From the Federal Government to the Front Lines of Primary Care: Lessons Learned in the Fight to Strengthen the Foundation of Healthcare

Introduction

Chronic diseases such as cancer, diabetes, heart disease, and obesity are the leading cause of illness, disability and death in the United States and currently affect 60% of the US population.¹ In 2022, 90% of the $4.5 trillion spent on US healthcare was spent on managing chronic diseases.¹ These costs are estimated to continue to skyrocket in the coming years - with cardiovascular health costs alone going from $634 billion in 2022 to an estimated $2 trillion in 2050.¹

As federal and state policy makers seek to lower mortality, prevent disease, and reduce health care expenditures in America, they must both understand and build upon the value of primary care. Primary care prioritizes both prevention and management of diseases and offers first contact accessibility for patients, continuity, comprehensive services, and coordinated care across the healthcare system.² There is unambiguous evidence that primary care is the only specialty that confers the health and financial benefits Americans need.³ And yet, primary care continues to be undervalued and under-resourced.⁴ More people than ever lack access to primary care and primary care faces severe workforce shortages and sky-rocketing rates of clinician burnout.^5–7

Despite primary care being a bi-partisan issue that affects every American, prioritizing and strengthening primary care has been challenging to date. However, there are some glimmers of hope, including primary care legislative wins in a select number of states (most notably Virginia, Rhode Island, Connecticut, California, and Oklahoma)⁸ as well as incremental changes on the federal level, including the Calendar Year 2026 Medicare Physician Fee Schedule,⁹ which takes steps to alleviate the pay imbalance between primary care versus specialty care services. These wins, as well as others, demonstrate that while strengthening primary care through policy change is onerous, it is possible and necessary. As Dr. Berwick and colleagues aptly wrote in 2025: “Affordable, accessible, and equitable health care must be established for everyone in the US…. Achieving these aims will require major shifts in investment, focus, and oversight. It must lean on the foundation of an integrated primary care system that emphasizes prevention, reaches out to community partners, encourages health-promoting behavior, identifies and treats problems early, links to specialty providers, and connects to public health and social systems.”¹⁰

But how can those of us working both within and outside of the walls of primary care best work to advocate for change? In our 50 plus years of collective service to primary care, we have learned some hard-earned lessons along the way and while our perspectives differ, it is our hope that in sharing them they might be of service to those working to transform primary care through policy solutions. 

Lessons from the Federal Level 

In 2021, the US Department of Health and Human Services (HHS) brought together 14 HHS agencies and launched the first of its kind Initiative to Strengthen Primary Health Care.¹¹ Bringing 14 HHS agencies together to work collaboratively on an important health care topic was a challenge given their different areas of focus, authorities, cultures, and leadership styles. However, guided by the principles of the National Academy of Sciences, Engineering and Medicine 2021 report on primary care³ and informed by stakeholder input, the HHS acknowledged the importance and value of primary care as the foundation of healthcare, agreed upon a shared vision for primary care, and recognized that each agency could contribute to its achievement. This alone was a win and a critical step forward for further collaborative action.

This initiative resulted in a coordinated set of actions aimed at strengthening primary healthcare across these 14 agencies, which were summarized in a 2023 issue brief.¹² I (JS) had the opportunity to lead the federal Initiative to Strengthen Primary Health Care and learned seven key lessons: 

1. Align with Administration priorities: As with any improvement initiative or policy/program change, leadership must be on board for change to occur. In this case, we needed buy-in from leadership in the White House, the HHS Secretary’s Office, Agency Administrators, and Congress, all of whom saw primary care strengthening as important but not a top priority. Thus, to move the HHS primary care initiative forward, it was essential to build the narrative that a strong primary care system was critical in order to achieve many of the Administration and HHS priority goals. One notable example in this effort was the priority of improving access to behavioral health care by integrating behavioral health services with medical care, particularly primary care. We thus continued to underscore the point that there must be a strong primary care system in which to integrate behavioral health services but that primary care in the US is crumbling. This lesson learned holds true for advocates outside of the federal government as well. Advocates would do well to align their messages with Administration priorities – show how your recommended policy change furthers the achievement of the Administration’s goals.

