Detailing the Primary Care Imperative–Remembering Barbara Starfield

Milbank Quarterly Classics
Primary Care

Barbara Starfield built the field of primary care research and galvanized research and policy documenting the central importance of primary care in health and health care delivery. Her work spanned decades, showing how primary care improves population health and lowers health care expenditures. It guided many of us in the quest to improve health and health care, and rates of publications with primary care in the title have more than doubled from fewer than 1,000 in 2005 to more than 2,000 in 2018. The remarkable and comprehensive review that Starfield and her colleagues, Shi and Macinko, published in 2005 in The Milbank Quarterly1 summarized a wealth of US and international studies demonstrating that a) health is better in areas with more primary care physicians, b) people who receive care from primary care physicians are healthier, and c) the main characteristics of primary care are associated with better health. Those studied characteristics are first contact care, holistic person-focused care over time, comprehensive care, and coordinated care, concepts expanded in various primary care medical home criteria at the national and state levels. Furthermore, better health outcomes are found in communities and countries that distribute health resources equitably, have no or low copayments for health care, have a universal financing mechanism guaranteed by a publicly accountable body (government or government-regulated insurance plans), and have professional incomes for primary care physicians comparable to those for other specialists. Systems with strong primary care orientation and where primary care physicians are identified as the usual source of care are associated with decreased racial and socioeconomic health disparities and with decreased deaths from premature mortality, infant mortality, and overall mortality from chronic pulmonary disease, cardiovascular disease, and heart disease.

Read The Milbank Quarterly Classic Article:

Contribution of Primary Care to Health Systems and Health

Barbara Starfield, Leiyu Shi, and James Macinko

What progress has the United States made since the 2005 Starfield publication? During this period, the United States has become even more racially and ethnically diverse, especially among younger groups. Many in the health sector—and elsewhere—have recognized the importance of the social determinants of health and the role the health sector can play in addressing those determinants.2 Growing rates of mental and behavioral health conditions, often coexisting with other chronic health conditions, have spawned progress in integrating mental and behavioral health in primary care teams. Spurred partly in response to the recognition of the multifactorial antecedents of health and the central role of mental health, general and subspecialty clinical practice has increasingly embraced team-based care, including some combination of nurse care coordinators, mental health personnel, and family health workers—a phenomenon that Starfield recognized while pondering how to maintain important personal relationships between patients and providers with the transformation to teams.1 Much work has gone into training team members in their collaborative efforts and, through such work, emphasizing the importance of maintaining a productive personal relationship with ongoing patients.

Despite these generally favorable changes in primary care, the United States has recently experienced striking increases in mortality among people aged 15-60 years.3 Although some of this growth reflects the opioid epidemic and other drug and alcohol use, much mortality comes from suicide (reflecting the increase in mental health conditions) and cardiovascular and heart disease, partly resulting from the epidemic of obesity. Although high-quality primary care could prevent many of these deaths, the United States perpetuates a serious imbalance in financial support for primary care versus other health investments, with primary care and mental and behavioral health chronically underfunded. Starfield noted that greater relative investment in primary care improves population health and decreases health care expenditures. The US strategy limits access to preventive care throughout the life course for some populations, especially those with low income. Coupled with the persistence of poverty among young families in the United States—much worse than in other OECD countries—the lack of adequate primary care creates an unhealthy underclass beginning in childhood (or even prenatally) and continuing to affect health and death over the decades.4 The persistent rapid growth of US health care expenditures further indicates the lack of systematic work to implement Starfield’s findings and recommendations. For example, although the Affordable Care Act included provisions to lower the growth in total health care expenditures, many provisions required upfront funding that Congress declined to provide. This failure reflects a lack of political will to take on a complex and powerful health care industry driven by specialist investigations and interventions, rather than investment in primary care to increase access, promote prevention, improve overall quality of care, and reduce unnecessary and potentially harmful specialist care. The United States has paid the price of increased disability, mortality, and other indicators of poor health along with rising costs, all highlighted by Starfield and her colleagues.

Are there important points of light? The Centers for Medicare and Medicaid Services have stimulated greater investment in primary care, especially through their State Innovation Models and Primary Care Plus initiative. However, here too strategies have had negligible impact on equitable pay for primary care physicians, with, for example, the resource-based value structure oriented to procedures over cognitive services and, thus, balanced against adequate support for primary care tasks.5 Several states have worked to increase primary care investment, some through their Medicaid programs and others through broader health policy oversight, including direct calls for identifying and increasing the percent of health care dollars spent on primary care from public and private sources.6 The National Academies of Science, Engineering, and Medicine recently empaneled a new study on Implementing High Quality Primary Care, the first serious attention to primary care by the Academies in more than a quarter century. We can hope this new attention will lead to stronger political will and policy changes that begin to approximate Starfield’s original vision for primary care.



  1.  Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank Q. 2005;83(3):457-502.
  2. National Academies of Science, Engineering, and Medicine. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health. Washington DC: National Academies Press; 2019.
  3. Woolf SH, Schoomaker H. Life Expectancy and Mortality Rates in the United States, 1959-2017. JAMA. 2019;322(20):1996-2016.
  4. DeVoe JE, Geller, A, Negussie, Y. Vibrant and Healthy Kids: Aligning Science, Practice, and Policy to Advance Health Equity. Washington, DC: National Academies of Science, Engineering, and Medicine; 2019.
  5. Landon BE. A Step toward Protecting Payments for Primary Care. N Engl J Med. 2019;380(6):507-510.
  6. Koller CF, Khullar D. Primary Care Spending Rate – A Lever for Encouraging Investment in Primary Care. N Engl J Med. 2017;377(18):1709-1711.

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Published April 2020
DOI: 10.1111/1468-0009.12460