Primary Care Moonshot: A Policy Proposal for Addressing Underinvestment in Primary Care

More than a decade after primary care was promoted in the Affordable Care Act as a means of improving health care outcomes and costs, we still have not seen large-scale changes in primary care delivery or payment.¹ Chronic underinvestment is a major cause of the glacial pace of primary care progress. The US spends approximately 5% to 7% of total medical expenditures on primary care, whereas comparable high-income countries, with less overall health care expenditures and better population health outcomes, spend approximately 13%.^2-4 We also seem to be moving in the wrong direction. A recent Milbank Memorial Fund report demonstrated that from 2013 to 2020, primary care spending decreased from 6.2% to 4.6% of total health care expenditures.⁵ Meanwhile, projected spending on oncology medications alone is expected to be $125 billion by 2027—an increase of approximately 50% from 2022. To truly advance primary care, we need greater investment and a fundamental restructuring of how we define and deliver primary care—at the expense of escalating spending in subspecialty care. For example, the Cancer Moonshot program, although admirable in its goals and efforts, concentrates resources in an already highly funded area. We need a comprehensive 10-year Primary Care Moonshot (coined previously by Renee Crichlow, MD) to help prioritize and leverage primary care to improve the health of individuals in the US.⁶

Invest in Primary Care Research by Creating Its Own Institute

The first avenue of necessary investment is primary care research. The National Institutes of Health (NIH), whose annual budget of nearly $48 billion provides the majority of federal health research funding, organizes its 27 institutes and centers largely around specific diseases (eg, National Institute of Neurological Disorders and Stroke; ~ $2.8 billion budget) or organ systems (National Heart, Lung, and Blood Institute; ~ $4 billion budget).^7-10 Although there is a National Institute of General Medical Sciences, it is focused on basic science research.¹¹ There is no institute within the NIH specifically dedicated to primary care research. Instead, the lead governmental organization funding primary care research is the Agency for Healthcare Research and Quality (AHRQ), whose annual budget of approximately $450 million is vastly overshadowed by the NIH, with only $2 million of its fiscal year 2025 proposed research budget dedicated to primary care.¹²

The underfunding of primary care research is reflective of the broader undervaluing of primary care and has meaningful consequences for primary care delivery reform. The lack of dedicated research funding creates important evidence gaps and promotes policies rooted in how primary care is perceived to work rather than how it is evidenced to work. For example, in 2020, we wrote about acute care utilization metrics in alternative payment models (APMs), to which primary care practices have repeatedly been held accountable but for which there is a dearth of evidence to support that high-quality primary care delivery can significantly and reliably improve.¹³

The NIH has made important steps toward improving the visibility and infrastructure of primary care research through a $30 million pilot program of a national primary care research network.¹⁴ However, this funding is focused on developing infrastructure to expand funded research to community-based primary care. It is not meant to provide direct funding for primary care research. Therefore, we propose dedicating a minimum of 10% of the NIH budget to form and fund research through a National Institute of Primary Care Delivery (NIPCD), which could operate in tandem with the national primary care research network. This level of investment could provide nearly $5 billion for rigorous development and evaluation of innovations in primary care delivery in addition to the congressionally mandated evaluations of primary care innovations undertaken by the Center for Medicare and Medicaid Innovation (CMMI). The NIPCD could also incentivize a primary care research pipeline and motivate existing primary care clinician-researchers to study primary care broadly instead of refitting primary care interests into specialty areas where funding exists.

Invest 13% of All Medical Expenditures in Primary Care and Establish an Office of Primary Care Coordination in HHS

To fully realize the potential of primary care, the US should commit through an act of Congress to spending 13% of all Medicare and Medicaid medical expenditures annually on primary care and require the same level of investment of commercial payers participating in Affordable Care Act health insurance exchanges by the end of the decade. Such an effort would resemble ongoing primary investment initiatives undertaken in several individual states and would bring US primary care investment to levels similar to its peer nations with better health outcomes.⁴

We recognize that increasing funding alone to primary care may not result in desired improvements. To optimize efforts around increased primary care investment, primary care practices will benefit from structured support and guidance with a clear vision and priorities for primary care reform. The US government should develop an Office of Primary Care Coordination (OPCC) embedded within HHS—the department whose mission is to enhance the health and well-being of all those in the US—to lead a 3-pronged national primary care agenda: promoting primary care orientation, advancement, and access.^15,16 The idea of a central primary care office has precedent in the Veterans Health Administration’s Office of Primary Care, and HHS could draw from this model.¹⁷ First, the OPCC would promote primary care orientation, which can be defined as health systems with a high ratio of primary care providers (PCPs) to specialists, primary care as first contact for new health concerns, and highly coordinated primary and specialty care.15,18 Establishing primary care orientation would require a reset of public perception, education, and expectations about core primary care functions (eg, having a PCP for first contact; comprehensive, continuous, and coordinated care) in addition to robust coordinated public investment.^15,18 

Second, the OPCC would catalyze and scale notable primary care advancements. Although in the past decade we have seen examples of compelling primary care advancements that expand primary care teams (eg, mental health integration, community health workers), link to community and social services (eg, transportation, food, housing), and better engage patients in self-management, these models were generally isolated and not scalable under the current primary care environment. Furthermore, although technology-
based solutions such as digital scribes and patient portals hold promise, more work is needed to assess efficacy, accessibility, and equity.^19-21 The OPCC can use evidence surrounding these advancements to address policy, investment, and equitable access barriers that prevent implementation at scale.

