The State of Primary Care in the United States

Policy Points Primary care, when done well, is the country's most cost-effective solution to runaway costs and widening health outcome gaps. Primary care is increasingly starved for resources, with associated reductions in relational continuity and comprehensiveness that collectively increase the risk of losing patient trust. The 2021 National Academies of Sciences, Engineering, and Medicine report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, supported a cascade of federal initiatives to strengthen, coordinate, and create accountability for primary care strategies, and although several derailed, they remain options for improving health and health care. The 2021 National Academies of Sciences, Engineering, and Medicine report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, spurred a cascade of federal payment, access, and accountability initiatives, but inconsistent federal leadership has derailed several of them. Congressional and HHS health goals would benefit from reviving stalled primary care infrastructure projects, establish outcome accountability for graduate medical education investment, and build on state models in Maryland, Rhode Island, Vermont, and California. CONTEXT: Primary care is the foundation of a high-functioning health system, yet it has been weakened for decades, and the consequences for patients, population health, and costs are increasingly apparent. The 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report offered 16 recommendations across five objectives for rebuilding primary care through payment, access, workforce training, health information technology, and accountability. METHODS: This Perspective reviews federal and state policy developments since the NASEM report against its five-objective framework, examining payment demonstration models, minimum primary care spend legislation, graduate medical education financing, and federal data infrastructure initiatives to assess where reform has taken hold, stalled, or been abandoned amid shifting administration priorities. FINDINGS: Partial payment successes, including the Advanced Primary Care Management code, the AHEAD model, and minimum-spend policies in nearly a dozen states, demonstrate that reform is feasible. Yet inconsistent federal leadership has undermined progress: the Making Care Primary model was abruptly terminated, and several near-complete Agency for Healthcare Research and Quality initiatives-a primary care dashboard, Healthcare Extension Cooperatives, and a clinician/practice database-were lost amid the agency's proposed dissolution. Meanwhile, cuts to Affordable Care Act subsidies and Medicaid threaten to disrupt care for millions and widen mortality gaps. States are increasingly serving as policy laboratories, with Maryland, Rhode Island, Vermont, and California offering replicable models for payment and accountability reform. CONCLUSIONS: The technical solutions needed to strengthen primary care largely already exist. What is missing is durable, coordinated federal and state investment paired with accountability. Securing primary care's future requires treating it as essential public infrastructure.