Primary care: The 'front door' of U.S. health care, but too few Americans are getting in

Primary care could be poised for a renewed emphasis nationally as health care leaders at the highest level work to Make America Healthy Again.

“Investing in Primary Care: The Missing Strategy in America’s Fight Against Chronic Disease” is a thematic report on the state of primary care within the U.S. health care system.

It came out after a year’s worth of health policy changes at the federal level with Health and Human Services Secretary Robert F. Kennedy, Jr., guiding direction in the administration of President Donald J. Trump. Some of their actions have sparked criticism, while some have prompted praise, and many physicians generally support the efforts to examine the causes of the rise of chronic disease, and to reduce those conditions’ ill health effects on Americans.

The report was published by the Milbank Memorial Fund, a nonpartisan foundation that analyzes state health care policies. President Debra Lubar, Ph.D., and National Director for Population Health Morgan McDonald, M.D., spoke to Medical Economics in recent interviews to share their views on the findings.

This transcript has been edited for length and clarity.

Medical Economics: How would you describe the state of primary care in the United States today?

Debra Lubar, Ph.D.: I think it's strained and somewhat threatened by the cost growth that's happening in other parts of the system. That's why we wanted to do this report to really highlight the health outcomes that we all want for our families. We want to prevent chronic disease. For our family members who have chronic disease, we want them to manage that well so that they can live their fullest lives. And we want longer, healthier lives for everybody and primary care is the front door to that, and in many ways, it's the backbone to that. So even though specialists are important, quality hospital care is very important, we know that that usual source of care, your relationship with your doctor and your care team, really is what is driving the health outcomes that we all want as a country. So, whether it's independent, whether it's part of a system, I think the key for us is we need more and better access to primary care.

Morgan McDonald, M.D.: I think most primary care clinicians, myself included, would probably use the word threatened. So, despite all the rewards of practicing in primary care, inadequate reimbursement from insurers, combined with increasing numbers of patients with chronic disease, mental health and social needs like housing or food insecurity, as well as those growing mounds of paperwork and documentation, really combine to overburden primary care clinicians. This contributes, as we know, to practice burnout, clinician burnout, and really dissuades medical residents from choosing primary care. One of the things that we highlight in our data is that only one in five physician trainees enters primary care now. That's about the same for physician associates and only about one-third of nurse practitioners enter primary care. And because of that, almost one-third of U.S. adults and 12% of kids go without a usual source of primary care.

Medical Economics: Can you talk about that importance about having that usual source of care?

Morgan McDonald, M.D.: Absolutely. Primary care is both the front door medicine as well as the backbone of good health in a community. Its focus, as we know, is on prevention and routine ongoing care that really is essential to lead the effort to better prevent and manage chronic disease. This report's emphasis, in particular, on a regular source of care also highlights the importance of having that clinician-patient relationship, and that's something that I know that I value the most in my primary care practice, is those relationships. And that bears out really in health outcomes. And so every study done today re-emphasizes a person's usual clinician is their most trusted resource for health-related decisions and also impacts their community as well. We've seen in recent data that for every 10 additional primary care clinicians per 1,000 people, life expectancy — life expectancy — at the county level, actually increases.

Medical Economics: The report cited the Make America Healthy Again agenda with a shift toward preventing chronic disease or slowing its progression. Why is primary care the specialty best positioned to lead this shift?

Debra Lubar, Ph.D.: Well, it is what I was saying about that usual source of care, that consistent expert engagement, trusted engagement, which is so important for people making health care decisions. And in many of our communities, people don't have access to that trusted relationship. We know that folks who have that trusted relationship have a 20% lower hospitalization rate. We know that they're much more likely to get the preventive care that they need, and we know that for people who are managing chronic disease, they have much better outcomes. So, no matter what specialties you're engaging with throughout your care, that primary care space is your front door to prevention and then to consistent care for whatever chronic diseases may develop over someone's lifetime. We know too that people who don't have access to that trusted source of care often end up in an emergency department, sometimes with conditions that could have been managed in a primary care setting, but they didn't have access to that, and sometimes they've waited, because they didn't have that access, to a point where they really did need emergency care. And both of those are not the most efficient use of resources and also not good for health outcomes. Those of us who are worried about the cost of care are starting to see more and more evidence that having that usual source of care, that trusted care provider, actually lowers the health care costs for that person, not because they're not getting care, but because they're getting the right care at the right time that they need.

Medical Economics: In the 2026 update, what was the finding that was most surprising to you?

Debra Lubar, Ph.D.: I think to me, the most surprising finding was that people with a usual source of primary care had nearly 54% lower health care costs. That's been a really hard thing to quantify, and this is one study, but we're seeing other studies that are verifying this. There's been this belief that primary care is a good investment because of the health outcomes and at Milbank, we definitely believe that. And there are some audiences where they really want to say, OK, well, how could we finance that? Where would that money come from? And I think increasingly we're starting to see that there are actual savings. Now, the timeline for those and whose money gets saved is something that affects policy solutions that can be used there, but I think that was a surprisingly large savings, and adding to that body of evidence that primary saves money over the long term.

Morgan McDonald, M.D.: As a primary care doc, I'm not surprised at all that people who have a usual source of care do see increased access to preventive services and follow through on those preventive services, things like cancer screenings and following through on dietary recommendations and exercise recommendations. I think the thing that really surprised me the most was the impact on cost. I knew that we were saving the system money. I didn't know how much money that we were saving the system. And so for adults with a usual source of primary care who have chronic disease, we're talking about a reduction in 50% from their overall health care cost. And that really tells us we should be investing more in primary care as an overall cost saving strategy for the health care system.

Medical Economics: The scorecard has seven recommendations to improve primary care. If you could turn the switch on tomorrow, so to speak, to make one of those happen, which one would you select to have the greatest effect on American health care?

Debra Lubar, Ph.D.: The most important thing is to invest in what's important to us. And if what we want is good health outcomes and a balanced health care system, we need to start with what we're paying for. So, the policy solutions that help us balance and more robustly fund the prevention part of our health care system, the primary care part of our health care system, I think are the most important policy tools. That's going to help with recruiting clinicians into primary care. It's going to help with improving access to primary care, and it's going to give us a health care system that aligns with our values around prevention and promoting health. And that is part of what is very consistent about this work with the Make America Healthy Again agenda, it’s really about getting upstream and reversing of the harms of chronic disease in this country.

Morgan McDonald, M.D.: It really would be paying more for primary care as a system and paying for it differently. We as Milbank have seen a lot of the changes that have happened within Medicare over the last couple of years. So in 2025 there was an additional Advanced Primary Care Management code that primary care clinicians can use that gives them basically a monthly increased reimbursement so that they can hire and retain teams that include additional staff like medical assistants or community health workers. We know that that is, in the end, a cost-saving effort. Also the Medicare Physician Fee Schedule that's going into effect this year values primary care at a higher rate than it has been valued before. That's a huge step in the right direction.

Medical Economics: What did I not ask about that you would really like to highlight or help our audience to understand?

Debra Lubar, Ph.D.: The one thing I would add is, there is also a big federal role here. Medicare drives a lot of how payment happens in this country. Medicaid, states have a lot of control over, and those can be really important drivers of how investments are made and how the balance is with primary care. There are the solutions about setting targets and those kinds of things that we focus on. But there's also really paying attention to what's happening in those public payer systems and how that impacts physician practices and what the balance of investment is there.

The other thing I would say is it's not just about putting more money into primary care, but it's about changing the way that primary care is reimbursed, so that it really is about whole person care. It's not just about adding more fee-for-service payments into a practice, but really helping a practice invest in the health of their patient population.