Primary Health Care As a Common Good
====================================

* Rebecca S. Etz
* Kurt C. Stange

## Abstract

Growing commodification of health care has resulted in a system that is impersonal, fragmented, and inequitable. A potential antidote to this poisonous situation is to understand and treat primary health care as a common good. Common goods are resources supported as essential to the wellbeing of all. They can be actualized through a Collective Impact approach of a developing a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations. Investing in primary health care as a common good, with investments in primary medical care spending, support, and workforce development, complemented by integrated support of public health and social drivers of health, can launch a transitional period that moves US health care toward greater accessibility, effectiveness, equity, and sustainability.

*   Common Good
*   Health Care Financing
*   Health Equity
*   Health Security Conference
*   Population Health
*   Primary Health Care
*   Social Justice

## Introduction

Common goods are resources agreed on by a group as necessary to the wellbeing and safety of all group members and therefore a vital resource of the collective. The usual examples include public safety, clean air and water, and public education. Because of this, common goods are collectively protected, supported and monitored to ensure long-term sustainability and equal access among all members of the collective.1

The concept of the common good has been part of Western thought for millennia, shifting over that time from concerns regarding moral virtue and ideal political communities toward consideration of the wellbeing of individuals.2 Advancing the common good requires supporting collective as well as individual resources that influence health.3

Most countries with high functioning health systems, and better health outcomes than the US,4 treat health care as a common good, particularly primary medical care and the larger concept of primary health care5 espoused by the Alma Ata6⇓⇓–9 and Astana Conferences.10 Primary health care is an approach to health policy and service provision that includes both primary medical care, delivered to individuals, and public health functions delivered at the population level.11

Among developed countries, the US is a conspicuous outlier in treating health care as a commodity to be bought and sold, more accessible to those with riches than to those with need.12,13 As a result, the US spends nearly twice as much as other wealthy countries on health care, and yet has worse health outcomes than poorer countries that spend far less.4

A recent report of the US National Academies of Science, Engineering, and Medicine (NASEM) proposes a way out of this embarrassing and destructive dilemma. The April 2021 report on *Implementing High Quality Primary Care* declared that primary care is a common good.14 To define primary care and primary health care5 as a “common good” is to declare that the collective matters as much as the individual. That for everyone to have a fair chance at reaching their full potential, essential health care, public health and social services must be integrated and equitably accessible to all.15,16 The strength and quality of the country’s primary health care is a public imperative.17

## What Is Known About Primary Health Care As a Common Good

Primary health care is the only health care component for which greater supply is associated with better population health and more equitable outcomes.18 Primary health care is diminished when treated as a commercial product to be bought, sold, and monetized.19 It is not a collection of material goods to be governed by the laws of privilege and marketplace.13 Defining primary health care as a common good is 1 way of recognizing that the wellbeing of all individuals is foundational to the wellbeing of everyone in a community, country, or population.20 It is a necessary function that our society provides to its members to ensure mutual health, safety and security.21,22

Sadly, the American health care system has thus far failed to adopt primary health care as a common good. Instead, it fosters artificial separations among primary medical care, public health, and social services that, when functioning together, constitute primary health care.23 These false divisions doom the ability of the US to mediate social inequities such that they do not result in health inequities. They limit any systemic ability to reach person and population health goals through interventions that integrate the complexly interdependent personal and community level factors affecting health.

Primary health care is essential to the societal aspiration of health equity.24⇓⇓–27 The lack of policies to govern primary health care as a common good has allowed US primary health care to be exploited in a manner consistent with the ‘tragedy of the commons’ ― where access is defined as beneficial, where some have greater abilities for access, and where those with access believe that greater access yields greater good.28⇓–30 This tragedy results in systemically supported health disparities between those who have privilege and those who do not, and encourages unsustainable resource consumption.