Third, investment and focus on primary care advancement could help to address a growing crisis in primary care access. The per capita supply of PCPs has decreased in the past 10 years, and wait times to see a PCP remain nearly a month long.²² Poor primary care access is in part related to payment structures that mainly reimburse the work of PCPs and do not support robust team-based care. For example, researchers in one study estimated that a PCP would need 27 hours a day to address all guideline-recommended care for a standard primary care panel.²³ High primary care workload concentrated to PCPs creates problems in both recruitment and retention: Fewer medical students and residents choose primary care training and careers, and practicing PCPs retire early. Higher population needs among aging baby boomers further exacerbate primary care shortages. Focusing only on increasing the supply of PCPs is unlikely to meaningfully improve primary care access. Expanding primary care service delivery to other team members, such as community health workers, can reduce the workload of PCPs; however, to do so, primary care payment models would need to better account for the work of all primary care team members. In the long term, distributing primary care functions across more expansive teams may improve PCP experience and indirectly support PCP recruitment and retention. The OPCC could champion policies that support and advance team-based primary care to improve primary care access.

Many offices spanning the US government (AHRQ, CMMI, CDC, etc) oversee some aspect of primary care; however, there is no office specifically dedicated to coordinating these disparate efforts. The OPCC could also serve in this role, collaborating with PCPs, community and industry innovators, the new NIPCD, and other federal offices interfacing with primary care policy to advance its 3-part agenda and optimize outcomes with increased primary care investment.

Revamp Reimbursement Approaches in Primary Care

Third, primary care payment reform should address reliance on pay-for-performance models and confront reimbursement inequities. To date, most federal primary care investment efforts are tied to pay-for-performance APMs. Within these models, much of the increased funding available to providers and practices is contingent on performance on predetermined quality measures, despite modest evidence of effectiveness.^24-26 The timeline and metrics we currently use to evaluate primary care in pay-for-performance models are inherently shortsighted—we would not necessarily expect results in 1- to 5-year timelines under which primary care performance has historically been assessed. It is therefore unsurprising that results of studies examining the Medicare Shared Savings Program, one of the most prominent pay-for-performance APMs focused on reducing total cost of care, have been mixed, with some finding that the program achieves net savings and others net losses for Medicare.^27-29 Primary care’s value to population health outside of the context of pay-for-performance models and its associated need for an influx of resources are well established.² Therefore, although there is promise for APMs and practice-driven quality improvement efforts in primary care, a Primary Care Moonshot would reduce the emphasis on linking primary care investment with pay for performance. Instead, a Primary Care Moonshot would invest in primary care for its own sake and on its own merits. Continuous evaluation of primary care will be important to inform a national primary care learning health system and iteratively improve on care delivery models; however, we think the explicit expectation of return on investment and payments tied to that expectation could continue to distract from progress in primary care orientation, advancement, and access.

In addition to challenges related to pay-for-performance and overall underinvestment, current inequities in health care coverage (both within and between payers) are unacceptable and contribute to inequities in primary care access. Medicaid programs reimburse clinicians on average 72% of what Medicare pays; this inequity is even more pronounced for primary care services, which are reimbursed at 67% of Medicare rates.³⁰ Disparate reimbursement rates constitute an underinvestment in primary care for historically underserved populations, including children, who make up nearly 50% of individuals ensured through Medicaid or the Children’s Health Insurance Program.³¹ Therefore, a Primary Care Moonshot would direct a portion of new federal primary care investment funds to permanently bring Medicaid reimbursement rates to parity with Medicare, an effort that was temporarily instituted by the Affordable Care Act.³²

Finally, how we define and reimburse for the care of disadvantaged populations in APMs can either worsen or reduce inequities in primary care access and outcomes. For example, early physician participation in accountable care organizations (ACOs) was lower in regions where a higher percentage of the population was Black, was living in poverty, was uninsured, had a disability, and/or had less than a high school education.³³ One hypothesis for this finding is that the structure of quality and financial benchmarks included in ACOs incompletely captured the resources needed to care for disadvantaged populations and may have dissuaded practices that care for such populations from participating in ACOs. To address this concern, CMMI has increasingly incorporated payment adjustments that provide more resources to practices that care for socially disadvantaged populations.^34,35 A Primary Care Moonshot could (1) expand increased reimbursement to all practices in a way that accounts for social determinants of health and the health impacts of structural inequities (eg, racism) and (2) evaluate and remove barriers to participating in APMs to broaden provider access and subsequent opportunity for better-resourced, higher-quality primary care delivery.

Conclusion

The past decade has seen important initial reforms and investment in primary care delivery. Through a Primary Care Moonshot, we can and should go bigger by investing in primary care research linked to a national primary care learning health system; making investments to promote structural changes supporting primary care orientation, advancement, and access; and ensuring equitable health care payment and coverage. With these investments, we could reorient the US health care system to a system of wellness and prevention, with long-term savings in health care expenditures and better health and health outcomes for everyone in the US.

Acknowledgments

The authors would like to thank Geetanjali Chander, MD, MPH; Mike Myint, MD, MBA; Ashok Reddy, MD, MS; and Joshua Seidman, PhD, for their review and formative feedback.

Author Information

Dr Staloff is a primary care physician and health services researcher in the Department of Family Medicine at UW Medicine in Seattle. Dr Marcotte is a primary care physician and health services researcher in the Division of General Internal Medicine at UW Medicine in Seattle and is a member of the editorial board of Population Health, Equity & Outcomes.

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