounter rate. Providers may be reimbursed for up to one medical, one dental, and one behavioral health visit provided to a recipient on the same day. 
      Expand access to primary care services provided via telehealth and ensure payment supports all modes of patient interaction. Approaches include:

      • Partner with state economic development and broadband agencies to expand access to, ensure payment support of, and increase adoption of broadband, especially in rural and other underserved areas.

      • Require all payers to pay for telehealth at parity with in-person visits (as
      long as additional facility fees are not charged)      		• Forty-one states and the District of Columbia require private insurers to cover telehealth visits at parity with in-person visits. 

      • Arkansas’ Center for Telehealth works toward statewide broadband adoption by providing technology training and infrastructure support. 
      Study and address the impact of provider consolidation on access to primary care, particularly in rural areas.• Many states are taking steps to assess and address the impact of vertical consolidation on healthcare costs and access, including access to primary care. 

      • Oregon’s Health Care Market oversight program reviews proposed health care
      mergers, acquisitions, and other deals to ensure that they support state goals related to equity, access, cost, and quality. Additional legislation enacted in 2025 expands Oregon’s corporate practice of medicine doctrine requiring that medical practices are owned and controlled by state-licensed clinicians. 
      Within state employee and retiree health plans, implement insurance benefit designs that reduce financial barriers to using designated primary care clinician.• The California Public Employees’ Retirement System (CalPERS) offers deductible credits for enrollees who complete preventive care activities. 
      • Connecticut’s Health Enhancement Program, operated by the state health employee health plan, rewards participants that complete certain preventive screenings and exams, as well as educational modules for chronic diseases, with decreased premiums and deductibles. 

      To read more about this topic, see “Additional Resources”

      Priority Area 4: Expand and Support the Current and Future Primary Care Workforce

      Expand the primary care pipeline, reduce barriers to joining the primary care workforce, and strengthen recruitment, training, and retention.

      Policy ActionsState Spotlights

      Measure and assess data on state’s primary care workforce needs and shortage areas. Approaches include: 

      •Use licensure or survey data to create workforce reports 

      •Create a registry to identify clinicians and employers 

      •Utilize an All-Payer Claims Database (APCD) or other data infrastructure to assess state workforce composition and distribution 

      •Leverage partnerships with universities and primary care Centers of Excellence to understand primary care workforce data and inform strategies       		•States such as Utah, Virginia, and Arkansas have used data from all-payer claims databases to conduct analysis of the primary care workforces. 

      •Vermont’s Health Care Workforce Census analyzes health care clinicians, including their distribution by geography and specialty, statewide. Vermont’s Office of Health Care Reform is creating a Health Care Workforce Data Center that will support analysis of primary care workforce shortages. 

      •The Behavioral Health Education Center of Nebraska helps support behavioral health workforce development in the state by leveraging data to inform recruitment strategies and training programs. 
      Expand the primary care workforce pipeline through programs, partnerships, and policy. Examples include: 

      •Partner with medical and professional schools to promote community-based training and pathway programs 

      •Initiate/expand loan forgiveness and scholarship programs, including for pre-med programs and other non-medical school programs 

      •Incentivize clinicians, including advanced practitioners, to specialize in primary care through salary supplements for primary care clinicians who opt to work in CHCs, public hospitals, and/or rural areas 

      •Improve monitoring of Medicaid graduate medical education (GME) accountability to ensure it supports primary care trainees 

      •Offer state tax credits for preceptors to provide supervision of primary care trainees 

      •Support existing and proposed teaching health center residency programs, particularly in rural areas       		Minnesota’s State Primary Care Office offers grants to support CHCs and other primary care practices operating in workforce shortage areas. The Rural Primary Care Residency Training Grant Program awards grants to eligible programs to plan, implement, and sustain rural primary care residency training programs. The Primary Care office also offers a range of resources and technical assistance on topics such as workforce retention and loan repayment. 

      • Through a partnership with the California Health Care Foundation, California has several initiatives to support statewide planning and coordination on the primary care workforce, including the California Health Workforce and Education Training Council, the Workforce for a Healthy California Initiative, and the California Future Health Workforce Commission. 