A policy analysis in the NASEM report calls for rebalancing investment to double the health care spending on primary medical care while reducing overall health care expenditure and increasing investment in public health, social and educational services, with a commercial sector incentivized to provide for the common as well as the individual good.14

Market-based competition creates business motivations for health care delivery that are both incongruous with the common good and indifferent to both the social mandates of equity in access and the sustainability of primary health care as a resource for the collective.19 A responsible public policy that treats primary health care as a common good supported by citizens, government, and the private sector creates a powerful balancing force31 to rein in the excesses of the unchecked medical-industrial complex.32

Balancing the forces of the marketplace with the social investment of the common good allows for policies able to support primary care as the foundation of a high functioning health care system. Primary medical care is the first point of contact for those seeking medical health services,33 and the launching point for integrating, personalizing, and prioritizing34 social and medical needs to provide each member and community within the population the potential for optimal health.35 Inability to provide integrated health solutions creates unnecessary and often unfair vulnerabilities.36

The COVID-19 pandemic brought to light the weaknesses of policy strategies that support false divisions among primary medical care, public health and social services.37 It also highlighted the vulnerabilities endemic in a population health approach focused primarily on individuals. Obstacles to population health, and the social and environmental factors able to sustain it, cannot be solved through solely through attention to 1 person and 1 illness at a time.20

Primary health care is essential for promoting population health.20,35 By providing acute, chronic, and preventive care, and personalized linkage to community services, primary care can help to prevent the spread of infectious diseases, reduce the burden of chronic diseases, and promote healthy behaviors.38 Caring about the whole while taking care of individuals is a cornerstone of primary health care.39

## Discussion

An actionable and transformative step to improve US health care would be to declare primary health care as a common good. This begins with raising the gaze from narrow interests ― the parts of health care and other health drivers ― to what works for the whole.39⇓⇓⇓–43 It requires increased investment in primary medical care from the current 6% to 12% of national health expenditures, and increased connections with public health, as recommended by the recent NASEM report.14 By bankrolling the most foundational and under-resourced aspect of US health care, this action would have an immediate effect on the quality, equity, effectiveness, and sustainability of US health care system.18,35

Policy translation can be advanced by tying primary health care as a common good to current concerns about health equity and recent reductions in life expectancy.44,45

Dedicated funding for primary care, dependent on demonstrating equitable access to care and the direct flow of funds from systems into the intended primary care settings is both actionable and supportive of the common good. A dedicated flow of funds (such as state-level minimum spending for primary health care), accompanied by dedicated oversight for access and funding sufficiency, would require administrative agency with state equivalents that monitor private/public primary health care resources and access. Such dedicated funding could bring better oversight capacity for the US Department of Heath and Human Services. It would also allow for more effective management of resources for Federally Qualified Health Centers and resources for the National Health Services Corps in conjunction with other public/private primary health care resources – 3 areas of governmental oversight which are currently divorced from each other. Such oversight implies expanded infrastructural needs and cost, and would necessitate Congressional action. This expansion would not serve as an added structural burden, but would rather provide for greater integration of work process and effort while also providing protection from the undue burdens now unequally levied on both the US primary medical care and public health platforms.

Primary health care as a common good can be operationalized through a collective impact framework that recognizes the complex interrelatedness and emergent properties of the multiple factors affecting health,46 by investing in 5 supportive conditions: 

1.  Working toward a common agenda in which stakeholders develop a shared vision for change that includes a common understanding of the problem and a joint approach to solving it through agreed upon actions.

2.  Shared measurement that assesses results consistently across all participants to align effort and hold each other accountable.

3.  Mutually reinforcing activities that are differentiated yet coordinated through a plan of action.

4.  Continuous communication across many players to build trust, assure mutual objectives, and foster common motivation.

5.  Backbone support from organization(s) with staff and skill to coordinate the efforts of participating organizations and agencies.47

The biggest challenge for realizing this as a national vision is related to the transitional steps required to build up a chronically underfinanced infrastructure and workforce.48 The politics are difficult. Part of the difficulty rests in the need to find resources, typically framed as supporting 1 financial area by taking from another. We cannot solve the ills of our health care system through a logic that demands and either/or answer. Solutions in health care rarely result in that kind of direct causality and instead require complex understanding not simply of immediate cost but also of long-term investment, savings, and opportunities created.

Another part of the political challenge toward realizing a shift in national vision rests in the fear that work for the whole must necessarily mean disadvantage to parts. In political discourse, this reads as the possibility that individual or minority interests could be sacrificed in the name of the common good2 and can lead to the branding of reasoned discussions as “socialist” and a shutdown of US-based conversation. This is antithetical to the model of primary medical care which is premised on care that is personalized and integrated with the priorities of the individual in mind.34 It tends to be a conversation grounded more in rhetoric than the everyday functioning of the common good of primary health care and discussed here.

