Physicians make the case for funding primary care as a public good

When you flip a light switch, you expect the lights to come on. When you turn the tap, you expect water. Four physicians writing in JAMA want primary care to work the same way, and they argue states already have most of the money and the legal tools to make it happen.

In a special communication published online May 20 in JAMA, Zirui Song, M.D., Ph.D., of Harvard Medical School; Wayne Altman, M.D., of Tufts; Renee Crichlow, M.D., of Boston University and the Codman Square Health Center; and Kevin Grumbach, M.D., of the University of California, San Francisco, lay out a financing model they call a “primary care common fund.” The idea is to treat primary care as a public utility: pool the money that public and private payers already spend on it, have a state authority administer that pool and pay practices directly, rather than through dozens of separate insurance contracts.

More than a third of U.S. adults lack a usual source of care, and the country devotes only about 5 cents of every health care dollar to primary care. Physician retirements, administrative burden and pay that lags well behind specialists are thinning the ranks, and the pipeline of new trainees entering the field is, in their words, “parched.”

Why states keep hitting the same walls

States have spent the past several years trying to push more money toward primary care. The paper names California, Colorado, Delaware, Maine, Massachusetts, Oregon, Rhode Island and Virginia among those that have pursued legislation or regulation to lift primary care's share of spending. Rhode Island, the first mover, raised primary care spending by commercial insurers from $48 million in 2007 to $86 million in 2023.

But the authors argue that the way states have gone about it runs into three structural problems that no amount of good intention can fix.

The first is federalism. States have authority over only a slice of the insurance market: Medicaid, Affordable Care Act (ACA) exchange plans, state employees and "fully insured" commercial plans. Together, those often add up to less than half of a state's residents. Self-insured plans, which now cover more than 60% of commercially insured lives in the country, fall under federal jurisdiction through the Department of Labor and sit beyond a state's reach. So do Medicare beneficiaries, federal employees and people covered by the VA, TRICARE and the Indian Health Service.

The second is what happens when states mandate spending through a fragmented payer system. Requiring every plan to put a certain percentage toward primary care means different dollar amounts for different payers, because prices and service mixes vary. It also means practices inside large health systems with higher negotiated prices collect more for each additional percentage point than smaller practices with less market power. The result, the authors write, could entrench or widen the very inequities states are trying to close.

The third is administrative drag. Practices already juggle multiple insurers with different prior authorization rules, claims processes and billing systems, and each payer tends to approach primary care investment its own way. Well-meaning but idiosyncratic efforts, the authors note, can make practice revenue more volatile, not less.

That diagnosis tracks closely with what the physician-researchers behind a recent national report have been describing. The JAMA paper cites the Milbank Memorial Fund's 2025 primary care scorecard, and in discussions with Medical Economics tied to that work, the people who produce and back it described a system out of balance.

"I think the state of primary care is that we are suffering and need more support in order to really support the care of all patients in the U.S.," said Yalda Jabbarpour, M.D., a family physician and vice president and director of the Robert Graham Center, a collaborator on the scorecard.

Ripley Hollister, M.D., a family physician and board member of the Physicians Foundation, which backs the report, pushed back on the idea that the system is beyond repair. "It's not really broken at all," he said. "It's just off balance." Primary care is "really under supported," he added, pointing to what he called a paradox: increase support for it, and total costs come down.

"If we increase our support of primary care, we will actually reduce health care costs," Hollister said.

Milbank’s 2026 report, “Investing in Primary Care: The Missing Strategy in America’s Fight Against Chronic Disease,” produced by the same collaborative, found that adults with a chronic illness and a usual source of care had nearly 54% lower total health care costs than those without one.

How would a primary care common fund work?

Under the proposal, the underlying financing of insurance stays where it is. Employers and individuals keep paying premiums for commercial coverage, and Medicaid still draws on federal and state funds. The change happens on the back end. The state redirects the primary care portion of those premiums, an insurer's contribution, into the common fund, which then pays practices.

The authors stress that the fund starts with no new money. Contributions would initially equal what payers are already spending on primary care, so the reform is achievable without additional spending. As states raise their targets over time, contributions would rise to match. Oregon, with a 12% primary care spending target, would assess 12% of plan premiums. California, which aims to grow primary care's share from roughly 7% in 2024 to 15% by 2034, would see contributions climb over the decade.

New money would be needed only if a state chose to fold in the uninsured, which the authors argue is justified if primary care is treated as a common good, and which they note is not entirely new spending since uncompensated care is ultimately borne by taxpayers anyway.