      • The Ohio Department of Health collaborates with the Ohio Association of Community Health Centers (OACHC) to support the Primary Care Workforce Initiative, which provides funding for medical, dental, behavioral health, advanced practice nursing, and PA students to have rotations in FQHCs recognized as patient-centered medical homes (PCMHs). 

      • Michigan’s MIDOCs is a state- and federally funded program expanding graduate medical education residency positions in select specialties to recruit and retain physicians in underserved areas of the state. 
      Reduce barriers clinicians face in joining the primary care workforce, including: 

      •Joining interstate licensing compacts 

      •Facilitating international medical graduates’ ability to practice 

      •Expanding scope of practice for advanced practitioners consistent with team-based care, training, capabilities, and workforce needs       		• Oregon’s Senate Bill 476 and Massachusetts’ Physician Pathway Act allows the states’ medical boards to issue a provisional license to qualified internationally trained clinicians. 

      •The model law for Full Practice Authority for Advanced Nurse Practitioners has been adopted in some form in 27 states. 
      Provide ongoing training and support for primary care retention and wellness. • Washington, DC’s Department of Health conducted listening sessions with PCPs and published a request for stakeholder input on opportunities to reduce clinician burnout and increase retention. DC’s workforce wellness report identifies promising strategies and recommendations for improving workforce wellness 

      • Virginia maintains a Primary Care Innovation Hub where stakeholders can access information about innovative workforce and payment pilots and policies, learning networks for best practices in technology, AI, integrated health, updated Medicaid policy guidance, and research on primary care policy. 

      Reduce common administrative challenges that lead to inefficiency and burnout: 

      • Limit use of prior authorization by commercial insurers and MCOs 

      • Encourage adoption of advanced primary care management (APCM) codes to reduce documentation burden 

      		• Regulations issued by Rhode Island’s Office of the Health Insurance Commissioner required insurers to reduce prior authorization requirements by 20%. 
      Study use of AI in primary care settings to reduce provider documentation time and burnout. Virginia operates a learning collaborative on primary care and AI. 

      To read more about this topic, see “Additional Resources”

      Priority Area 5: Build Provider Capacity to Provide Patient-Centered, Whole-Person Care

      Support practice transformation and facilitate the development of resources, tools, and technology to strengthen the ability of primary care clinicians to provide whole-person care, including behavioral and social supports. 

      Policy ActionsState Spotlights

      •Provide resources, grants, and technical assistance to support PCPs with practice transformation standards and resources that foster high-quality, team-based care (“Advance Primary Care”) and can be the basis for alternate payment mechanisms (see above): 

      • Create a medical home certification program that includes necessary supports and technical assistance to help practices meet requirements for patient-centered, team-based, accessible, and coordinated care 

      • Partner with universities, health systems, and provider associations to support Primary Care Centers of Excellence 

      		•The North Carolina Area Health Education Center assists practices in evolving care delivery and adopting new payment models. 

      • Washington’s Primary Care Practice Recognition program scores practices on how well they are meeting ten practice accountabilities, including whole-person care and behavioral health integration, among others. 

      • Vermont’s Blueprint for Health and Maryland’s Primary Care Program provide technical assistance, opportunities for learning and innovation, and/or shared services to expand the capacity of primary care practices in areas such as chronic care management and care coordination. 

      • California’s Equity and Practice Transformation Payments Program is providing $140 million over three years on a one-time basis to support primary care practices engaged in delivery system transformation. Alongside the funding, the California Department of Health Care Services is offering a statewide practice transformation technical assistance center. 
      Enhance the ability of primary care practices to implement, consult, and coordinate care for patients with behavioral health needs. Approaches include: 

      •Support increased uptake of the Collaborative Care Model (CoCM), an evidence-based primary care-based behavioral health integration model. 

      •Increase funding and support for community health centers to improve integration of primary care and behavioral health, and/or foster partnerships among CHCs and community based behavioral health clinics (CCBHCs), which deliver both crisis and an array of evidence-based behavioral health services and supports. 