It is true that adding resources to primary care is most often seen as requiring a shift of resources away from hospital and specialty care sectors and toward primary care, while also advancing the necessary linkages of primary medical care with public health and social sectors.15,49,50 Countries that take that approach are often not successful and frequently fall behind in adequacy of funding (such as England’s NHS and Canadian Provincial investments) or due to shifts of responsibility (for example, Australia funds primary care via the Federal Government while States fund hospitals, creating constant battle about who has responsibility vs who bears consequences/rewards).

Successful strategies to strengthen primary health care must support the connections to hospital and specialty care sectors to maintain their optimal performance as partners in the stewardship of our population’s health. In the past, the challenge of maintaining budget neutral solutions to US health care weaknesses has prevented viable options for strengthening primary health care as it pitted the resourcing of primary health care in competition with the resourcing for specialty and hospital care. This strategy has led the US to suffer the worst health outcomes of most industrialized nations4 and has allowed us to be 1 of the few countries in which life expectancy has been declining, year over year.45 It is a strategy we can no longer survive.

Recognizing primary health care as a common good means recognizing that we will not compete our way into better health care. Instead, we must decide, to see population health as an investment – a position previously supported through a joint statement of the professional Boards and Societies of Family Medicine, Internal Medicine, and Pediatrics.51

The transitional steps are equally challenging and will take time. Building up the necessary workforce is a time intensive strategy52 that will require the management of interim expectations until that workforce and infrastructure are constituted to meet the current vastly unmet needs for primary health care.53

Opportunities include building on the work of physician-led accountable care organizations54,55 and the personal care provided by the growing direct primary care movement.19,56,57

## Conclusion

A potent solution to the impersonal, fragmented, and inequitable US health care system is to treat primary health care as a common good. Valuing primary care as a common good resource to appropriately steward the health of our nation will require accompanying investments in primary care spending, support, and workforce development. This immediately actionable step can launch a transitional period that moves US health care toward greater accessibility, effectiveness, equity, and sustainability.

## Notes

*   This article was externally peer reviewed.

*   *Conflicts of interest:* None.

*   *Funding:* This work was supported by a grant from the University Suburban Health Center Foundation for the Wisdom of Practice Initiative and by Distinguished Scholar Fellowships from the American Board of Family Medicine Foundation. The conference proceedings described in this article were made possible through generous support provided by the Robert Wood Johnson Foundation and The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author(s) and not necessarily those of the Robert Wood Johnson Foundation or The Commonwealth Fund, its directors, officers, or staff. Additional support has been provided by the ABFM Foundation.

*   To see this article online, please go to: [http://jabfm.org/content/37/S1/S15.full](http://jabfm.org/content/37/S1/S15.full).

*   Received for publication November 23, 2023.
*   Revision received March 19, 2024.
*   Accepted for publication March 25, 2024.

## References

1.  1.1.  Zalta EN
    
    Hussain W. The common good. In: Zalta EN, ed. *The Stanford Encyclopedia of Philosophy*. Department of Philosophy, Stanford University; 2018. vol. November 23, 2023.
    
    

2.  2.Jaede M. Working paper: the concept of the common good. *(PSRP Working Paper 8)*. Global Justice Academy, University of Edinburgh; 2017. Accessed February 23, 2024. Available at: [https://peacerep.org/wp-content/uploads/2017/05/Jaede-working-paper-PSRP.pdf](https://peacerep.org/wp-content/uploads/2017/05/Jaede-working-paper-PSRP.pdf).
    
    

3.  3.Roy B, Riley C, Sears L, Rula EY. Collective well-being to improve population health outcomes: an actionable conceptual model and review of the literature. Am J Health Promot 2018;32:1800–13.11.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

4.  4.Schneider EC, Shah A, Doty MM, Tikkanen R, Fields K, Williams RD II.. Mirror, Mirror 2021: reflecting poorly—health care in the US compared to other high-income countries. 2021. Accessed November 23, 2023. Available at: [https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly](https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly).
    