People would stay enrolled in their insurance for everything outside primary care. The fund would take over coverage and payment for primary care alone, set prices or per-member-per-month payments and let states decide whether to keep or drop cost sharing. The other roughly 95% of health care spending, the part governed largely by market forces, would be left untouched.

The authors describe the model as a compromise between single-payer and free-market philosophies. Unlike Medicare for All, the common fund is run by states and pays only for primary care. They draw an analogy to Medicare Advantage, which is single-payer financed but multipayer administered. The common fund, they write, is the mirror image: multipayer financed but single-payer administered.

A familiar argument

The advantages the authors claim line up with longstanding arguments from primary care advocates. Patients could keep their clinician when they change jobs or insurance; billing would run through a single schedule; and states could move toward prospective or hybrid payment that fee-for-service has never supported well.

The case for spending differently, not just spending more, came up in interviews around the Milbank scorecard, as well.

"It's not about the take-home pay of doctors," Jabbarpour said. "When I say investing more and differently in primary care, I mean, we need to increase our investment and move it away from a fee-for-service system, a transactional system, because primary care is not a transactional model of care." Paying only for office visits, she said, fails to cover the after-hours calls, portal messages and team-based work that primary care actually involves. "Because we're only getting 5 cents on the dollar, that's not enough to support all those team members in a primary care office."

She has described, in her own words, something close to what the JAMA authors propose. "There have been calls for this by big thinkers in primary care, to almost carve primary care out of the entire health care spend," Jabbarpour said. Pay practices a set amount up front to care for a defined population, she added, and the result "would work better for everyone."

Morgan McDonald, M.D., national director for population health at the Milbank Memorial Fund, said most primary care clinicians "would probably use the word threatened" to describe where things stand.

Milbank’s data put primary care at 4.5% of total health care spending in 2023 for physician services, a figure she said has been flat or slipping over a decade. Asked what single change would matter most, she pointed to payment: "It really would be paying more for primary care as a system and paying for it differently."

Debra Lubar, Ph.D., president of the Milbank Memorial Fund, made a similar point about rebalancing rather than spending more overall. "We know that only about 5% of health care dollars go to primary care, even though it's something like 40% of the services provided, and that really needs a rebalancing," she said. "We're not talking about spending more overall on health care. We're talking about really balancing those payments."

The legality and the limits

The mechanism that makes the common fund plausible, the authors argue, rests on a distinction between two kinds of state power.

The Employee Retirement Income Security Act of 1974 (ERISA) bars states from regulating self-insured plans. But states can tax employers as business entities. That difference, they write, gives states a way to pull self-insured money into a common fund without running afoul of federal law, and self-insured employers would have little reason to pay twice for primary care once they are contributing.

There is precedent for carving primary care out of insurance entirely. Direct primary care (DPC) practices, which charge patients an enrollment fee and do not bill insurance, are growing nationally, and some employers already cover those fees for workers. The common fund, the authors write, is essentially a more universal version of that arrangement.

Related content: 'A shoestring and a stethoscope': Atlas MD's Josh Umbehr, M.D., on the real economics of direct primary care

They’re candid about what the model does not solve. It doesn’t address inequities in financing for everything outside primary care; it leaves the broader administrative system intact; and bolstering primary care finances, they acknowledge, may not by itself produce enough clinicians to meet demand. Policies that address the clinical workforce would be an important complement.

McDonald told Medical Economics that only about one in five physician trainees enters primary care, along with a comparable share of physician associates and about a third of nurse practitioners.

Jabbarpour tied the early exits directly to the money, describing a workforce that is "overburdened and under resourced."

Where it could actually happen

The authors see a state-level approach as more realistic than a federal one, and they point to two states where the idea has gained traction. The California Academy of Family Physicians has adopted a policy to establish a Primary Care for All program built on the public utility, common fund model.

In Massachusetts, current primary care bills include a stabilization fund that resembles the concept, the state's Medicaid program already pays primary care through a subcapitation model, and a new state task force has weighed an all-payer capitation model with prospective payments, at least 95% of which would flow directly to practices.

The authors close where they began, with the basic claim that primary care fits awkwardly inside an insurance model built to cover large, unpredictable costs. Primary care, though, is largely predictable. On a spectrum, it’d be closer to food, housing or other common necessities than it would to a catastrophic medical event. Whether states agree enough to act on that premise is the open question.

The approach has precedent and a path toward feasibility, the authors say. It just has not been built yet.

The special communication was published May 20, 2026, in JAMA: Primary Care as a Public Utility