The Health of US Primary Care: 2024 Scorecard Report — No One Can See You Now

Five Reasons Why Access to Primary Care Is Getting Worse (and What Needs to Change)

Executive Summary

Primary care is in crisis. In 2023, the inaugural Primary Care Scorecard made clear the systemic lack of support for primary care in the United States, which is harming people’s health and weakening the US health system.² It is no surprise that one year later, in the absence of a coordinated effort among policy leaders, we see news stories on the diminishing availability of primary care physicians and long wait times for primary care visits.³ Headlines such as “Primary Care Saves Lives. Here’s Why It’s Failing Americans”⁴ and “The Shrinking Number of Primary Care Physicians Is Reaching a Tipping Point”⁵ dominate the lay media’s reporting on primary care. Despite the overwhelming evidence that access to primary care improves population health, reduces health disparities, and saves health care dollars, support for primary care continues to dwindle. As a result the average life expectancy in the United States continues to stagnate,⁶ and health disparities in preventive services and other basic primary care services persist, accounting for 60,000 excess deaths each year.⁷

Grounded in the recommendations of the 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report, Implementing High Quality Primary Care: Rebuilding the Foundations of Healthcare, ⁸ this year’s Scorecard report assesses the health of primary care at the federal level using measures of access, financing, workforce/training, and research. This assessment identifies five reasons why primary care in the United States is inaccessible for so many Americans. (See the data dashboard for state-by-state data.)

Reason 1: The primary care workforce is not growing fast enough to meet population needs.

• The number of primary care physicians (PCPs) per capita has declined over time from a high of 68.4 PCPs per 100,000 people in 2012 to 67.2 PCPs per 100,000 people in 2021.
• While the rate of total clinicians in primary care, inclusive of nurse practitioners (NPs) and physician assistants (PAs), has grown over the past several years, it is still insufficient to meet the demands of overall population growth,⁹ a rapidly aging population with higher levels of chronic disease,¹⁰ and workforce losses during the pandemic.¹¹ Compared to Canada, which boasts a primary care physician-only density of 133 per 100,000 people, the US primary care total clinician (physician, NP, and PA) density was only 105 per 100,000 people in 2021.¹²

Reason 2: The number of trainees who enter and stay on the professional pathway to primary care practice is too low, and too few primary care residents have community-based training.

• In 2021, 37% of all physicians in training (residents) began training in primary care, yet only 21% of all physicians were practicing primary care three to five years after residency. More than half of residents with the potential to enter primary care subspecialized or became hospitalists instead.
• In 2020, only 15% of primary care residents spent a majority of their time training in outpatient settings where a majority of the US population receives their care.¹³ Fewer than 5% of primary care residents spent a majority of their training with the most underserved communities in the United States.
• The number of medical residents per person in primary care has risen at a slower pace than all other specialties, increasing by only 21% compared to 26% in other specialties.

Reason 3: The US continues to underinvest in primary care.

• The investment in primary care as a share of total health care spending has dropped from 5.4% in 2012 to 4.7% in 2021.
• Medicaid and commercial insurer investment in primary care has decreased since 2012, and Medicare investment remains low. Since 2019, primary care investment has steadily declined for all payers; this decline is most pronounced in the Medicare population.

Reason 4: Technology has become a burden to primary care.

• Data limited to family physicians demonstrate that health care technologies do not serve primary care physicians adequately; more than 40% of family physicians report unfavorable scores in electronic heath record (EHR) usability, and over 25% report overall dissatisfaction with their EHR.

Reason 5: Primary care research to identify, implement, and track novel care delivery and payment solutions is lacking.

• Since 2017, only around 0.3% of federal research funding (administered through the National Institutes of Health and the Agency for Healthcare Quality and Research, for example) per year has been invested in primary care research, limiting new information on primary care systems, payment and delivery models, and quality.
• Lack of adequate data about the primary care infrastructure hinders this Scorecard’s capacity to fully track progress on the NASEM report objectives: (1) Pay for primary care teams to care for people, not doctors to deliver services; (2) Ensure that high-quality primary care is available to every individual and family in every community; (3) Train primary care teams where people live and work; (4) Design information technology that serves the patient, family, and the interprofessional care team; (5) Ensure that high-quality primary care is implemented in the United States.

There are bright spots where innovative primary care policy is being implemented, resulting in improved access to team-based care and new pathways for primary care clinicians. We describe some of these initiatives in this report and hear from essential primary care team members, such as community health workers and medical assistants, whose numbers and training we can’t yet track due to data limitations.

Without policy solutions to the problems outlined in this report, however, access to primary care will continue to erode, as will the health of the nation. To ensure Americans can get primary care when and where they need it and can live longer, healthier, and more productive lives, policymakers will need to support the primary care workforce and pipeline with the systemic reforms outlined in the 2021 NASEM report.

Notes

1. Save graduate medical education. American Medical Association website. https://www.ama-assn.org/education/gme-funding/save-graduate-medicaleducation. Published December 5, 2023. Accessed December 8, 2023.
2. Jabbarpour Y, Petterson S, Jetty A, Byun H. The health of US primary care: a baseline scorecard tracking support for high-quality primary care. The Milbank Memorial Fund and The Physicians Foundation. https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard. Published February 2023. Accessed January 30, 2024.
3. Heath S. Average patient appointment wait time is 26 days in 2022. Patient Engagement HIT website. https://patientengagementhit.com/news/averagepatient-appointment-wait-time-is-26-days-in-2022. Published September 15, 2022. Accessed November 7, 2023.
4. Sellers FS. Primary care saves lives. Here’s why it’s failing Americans. Washington Post. November 9, 2023. https://www.washingtonpost.com/health/2023/10/17/primary-care-saves-lives. Accessed December 13, 2023.
5. Rosenthal E. The shrinking number of primary care physicians is reaching a tipping point. KFF Health News. https://kffhealthnews.org/news/article/lack-of-primary-care-tipping-point. Published September 8, 2023. Accessed December 13, 2023.
6. Arias E, Tejada-Vera B, Kochanek KD, Ahmad FB. Provisional life expectancy estimates for 2021. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/vsrr/vsrr023.pdf. Published August 2022. Accessed January 30, 2024.
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8. Implementing high-quality primary care: rebuilding the foundation of health care. The National Academies of Sciences, Engineering, and Medicine. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care. Published 2021. Accessed August 2, 2022.
9. 2017 projected age groups and sex composition of the population: main projections series for the United States, 2017–2060. U.S. Census Bureau, Population Division. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html. Published 2017. Accessed January 30, 2024.
10. Ansah JP, Chiu CT. Projecting the chronic disease burden among the adult population in the United States using a multi-state population model. Front Public Health. 2023;10:1082183. doi:10.3389/fpubh.2022.1082183.
11. Shanafelt TD, Dyrbye LN, West CP, et al. Career plans of US physicians after the first 2 years of the COVID-19 pandemic. Mayo Clinic Proceedings. 2023;98(11):1629-1640. doi:10.1016/j.mayocp.2023.07.006.
12. Healthcare resources: physicians—overall. OECD.Stat. https://stats.oecd.org/Index.aspx?QueryId=74634. Accessed January 30, 2024.
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