    

5.  5.Phillips RL, Nielsen M, Cohen DJ, Hughes LS, Bitton A, Bazemore AW. The essential role of primary health care for health security. J Am Board Fam Med 2024;37S1:S21–S25.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTg6IjM3L1N1cHBsZW1lbnQxL1MyMSI7czo0OiJhdG9tIjtzOjMwOiIvamFiZnAvMzcvU3VwcGxlbWVudDEvUzE1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

6.  6.Wibulpolprasert S, Tangcharoensathien V, Kanchanachitra C. Three decades of primary health care: reviewing the past and defining the future. Bull World Health Organ 2008;86:3.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.2471/BLT.07.049239&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=18235878&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000252335300002&link_type=ISI) 

7.  7.The World Health Report 2008: Primary Health Care – Now More than Ever (2008).
    
    

8.  8.The Alma-Ata conference on primary health care. WHO Chron 1978;32:409–30.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=31034&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1978FY26500001&link_type=ISI) 

9.  9.World Health Organization. Primary health care. Accessed March 3, 2024, Available at: [http://www.who.int/topics/primary\_health\_care/en/](http://www.who.int/topics/primary_health_care/en/).
    
    

10. 10.World Health Organization, Ministry of Healthcare Republic of Kazakhstan. Global Conference on Primary Health Care. 25-26 October 2018 - Astana, Kazakhstan. World Health Organization. Accessed March 24, 2019. Available at: [https://www.who.int/news-room/events/detail/2018/10/25/default-calendar/global-conference-on-primary-health-care](https://www.who.int/news-room/events/detail/2018/10/25/default-calendar/global-conference-on-primary-health-care).
    
    

11. 11.Muldoon LK, Hogg WE, Levitt M. Primary care (PC) and primary health care (PHC). What is the difference? Can J Public Health 2006;97:409–11.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1007/BF03405354&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=17120883&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

12. 12.Lown B. The commodification of health care. PNHP Newsletter 2007;40–4. Physicians for a National Health Program. Accessed July 15, 2014.
    
    

13. 13.Heath I. Patients are not commodities. BMJ 2006;332:846–7.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjEyOiIzMzIvNzU0NS84NDYiO3M6NDoiYXRvbSI7czozMDoiL2phYmZwLzM3L1N1cHBsZW1lbnQxL1MxNS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

14. 14.National Academies of Sciences, Engineering and Medicine. *Implementing high-quality primary care: Rebuilding the foundation of health care*. The National Academies Press; 2021.
    
    

15. 15.Westfall JM, Liaw W, Griswold K, et al. Uniting public health and primary care for healthy communities in the COVID-19 era and beyond. J Am Board Fam Med 2021;34:S203–S209.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6MTg6IjM0L1N1cHBsZW1lbnQvUzIwMyI7czo0OiJhdG9tIjtzOjMwOiIvamFiZnAvMzcvU3VwcGxlbWVudDEvUzE1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

16. 16.Plochg T, van den Broeke JR, Kringos DS, Stronks K. Integrating primary care and public health. Am J Public Health 2012;102:e1; author reply e1–e1; author reply e2. Octe1; author reply e1-2.
    
    

17. 17.Institute of Medicine. *Primary Care and Public Health: Exploring Integration to Improve Population Health*. National Academies Press; 2012.
    
    

18. 18.Starfield B, Shi LY, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005;83:457–502.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1111/j.1468-0009.2005.00409.x&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=16202000&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000232231200005&link_type=ISI) 

19. 19.Grumbach K. Forging a social movement to dismantle entrenched power and liberate primary care as a common good. Ann Fam Med 2023;21:180–4.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMjEvMi8xODAiO3M6NDoiYXRvbSI7czozMDoiL2phYmZwLzM3L1N1cHBsZW1lbnQxL1MxNS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

20. 20.Peek CJ, Westfall JM, Stange KC, et al. Shared language for shared work in population health. Ann Fam Med 2021;19:450–7.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6ODoiMTkvNS80NTAiO3M6NDoiYXRvbSI7czozMDoiL2phYmZwLzM3L1N1cHBsZW1lbnQxL1MxNS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

21. 21.Reiss-Brennan B, Phillips RL, Leykum LK. Foundational collective actions for achieving agile high-quality primary care in the United States. J Gen Intern Med 2023;38:1744–6.
    
    

22. 22.Habib DRS, Klein LM, Perrin EM, Perrin AJ, Johnson SB. The role of primary care in advancing civic engagement and health equity: a conceptual framework. Milbank Q 2023;101:731–67.
    