      •Encourage teleconsultation models to bring specialty services into primary care settings 

      •Allow Medicaid billing for asynchronous provider to provider “e-consults” to enhance coordination between specialists and PCPs 

      		• Two-thirds of states provide coverage for CoCM under Medicaid 
      North Carolina offered an enhanced reimbursement rate for primary practices implementing the collaborative care model and leveraged state funds to provide capacity building grants to support provider adoption 

      • In 2023, MassHealth of Massachusetts added current procedural terminology (CPT) codes and issued guidance for billing of Provider-to-Provider E-Consults. 

      • At least 30 states, including Missouri and Illinois, provide Medicaid coverage for interprofessional consultation. 

      • The Colorado Pediatric Psychiatry Consultation & Access Program (CoPPCAP) supports Colorado pediatric primary care providers to assess and provide treatment for pediatric behavioral and mental health conditions presenting in the primary care setting, via peer, e-consultation, and linkages to specialty services. 

      • In Vermont, the Department of Health and the Blueprint provide funding for mental health and substance use disorder (MH and SUD) services for people receiving medication for opioid use disorder, including those receiving treatment in primary care practices, through the Hub and Spoke program. The Blueprint’s Mental Health Integration pilot provides primary care practices with resources for standardized MH, SUD, and social needs screenings and for staffing to provide interventions and/or connect people to social service or other community service providers. 
      Enhance the ability of primary care practices to coordinate patient physical health, oral health, and social needs. Approaches include: 

      •Strengthen partnerships with community care hubs (CCHs) and other community backbone organizations that can assist patients with social support needs and barriers to care 

      •Improve tools and partnerships to help connect patients with resources to address social needs through Community Information Exchange (CIE) referral systems for social needs 

      •Adopt APMs, reimbursement models, and implementation support for PCPs to provide coordination and linkage to services for patients’ physical, behavioral and social needs, including dental services and social supports 

      		• FQHCs participating in Ohio Medicaid’s APM receive additional fixed amounts over the regular PPS rate for services that include dental, behavioral health, physical or occupational therapy, and transportation. 

      • Under Washington’s Medicaid waiver, the state’s nine Accountable Communities of Health (ACHs) manage Community Care Hubs (CCHs) that organize and support a network of organizations providing community-based care coordination services to individuals with both health and social needs. 

      • The Iowa Community HUB is a statewide nonprofit CCH that connects communities with health promotion programs and connects individuals with CBOs providing social services and supports. Primary care providers can refer patients to the hub for a variety of service and supports, including housing stability, transportation access, nutrition, chronic disease self-management, childhood obesity, cancer survivorship, and diabetes prevention. 

      • Connect Oregon, one of two main statewide CIE efforts, connects Coordinated Care Organizations (CCOs), health care providers, community-based organizations, HRSN service providers, and public agencies. These partners use the Unite Us platform to identify, deliver, and pay for services that address community needs 
      Encourage improved interoperability and bi-directional payer information sharing that enables Advanced Primary Care. Approaches include: 

      •Strengthen state-based interoperability through investments in APCDs and Health Information Exchanges (HIEs), and CIEs 

      •Leverage federal Medicaid matching funds, state revenues, fee assessments, or other funding sources to support APCD systems 

      •Provide grants or resources to support primary care practices with EHR and technology upgrades 
      		HIEs in states like Arkansas, Maryland, and Oklahoma can improve patient care coordination and reduce fragmentation of care by facilitating the secure sharing of patient information across health care providers. 

      To read more about this topic, see “Additional Resources”

      Additional Resources

      Make and Keep Primary Care a Top Policy Priority

      Pay Primary Care More and Differently

      Make it Easier for People to Access Their Primary Care Clinician

      Expand and Support the Current and Future Primary Care Workforce 

      Build Provider Capacity to Provide Patient-Centered, Whole-Person Care

      Acknowledgements

      This brief was developed through a collaboration between the National Academy for State Health Policy and the Milbank Memorial Fund. Authors include: 

      • Christopher Koller (Milbank Memorial Fund) 
      • Diana Bianco (Milbank Memorial Fund) 
      • Katie Greene (National Academy for State Health Policy)
      • Maddy Hraber (National Academy for State Health Policy) 
      • Sandra Wilkniss (National Academy for State Health Policy) 

      This brief was supported in part by a grant from the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation. 

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