Primary Care’s Essential Role in Advancing Health Equity

Misaligned System Incentives Worsen Inequity

Unlike some other countries that have more robust primary care, the US lacks centralized decision making about policies impacting the distribution of primary care resources. Thus, systemic change depends on the competing economic, political and government efforts which operate independently.⁴ Misaligned system incentives over time lead to inequitable investments, especially in Black, Indigenous, and other historically marginalized communities. Many communities are left with a depleted primary care workforce struggling to deliver care in a weakened primary care infrastructure.

A Paradigm Shift

Work to strengthen primary care and ensure that primary care policies prioritize equity requires a paradigm shift in the US^2–3 First, we need to recognize high-quality primary care as a common good. As noted in the NASEM report, “Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes. For this reason, primary care is a common good, making the strength and quality of the country’s primary care services a public concern.”⁴

Second, the paradigm shift requires a commitment to both immediate action and a long-term perspective on returns. Primary care practices need assistance and more equitable payment models now.² Primary care practices in historically marginalized and under-resourced communities need even greater investments and support to move toward and succeed within flexible, equitable, value-based payment models. In addition, successfully addressing historic deficits in support for primary care and long-standing health inequities requires time, flexibility, and persistence. Although evidence supports cost-savings over time, expectations of short-term return-on-investment can perpetuate health care inequities and can undermine long-term commitments to increasing primary care spending and provider payments.

Third, all partners should be held accountable for progress on equity, not just primary care practices. Prioritizing equity in primary care is an “all hands-on deck” activity that will require stronger governance and accountability mechanisms that encourage participation and oversight from patients (including people with lived experience dealing with health and social inequities), communities and community-based organizations, practices, public health systems, payers, policy makers, and others. Other providers, including specialists and hospitals, need to recognize and support the role of primary care and the value it brings to patient and population health, rather than seeing it simply as a source for referrals to their more lucrative specialty services. This means that all parties – not just beleaguered primary care practitioners and practices – are aligned and accountable for advancing primary care’s essential role in advancing health equity.

US and International Policies to Strengthen Primary Care

Despite substantial evidence that universal access to high-quality primary care will be required to advance health equity, primary care is not mentioned in the 2022 White House Health Equity Plan⁵ and is frequently absent from federal policy conversations. Recent actions by the US Department of Health and Human Services⁶ elevate the discussion of primary care as a national priority to strengthen primary care and to advance health equity and other federal health priorities, but stops short of the paradigm shift that is required.^2,3,7 Improving outcomes for priority populations mentioned in the White House Health Equity Plan – such as Black and American Indian and Alaska Native pregnant and childbearing people; underserved veterans, including veterans of color and veterans who live in rural communities; and other underserved communities of color – will require focused investments in improved access to high-quality primary care specifically for these populations.

Global health equity efforts by the World Health Organization and World Bank recognize the importance of investing in primary care systems according to need, and of enveloping the health care system in a strong social infrastructure to improve food security, housing, education, public health, and environmental factors.^8–9 The US can learn from international efforts that focus on this broader concept of primary health care, which emphasizes engaging and empowering individuals, families, and communities. This approach is rooted in social justice, equity, solidarity, and participation, and based on the recognition that enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction. As such, primary health care encompasses primary care but also includes public health and multi-sector policies to address the upstream and wider determinants of health.

As Barbara Starfield so eloquently states, “The focus of primary care on recognizing and meeting patients’ needs (including but not limited to ‘diagnoses’) is the reason primary care–oriented services are associated with greater equity in distribution of health in populations. Different populations differ in the kind and extent of their health problems, with more socially deprived populations having a greater number, greater severity and greater variability in their health needs than is the case in more socially advantaged populations. Primary care, the place where needs are best recognized, is the venue by which equity in health services and, hence, equity in those aspects of health responsive to health services, is attained. Person-centered services are the essential hallmark of primary care.”¹⁰