    

23. 23.Miller WL. The story of general practice and primary medical care transformation in the United States since 1981. Commissioned paper for the NASEM Consensus Report: Implementing high-quality primary care rebuilding the foundation of health care. 2021:1–60. Accessed April 15, 2022. Available at: [https://www.nap.edu/resource/25983/The%20Story%20of%20General%20Practice%20and%20Primary%20Medical%20Transformation%20in%20the%20United%20States%20Since%201981.pdf](https://www.nap.edu/resource/25983/The%20Story%20of%20General%20Practice%20and%20Primary%20Medical%20Transformation%20in%20the%20United%20States%20Since%201981.pdf).
    
    

24. 24.Primary Care Collaborative. Primary care: a key lever to advance health equity. Accessed November 15, 2023, Available at: [https://www.pcpcc.org/health-equity-report](https://www.pcpcc.org/health-equity-report).
    
    

25. 25.Rittenhouse D, Genevro J, Phillips K, Manchanda R. How primary care investments can advance equity *The Milbank Blog*. Milbank Memorial Fund; 2023. Accessed May 10, 2023. Available at: [https://www.milbank.org/2023/05/how-primary-care-investments-can-advance-equity/](https://www.milbank.org/2023/05/how-primary-care-investments-can-advance-equity/).
    
    

26. 26.Shi L. The impact of primary care: a focused review. Scientifica (Cairo) 2012;2012:432892.
    
    

27. 27.McNeely L, Douglas M, Westfall N, Greiner A, Gaglioti A, Mack D. Primary care: A key lever to advance health equity. 2022:1–15. Accessed May 13, 2022. Available at: [https://www.pcpcc.org/health-equity-report](https://www.pcpcc.org/health-equity-report).
    
    

28. 28.Ostrom E. Beyond markets and states: polycentric governance of complex economic systems. The American Economic Review 2010;100:641–72.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1257/aer.100.3.641&link_type=DOI) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000279253100001&link_type=ISI) 

29. 29.Folke C, Carpenter S, Elmqvist T, et al. Resilience and sustainable development: building adaptive capacity in a world of transformations. Series on Science for Sustainable Development, No 3. International Council for Science; 2002:37 p.
    
    

30. 30.Woolf SH, Stange KC. A sense of priorities for the health care commons. Am J Prev Med 2006;31:99–102.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=16777549&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000238721300014&link_type=ISI) 

31. 31.Franks P, Clancy CM, Nutting PA. Gatekeeping revisited–protecting patients from overtreatment. N Engl J Med 1992;327:424–9.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJM199208063270613&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=1625720&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1992JG35600013&link_type=ISI) 

32. 32.Relman AS. The new medical-industrial complex. N Engl J Med 1980;303:963–70.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJM198010233031703&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=7412851&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1980KL95600003&link_type=ISI) 

33. 33.Green LA, Fryer GE Jr., Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med 2001;344:2021–5.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJM200106283442611&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=11430334&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000169508200011&link_type=ISI) 

34. 34.Etz R, Miller WL, Stange KC. Simple rules that guide generalist and specialist care. Fam Med 2021;53:697–700.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.22454/FamMed.2021.463594&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=34587265&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

35. 35.Stange KC, Miller WL, Etz RS. The role of primary care in improving population health. Milbank Q 2023;101:795–840.
    
    

36. 36.Lynch JM. *A whole person approach to wellbeing: Building a sense of safety*. Routledge; 2021.
    
    

37. 37.Stange KC. What a pandemic reveals about the implementation of high quality primary care. Commissioned paper for the NASEM Consensus Report: Implementing high-quality primary care rebuilding the Foundation of Health Care. National Academy Press; 2021:1–45. Accessed September 16, 2022. Available at: [https://www.nap.edu/resource/25983/What%20a%20Pandemic%20Reveals%20About%20the%20Implementation%20of%20High%20Quality%20Primary%20Care.pdf](https://www.nap.edu/resource/25983/What%20a%20Pandemic%20Reveals%20About%20the%20Implementation%20of%20High%20Quality%20Primary%20Care.pdf).
    
