The Path to Coordinated Federal Leadership to Strengthen Primary Health Care

Introduction

As the nation struggles to find a new equilibrium in health care services delivery and financing in the wake of the COVID-19 pandemic, it faces four foundational and interconnected population health challenges: a growing recognition of the toll of health inequities on vulnerable populations, pandemic recovery and future resilience, a resurgent opioid epidemic, and a growing mental health crisis, especially for children and teens.

Investment in primary care, which the 2021 National Academies of Science, Engineering, and Medicine (NASEM) report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care named a common good, will help the US address each of these challenges. But aligning federal levers will be necessary.

The NASEM report recognized that primary care, the largest platform for health care and the only one associated with improved health equity, has no coordinating leadership at the federal level. The report recommended that the U.S. Department of Health and Human Services (HHS) fill this void by establishing a Secretary’s Council on Primary Care, which would be advised by a Primary Care Advisory Committee, consisting of stakeholders.

Through its Initiative to Strengthen Primary Health Care, launched in 2021, HHS is currently coordinating a multiagency effort that will likely support a Secretary’s Council on Primary Care. HHS commitment of staffing and resources to a council will be critical to coordinating primary care strategy on payment, workforce, research, technology use, and measurement. NASEM is prepared to support an advisory committee to help the council achieve success in its early stages. But sustaining this effort will eventually require congressional support for the creation of a robust Office of Primary Care, with dedicated funding and staffing to support a more permanent infrastructure.

The timing of this opportunity is critical. Primary care has generally lost ground in federal policy and in investment across all payers. There are powerful industry pressures on Congress and federal agencies to maintain the status quo, which makes primary care a perpetual financial loss leader. Growth in graduate medical education (GME) now largely serves the needs of recipient institutions rather than the populations they serve, meaning it provides subspecialty training to support more lucrative services. The primary care payment model experiments advanced by the Center for Medicare and Medicaid Innovation (CMMI), hampered by strict statutory language on cost effectiveness, struggle to achieve broader implementation. As a result, the portion of dollars in Medicare going to primary care relative to other specialties is decreasing, and health systems increasingly orient their services and physician training to higher-margin specialty services. As goes Medicare, so goes commercial health insurance provider payment policy, amplifying these trends. Without the triad of a coordinating council in HHS, an advisory committee, and an Office of Primary Care, the country is unlikely to be successful in addressing four of its most important health challenges: health inequities, pandemic response and resilience, the opioid epidemic, and access to mental health services.

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