2. Get Congress on board: While we chose to focus first on actions that HHS could take immediately, for many of the most consequential items, like graduate medical education reform or scaling health centers and workforce programs, legislative action is necessary. Only Congress can authorize new funding and make changes to the statutory authority of agencies or to specific programs and policies. Thus, Congress must be on-board. Had the White House taken on primary care strengthening as a top priority, the President’s budget would have been crafted to include the needed funding and legislative changes. The final budget is determined by Congress, however. Federal agencies, with the approval of the White House, can also engage with Congress by providing testimony at Committee hearings, using data, including from federal programs, to support recommendations and advice.

3. Stakeholders and constituents: Speak up and with one voice: How do we spur Congress to act? It’s about the constituents. Constituents and other stakeholders need to speak up, speak with one voice, and work across the aisle on this bipartisan issue. From a constituent viewpoint, the issue is the lack of access to primary care, which is impacting people across the nation. The rallying cry should be “I can’t get an appointment with a primary care provider”. While the root causes for poor access to primary care are complex and multi-factorial, including items such as workforce shortages, systematic undervaluing and insufficient investment in primary care, an ineffective payment model (fee for service), and compensation disparities across primary care and specialty care, a strong constituent voice forces Congress to examine some of these root causes and potential solutions.

4. Big problems are not solved with short term thinking: Primary care strengthening, like many tough policy issues, requires long-term thinking, but that is difficult for the government, which thinks in 4 or 8-year intervals and 1-year budgets. With a long-term effort, a phased approach to making change is necessary: what can we do now, and how can we build sequentially on our actions to achieve our goal? Reinforcing and further building bipartisan support for primary care are necessary to facilitate sequential actions that are developed and implemented across Administrations.

5. Develop a culture of quality improvement and evaluation: If we begin with actions that do not require additional funding or legislative changes, then optimizing programs is a reasonable approach. This is about quality improvement and using data to improve program efficacy and outcomes. Many agencies, however, lacked the necessary qualitative and quantitative data to target improvement. Funding for program evaluations and accountability of grantees and contractors are often insufficient; thus, data are lacking. If we are going to build a movement towards the strengthening of primary care, we must build effective strategies for evaluation of impact. Measuring outcomes and evaluating users’ experiences are key for building long term effective strategies.

6. Warning: public release of a strategy constrains innovative thinking: Governmental agencies refrain from making public commitments that they may not be able to meet. For example, the decision to make the coordinated set of HHS actions public constrained innovative and longer-term thinking. Rather than generating new ideas to address the root causes of problems, a re-listing of the current programs - organized by well stated goals and objectives - seems to be the usual approach to developing government strategies. This is deemed less risky and has the added value of highlighting agencies’ current good work. While this is not something that can be necessarily changed from outside of the government, individuals and groups looking to do transformational work at the federal level need to be aware of this constraint.   

7. Align incentives – other stakeholders must see the value: To speak with one voice, we need to align incentives. Other stakeholders in the healthcare system, like hospitals, specialists, public and commercial payers, managed care organizations, and employers need to see the value of strong primary care. To do so, incentives for improving quality, reducing costs, preventing disease, improving health outcomes for all people, and positive patient experiences, need to be applied across the healthcare system.

Lessons from the Front Lines of Primary Care

In my work (KGB) on both the front lines of primary care as well as in my efforts to reform primary care policy on the state level, there are 6 key lessons I have learned:

1. Power of stories: To move primary care policy forward, we must gather and share stories of individuals who are directly impacted by the crumbling of primary care. We must also hear from patients whose lives have benefited from the continuous and comprehensive care they receive when engaging in primary care. Stories of hope, healing, chronic conditions reversing, and breakthroughs are everyday occurrences within the walls of primary care. However, primary care clinicians are often too burdened by providing primary care, including addressing the never-ending messages, labs, phone calls, and requests that they receive through the electronic medical record, to take the time to reflect and share these stories. And yet, these stories can truly make this crisis come to life for policy makers. Those on the front lines need to be taught to listen intently to the individual and collective stories of our patients and use these stories to advocate for change.