    

38. 38.Stange KC, Jaén CR, Flocke SA, Miller WL, Crabtree BF, Zyzanski SJ. The value of a family physician. J Fam Pract 1998;46:363–8.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=9597993&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000073544100010&link_type=ISI) 

39. 39.Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care 2002;14:267–8.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1093/intqhc/14.4.267&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=12201184&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000177425200001&link_type=ISI) 

40. 40.Stange KC. Refocusing knowledge generation, application and education: raising our gaze to promote health across boundaries. Am J Prev Med 2011;41:S164–S169.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/j.amepre.2011.06.022&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=21961659&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

41. 41.Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med 2009;7:293–9.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy80LzI5MyI7czo0OiJhdG9tIjtzOjMwOiIvamFiZnAvMzcvU3VwcGxlbWVudDEvUzE1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

42. 42.Stange KC. A science of connectedness. Ann Fam Med 2009;7:387–95.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NzoiNy81LzM4NyI7czo0OiJhdG9tIjtzOjMwOiIvamFiZnAvMzcvU3VwcGxlbWVudDEvUzE1LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

43. 43.Stange KC. Ways of knowing, learning, and developing. Ann Fam Med 2010;8:4–10.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6ODoiYW5uYWxzZm0iO3M6NToicmVzaWQiO3M6NToiOC8xLzQiO3M6NDoiYXRvbSI7czozMDoiL2phYmZwLzM3L1N1cHBsZW1lbnQxL1MxNS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

44. 44.Yan BW, Arias E, Geller AC, Miller DR, Kochanek KD, Koh HK. Widening gender gap in life expectancy in the US, 2010-2021. JAMA Intern Med 2023;184:108–10.
    
    

45. 45.Woolf SH. Falling behind: The growing gap in life expectancy between the United States and other countries, 1933-2021. Am J Public Health 2023;113:970–80.
    
    

46. 46.Kania J, Kramer M. Embracing emergence: how collective impact addresses complexity. Stanford Social Innovation Review. Accessed 16 December 2019.
    
    

47. 47.Kania J, Kramer M. Collective impact. 2011.
    
    

48. 48.Galea S. The post–COVID-19 case for primary care. JAMA Health Forum 2022;3:e223096.
    
    

49. 49.Veenema TW, Toner E, Kobokovich A, Cicero A. Integrating Primary Care and Public Health to Save Lives and Improve Practice During Public Health Crises: Lessons from COVID-19. 2021. Accessed September 16, 2022. Available at: [https://www.centerforhealthsecurity.org/our-work/publications/primaryhealthcare-publichealthcovidreport](https://www.centerforhealthsecurity.org/our-work/publications/primaryhealthcare-publichealthcovidreport).
    
    

50. 50.Committee on Integrating Primary Care and Public Health of the Board on Population Health and Public Health Practice. *Primary Care and Public Health: Exploring Integration to Improve Population Health*. National Academies Press; 2012.
    
    

51. 51.Primary Care Speaks As One. Unified voice, unified vision - changing primary care finance. Accessed November 23, 2023, Available at: [https://www.newprimarycareparadigm.org/](https://www.newprimarycareparadigm.org/).
    
    

52. 52.Bazemore A, Wilkinson E, Petterson S, Green LA. Proportional erosion of the primary care physician workforce has continued since 2010. Am Fam Physician 2019;100:211–2.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=31414781&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

53. 53.Klein S. Strengthening the primary care workforce to meet population needs. *The Commonwealth Fund Newsletter Articles*. Commonwealth Fund; 2023. Accessed November 23, 2023. Available at: [https://www.commonwealthfund.org/publications/newsletter-article/strengthening-primary-care-workforce-meet-population-needs](https://www.commonwealthfund.org/publications/newsletter-article/strengthening-primary-care-workforce-meet-population-needs).
    
    

54. 54.McWilliams JM, Hatfield LA, Chernew ME, Landon BE, Schwartz AL. Early performance of accountable care organizations in Medicare. N Engl J Med 2016;374:2357–66.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJMsa1600142&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=27075832&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

55. 55.McWilliams JM, Chernew ME, Landon BE, Schwartz AL. Performance differences in year 1 of pioneer accountable care organizations. N Engl J Med 2015;372:1927–36.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1056/NEJMsa1414929&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=25875195&link_type=MED&atom=%2Fjabfp%2F37%2FSupplement1%2FS15.atom) 

56. 56.DPC Alliance. Direct Primary Care Alliance - home. Accessed February 9, 2023, Available at: [https://dpcalliance.org/](https://dpcalliance.org/).
    
    

57. 57.Direct Primary Care Coalition. Accessed February 9, 2023, Available at: [http://www.dpcare.org/](http://www.dpcare.org/).