2. Patients come first: We have built a system of care delivery where patients too often feel like an afterthought. Navigating care, medications, referrals, and social determinants of health is extraordinarily difficult for all patients and made near impossible for people with disabilities and those who lack fluency in English. We need a system informed by patients and built for patients. To ensure patient-centeredness, we must prioritize the establishment and strengthening of diverse patient and community advisory groups whose insights are used to improve care delivery, not just serve as a token set of voices.

3. Defining exactly what primary care is (and what it is not): Whether it is in the State House or Congress, definitions of primary care are often wide ranging and sometimes simply wrong. Primary care leaders must do a better job of defining who we are and what we do so that policy makers have a better understanding of the building blocks of primary care. For primary care to truly thrive, healthcare dollars must be specifically targeted towards increasing the reimbursement of all primary care services as well as the compensation of primary care team members.

4. Payment matters: Increasing investment in primary care can provide needed resources to practices to staff interdisciplinary teams and improve practice functioning for better patient care and workforce wellbeing. Payment that is prospective and risk adjusted supports primary care’s quest to fully provide preventive care and chronic disease management, including addressing health-related social needs. Increased investment can also help address workforce shortages, as compensation and work-life balance disparities lessen between primary care and specialty clinicians. Tracking the impact of dollars invested in primary care is also critical, but as more systems shift to performance-based incentives, the work of performing well on quality metrics is falling on the shoulders of primary care providers who do not always see direct compensation for their efforts. There must be greater payment transparency, with more funds going directly to the front lines of primary care to do the work. 

5. Build ally-ship across primary care specialties: Despite holding similar aims in their care of patients, primary care specialties (e.g. family medicine, general internal medicine, general pediatrics, combined internal medicine/pediatrics (med/peds), geriatrics, obstetrics and gynecology) often work in silos. Furthermore, because of the chronic undervaluing of primary care by healthcare systems, these specialties often see each other as threats rather than allies. Primary care leaders should build strong collaboratives across primary care specialties. This allyship strengthens primary care advocacy efforts and can improve the sense of wellbeing of the primary care workforce.

6. Providers and patients should not be afraid to speak out: Primary care cannot be advanced within the walls of city, state, or federal government. Every person, whether patient or provider - must speak out on the importance of primary care. 

Final Recommendations and Conclusion

Primary care strengthening will require advocacy at the state and federal levels. Key policy issues to address are increasing the investment in primary care, reducing the pay gap between primary care physicians and specialists, and financially supporting comprehensive care, care coordination and interdisciplinary teams through more effective payment methods. Well-staffed primary care practices will increase access for patients, deliver on comprehensiveness and care continuity, and improve provider wellbeing and retention. In addition, health care system change is required to align incentives across all levels of care to keep people healthy and out of the hospital and emergency departments.

Applying lessons learned to achieve these changes: Strategies for advocates:

• Making America healthy through disease prevention and chronic disease management is a noteworthy goal. Align your message with this priority: Strengthened primary care is an important and necessary solution.

• Advocates must engage the White House and the Secretary of HHS and at the state level, the Governor and the Secretary of Health.

• In concert with Executive level advocacy, use the rallying cry of constituents and aligned stakeholders to spur the legislative branch to action. Share compelling stories to make the issue real.

• Advocate for collaboration across federal or across state agencies but recognize the limitations in their ability to make change. Use a multi-pronged (executive and legislative) approach.

• Develop a multi-stakeholder coalition, such as state level Primary Care Councils and National Collaboratives – patients, providers across specialties, payers and employers, with bipartisan representation to engender buy in and to speak with one voice.

• Foster bipartisanship on the issue of primary care for long term action. This requires strategic relationship development across the aisle for the long haul.

• Advocate for data collection to monitor for accountability, and areas for improvement. Monitor primary care spending at both the state and the national level and the impact of changes made to strengthen primary care.

Every person living in America is impacted by the lack of access to high quality primary care.  This bipartisan issue can and must be solved.  Please take our lessons learned, build upon them, and create some of your own so that we can work together to make high quality primary care accessible and available to all.